Maternal Mortality
(MDGs).
By: Timothy Oliveira, Henry Jiang, Alanna
Fitzgerald-Husek and Paul B. Jones (Class 2011)
“An estimated
6,000 mothers die
in childbirth every
year [in Uganda].
The cause? Lack
of skilled
attendants and
emergency care.
More often than not, if mothers do arrive
at a care facility, they're already half
dead. …It takes about four hours for a
mother to bleed to death after delivery.
But when you deliver at home and live
two hours from the nearest clinic, time is
not in your favour.” – Dr. Jean
Chamberlain Froese
Maternal mortality is arguably one of the
most under reported stories of our time.
More recently though it has garnered
some much needed attention of leaders
from the Group of 8, a group of the
world’s major advanced economies.
Canada, which hosts this year’s G8
meeting in Muskoka, is supporting a
plan to improve maternal and child
health in the world’s most vulnerable
regions.
Some may ask, why focus on maternal,
newborn and child health? Sophia Loren
once said, “When you are a mother, you
are never really alone in your thoughts.
A mother always has to think twice,
once for herself and once for her child.”
This simple yet profound statement
embodies a reality recognized by experts
at the United Nations Development
Programme, and is the reason why
maternal health is critical to
development. It is goal number five of
the Millennium Development Goals
Mrs. Elenor Mwesigye 27 year old
woman is rushed in to the Mbarara
Hospital in Mbarara, Uganda by her
family in the back of a truck after
developing a severe post partum
hemorrhage. You have just arrived in
Uganda one week ago for five weeks of
post-MF4 electives, currently you are
assigned to the OB ward, and you’ve
been asked to assess this patient.
Postpartum hemorrhage (PPH) is defined
as any blood loss that has the potential to
produce hemodynamic instability.
Typically it is divided into two
categories early and late PPH. Early
PPH occurs within first twenty four
hours postpartum while late PPH occurs
twenty-four hours to twelve weeks
postpartum. PPH occurs in
approximately five percent of all
deliveries and is the leading cause of
maternal mortality globally.
On physical exam the patient is in
distress. She is quite agitated and her
skin is clammy. She is hypotensive and
dyspneic. You can’t seem to find a
peripheral pulse. You start calling for
help. You also start searching for
gloves, which are in short supply. This
woman has an active vaginal bleed, and
you are aware that that HIV and other
infectious diseases are prevalent in
Uganda.
While Canada and Uganda both have
populations of approximately 33 million
people, in many ways this marks the end
of their similarities. Uganda has a total
fertility rate of 6.37 children
born/woman (ranking 2nd globally)
compared to Canada where the average
is 1.58 children born/woman (ranking
178th). Another dramatic contrast is
maternal mortality ratio, which is a ratio
representing the annual number of
deaths of women from pregnancy-related
causes per 100,000 live births. In
Uganda the ratio is 550 while Canada it
is 7. More concretely lifetime risk of
maternal death is 1 in 11000 in Canada
compared to 1 in 25 in Uganda.
Maternal Mortality By The
Numbers
 Hemorrhage 25%
 Infections 15%
 Eclampsia 12%
 Obstructed labour 8%
 Unsafe abortion 13%
 Other direct causes 8%
 Indirect causes 20%
The world health report 2005 – Make every mother
and child count. Geneva, World Health Organization,
2005
One of the Ugandan Residents arrives
with extra gloves. You begin going
through the ABCs. You ask if there is
any oxygen for this woman but the
Resident says that there is no oxygen
available for her at this time and that
the only option would be to take oxygen
from a more stable patient to give to this
woman. You begin trying to start an IV
but after repeated attempts you ask for
assistance from the Resident and ward
nurse. Two large bore IVs are placed
and you begin giving the patient normal
saline. You ask about cardiovascular
monitoring equipment and are reminded
that given limited resources you will
need to rely heavily on signs from your
clinical examination.
You gather her history with the
assistance of an informal interpreter
and the patient’s family. You learn that
she just gave birth to a stillborn child
after a long and complicated labour
which lasted approximately 18 hours.
She laboured at home in a small village
about one hour outside Mbarara and
was attended to by her sister and mother
in law (neither of whom have any formal
training as birth attendants). This was
her fifth pregnancy and would have been
her fourth child, her third pregnancy
ended in an early miscarriage. Her
previous pregnancies were spontaneous
vaginal deliveries with no major
complications.
Recognizing your limited knowledge you
ask the Resident about causes of
postpartum hemorrhage. He says it’s the
four T’s: Tone, Tissue, Trauma, and
Thrombin (meaning a coagulopathy).
You remember what you learned in MF3
and do your best to manage the
hemorrhage by externally massaging the
woman’s uterus as the Resident looks
for lacerations of the cervix, vagina or
perineum. You are worried as Mrs.
Mwesigye looks increasingly unwell and
continues to lose more blood.
McMaster Medical Students walking to Mbarara
Hospital, Uganda. Photo by Natalie Chan.
You ask if there are any uterotonics like
Oxytocin or Ergonovine, but they do no
have either of these. The nurse says the
hospital does have a limited supply of
Misoprostol which is administered. The
patient needs an urgent blood
transfusion and surgical intervention.
Unfortunately, before this can be
arranged, Mrs. Mwesigye passes away,
despite the Resident’s best efforts. You
are quite upset and the Resident takes
you outside to talk.
He reminds you that maternal mortality
is an all too common problem in his
country and that often it is not possible
to save mothers who present to the
hospital so late. He encourages you to
take the rest of the day off to process
what you have just witnessed and you
thank him for his understanding and
commend him on his heroic efforts. He
says, “Sometimes you just have to be
comfortable not knowing all the
answers”. You are amazed by the
knowledge and resourcefulness of the
Uganda physicians and nurses.
Countries say they are committed to
reducing the maternal mortality ratio by
seventy-five percent by 2015. Despite
this commitment between 1990 and
2005 the maternal mortality ratio has
only been reduced by five percent
globally. Experts agree that MDG Goal
number five lags behind all others. Sadly
ninety-nine percent of all maternal
deaths occur in the developing world,
where eighty-five percent of the
population lives, more than half in sub-
Saharan Africa alone.
Much more needs to be done to protect
mothers and their children in the
developing world. If children are the
future, then mothers serve a critical role
in guiding and nurturing their offspring
and indeed our collective future. As
Sarah Josepha Hale said, “No influence
is so powerful as that of the mother”. It
is time we do more to save the mothers.
For more information about maternal
mortality:
 http://www.who.int/making_pregnancy_safe
r/topics/maternal_mortality/en/index.html
 http://www.undp.org/mdg/goal5.shtml
 http://www.savethemothers.org/
 http://www.intrahealth.org/page/intrahealth-
voices-life-saving-practice-can-change-
mothers-fate
Authors’ note: The goal of the continuing
Global Health Committee (GHC) article
series in Placebo is to provide you with an
introduction to neglected infectious diseases
and raise awareness about issues relevant to
global health. While the actual cases discussed
are fictional, we have tried our best to ensure
that the natural history, clinical
manifestations, investigations and treatments
are true to life.