PREGNANCY AND CHILDBIRTH IN DEVELOPING COUNTRIES
Rani Bang
Since ancient days. Motherhood has been respected and given lot of status in all traditional societies. But it seems that this adored motherhood has also created many health problems in the women's life. Motherhood is the Achillis heel of women's health
Pregnant and nursing mothers are one of the most vulnerable groups in a community as there is a heavy demand in terms of nutrients during these periods. Unfortunately in India and in most of the developing countries, the proportion of women who go through these stressful periods with adequate preparation is very small and we have got to concern ourselves specially with the women of low socio-economic group who do not even have the basic necessities of life and hence who are worst hit during this phase.
Let me put forward some facts about the health of Indian women during pregnancy and childbirth.
1. The Stress Period
Between 15 and 45 years of age, that is in the 30 year span of reproductive life, an average Indian woman becomes pregnant about 8 times. She may ultimately be left with only 3-5 children because,
a) abortion and stillbirth rate is very high : 15-25 percent;
b) infant mortality rate is 122 per 1000 live births;
c) death rate of children under five is 18 per 1000 per year.
Each live born infant is breast-fed generally up to 2-3 years and the milk output is quite substantial in the first 18-24 months.
Thus of the total 360 months of reproductive life, 200 months or 50-60 percent of the time is spent in pregnancy and lactation. Of this some 140 months are completed before the woman reaches 35 years of age.
2. Nutritional status during Pregnancy
The population of India according to 1981 census Is 680 million. Of the total female population in India, 140 million are in the reproductive age group.
Most of those women are underweight and their food intake even in the non-pregnant state is extremely poor. Added to this is the fact that although the nutrient requirements go up in pregnancy and lactation, the food Intake of those women does not change from what it is In the non-pregnant state.
An Indian woman is only nominally In charge of the kitchen. Her role Is like a servant cook ! just to cook, serve first the husband then the children and other family members and to remain satisfied with whatever remains at the end. In such a situation, who is bothered about her nutrition ? This social factor and the poverty together result In various nutritional deficiencies.
a) 30-50 percent of the women have iron and folic acid deficiency anaemia. 20 percent of maternal deaths are directly or indirectly related to anaemia as opposed to virtually
none in developed countries.
b) 30 percent have B- complex defieciencies leading to sore tongues making further restrictions In food Intake.
c) Incidence of vitamin A deficiency is also quite high leading to night-blindness.
d) About 10-15 percent of women have toxaemia and It accounts of 15 percent of maternal mortality. Maternal deaths from toxaemia are mainly due to eclampsia. These
eclamptic deaths are by and large avoidable with good antenatal care.
e) Anaemia - Toxaemia syndrome leads to an increase In the incidence of haemorrhages In pregnancy and during childbirth. Even if the amount of haemorrhage Is small, women can not tolerate even that much strain due to the already existing anaemic state. Haemorrhage, antepartum, Intrapartum andpost partum is the most Important cause of maternal death In India accounting for about 25 percent. 80 percent from antepartum and postpartum haemorrhages are avoidable provided proper antenatal and Intranatal care Is given and blood transfusion is available
f) Calcium deficiency Is quite common and the Incidence Increases with parity leading to deformities of the pelvis causing (ultimately) malpresentatlons, malpositions, obstructed labour and maternal deaths. Obstructed labour accounts for 15 percent maternal deaths.
g) Dietary surveys have revealed a startling fact that the women in India consume only 1500-1600 calories per day during pregnancy while the calory requirements of a
moderate working non-pregnant woman are 2200 and of a pregnant woman 2500 calories per day.
The daily protein intake is between 30-40 grams while the recommended one is 55 grams per day.
The average weight gain during pregnancy is 6-8 kg., while the ideal is 12-13 kg. This leads to the birth of smaller babies (average birth wt. is 2,7 kg. compared to 3.2 kg. in
the higher income group). This results in high new-born deaths. About 50 percent of women don't show any weight gain during the last trimester.
Studies have shown that just increasing the food intake during the last 3 months of pregnancy can lead to the birth of healthier babies.
3. Antenatal Care
80 percent of the population lives in rural areas where there are no health facilities.
There is one primary Health Centre for 100.000 people and one Auxiliary nurse midwife, moving on foot is supposed to cover 10.000 people scattered in many villages. It's humanly impossible for her to reach all the women.
So the immunization of pregnant women against tetanus is mostly not done or is incomplete resulting in the high incidence of purperal tetanus and tetanus neonatorum
Efficient antenatal care is available to only 10 percent of women, specialized care is available to only a few and the majority (90 percent) of pregnant mothers have no skilled attention of any sort - either from medical or paramedical personnel, so there is no detection of cases at risk.
The villages are so remote and there are no transport facilities. The deliveries are conducted in the most unhygienic surroundings. So the incidence of sepsis is quite high. As there are no referral facilities many women die of a ruptured uterus following obstructed labour.
4. Maternal Mortality Rate
The high incidence of malnutrition coupled with poor antenatal and obstetric care results in an extremely high maternal mortality rate around 370 per 100.000 births.
A comparison with the figures from the developed countries will help to know the gravity of problem.
Maternal mortality rates in some countries
(maternal deaths per 100.000 births)
Sweden 7.7
U.K. 10.7
U.S.A. 12.0
Poland 14.3
Japan 27.6
India 370.0
The figures in the rural areas of India are still higher. One reported from a rural referral centre in Punjab is 1800 / 100.000.
Again it has been further estimated that for every woman who dies as a result of pregnancy and childbirth, there are at least 20 who suffer from impaired health and lowered efficiency. Judged on this basis, the number of women who suffer ill health as a result of pregnancy and childbirth in India may run into millions.
At least 70-80 percent of the maternal deaths are preventable such as those associated with sepsis, eclampsia, tetalus, haemorrhage, malpresentation etc
5. Childbirth
90 percent of the deliveries are conducted at home outside the hospital and the majority in the absence of a nurse or a trained midwife.
The deliveries in rural area are conducted at home by the traditional birth attendants 'Dais', This Dai is the 'rural abstetrician' and people have great faith and confidence in her. During our experience of work in the rural areas, we have seen that these Dais are really good in their skill and sometimes can give a judgement better than a doctor. The problem with them is, as they are not aware of aseptic requirements during the process of labour, they conduct deliveries in a most unhygienic fashion. They generally cut the cord with a rusted saw or sickle or sometimes even crush the cord by stone. In addition they apply cow-dung or mud or turmeric power over the stump of the cord. Because of these unhygienic methods the sepsis and tetanus rate is very high with consequent high mortality and morbidity.
The Dai does not do antenatal and postnatal check-ups as she is called only to conduct deliveries.
Many persons working in the field of rural community health now feel that the Dais are already established in the society, and if they are given some scientific training about asepsis and antenatal and postnatal checkups they will prove to be boon to the women in rural areas where hardly any other facility exists.
I want to stress the importance of training Dais from the feminist point of view. Now-a-days, there is great talk about health politics and self-help in feminist circles. There is a rising interest in this subject in developed countries.
Fortunately this self-help movement has existed in Indian society for ages and women will not be entirely dependent on male doctors If Dais are given a little more training in maternal and child health.
Now in developed countries more and more women demand and wish to have delivery at home. In India, deliveries occur at home due to non-availability of hospital services but I was wondering why the women in the developed world seek for home delivery in spite of the availability of very good health services. My doubt was cleared when I visited the Maternity hospital in Geneva. On entering the labour room it was surprising to see so many machines near the labour tables fixed on the delivering women. Labour is a natural process and the doctor is called for intervention in a small percentage of cases. But this natural process of labour has been mechanised in the western society and it is no wonder that women in western society wish to give birth at home, but of course with all the facilities including blood transfusion and quick referral system in case of an emergency.
Another point is the position of woman during labour. My experience tells me that almost all women in rural areas adopt a squatting position during delivery. We doctors with the scientific training and ideas, try to discourage this and force these women to adopt the lying down position at the time of delivery It's interesting to note that the squatting position is really good as there is an increase in the anteroposterior diameter of the pelvic inlet by 1/2 to 1" and this helps in easy progress of labour. Also the bearing down is better in this position.
It s tragic that we doctors with the modern training overlook some of the good and useful traditions.
6. Lactation
Prolonged and successful lactation is the rule in both urban and rural areas. The mean duration of lactation even among the urban poor is 19.8 months and failure of lactation occurs in only 3.5 percent of cases. Age has no relation to lactation though educational status of women exerts a strong negative influence. It is possible that this is due to the high tension advertisements of the baby food industry. Successful lactation is due to the increased frequencies of sucking on demand both during the day and night. This acts as a reflex leading to better milk output and also makes the woman relatively infertile — a natural contraceptive!
The interpregnancy interval in mothers who don't use any contraceptive method but who lactate for a long time is 26 months. It is calculated that the number of pregnancies
prevented by prolonged breast feeding in the Third World is far greater that those prevented by all the family planning measures.
The quantity of breast milk does not decrease up to 1 year. The calory requirements are higher than those during pregnancy but in reality the food intake of lactating mothers is worse than in the pregnant stage.
The need to prevent another pregnancy comes with the return of menstruation but her experiences with a loop, condom and pills are such that pregnancy appears to be preferable.
7. Health system in India
The problems of women and their malnourished children constitute 70-80 percent of the health problems in any underdeveloped society. Most of them are preventable and need very basic care. But unfortunately the medical system is not oriented towards these. Also it is observed in India that the woman is treated just like a machine producing babies and there is very little concern about her health. This lack of concern for women's health is fundamentally an offshoot of a deeper and more complex malady, namely the inferior status and expendable nature of the female in Indian society.
The sex ratio in India is one of the lowest in the world (925 women per 1000 males) and it is further declining gradually and this is seen right from the infancy. This is due to the negligence and apathy towards the female whether child or mother.
The neglect of women is seen in all aspects of life in literacy rates, in employment, wages and working conditions, in decision making. Thus the average Indian woman lacks a proper socio-economic status and she and her life is not of much social significance.
The health status of women is a good reflection of their overall status in the society. Hence their health status can not improve merely by providing more health facilities. It must be appreciated that motherhood, how so ever significant, is only one aspect of female life. Unless and until deliberate efforts are made to bring women into the mainstream of developmental activities and to enhance their economic and social role, simply trying to improve health of women by doling out welfare programmes leads to disastrous failures and wasteful expenditure.