|03. What Is the Evidence for the Role of Antenatal Care Strategies in the Reduction of Maternal Mortality and Morbidity?|
Maternal mortality has been likened to the tip of the iceberg, maternal morbidity to its base (Bergström 1994). This implies that many more mothers experience disease and suffering in consequence of pregnancy than those who die. Maternal disease is often reflected in the offspring: low birth weight, malnutrition, other ailments, which underlines the importance of this issue. Short term illnesses following childbirth can be classified as 1. Puerperal hypertension, 2. Peripartal cardiac failure, 3. Thrombosis and embolism, 4. Acute prolapse of the cervix, 5. Pelvic instability and pain, 6. Psychiatric illness, 7. Sepsis and other infections, and 8. Others. Some of these were discussed in the section of maternal mortality. Most of them are time-limited and not seen as part of the global problem discussed here. Long term sequelae of debilitating proportion were classified by (Royston and Armstrong 1989) into 1. Fistula, 2. Neurological dysfunction, 3. Vaginal stenosis, 4. Sheehans syndrome, 5. Chronic pelvic inflammatory disease, 6. Infertility, 7. Ectopic pregnancy, 8. Anaemia and 9. Uterovaginal prolapse. To these may be added 9. Urinary stress incontinence. Sheehans syndrome is extremely rare and some of the others are equally common in developed and developing countries.
Rectovaginal and vesicovaginal fistulas are common in Africa but hardly ever seen in Europe and North America. They are caused by delayed obstructed labour and cause immense pain and suffering. Some medical centres have specialised surgical fistula units; treatment periods are long and results not guaranteed. Demand for treatment is much higher than existing resources. Prevention is clearly possible, as outlined in the paragraph on obstructed labour.
Pelvic inflammatory disease, infertility and ectopic pregnancy are parts of the same problem: genito-urinary infections. Bilateral tubal occlusion as demonstrable cause of female infertility is much higher in Africa than in Asia, Latin America, East Mediterranean and developed countries (Cates et al . 1988). Africa, therefore, should be specially targeted for preventive action, as outlined in the paragraphs on sepsis and unsafe abortion. This should go concomitantly with HIV and AIDS education. AIDS education is multisectorial (Bergsjø 1996), and the message probably best heeded at individual level. Antenatal care programmes should have family planning and safe sex as integral parts of the package.