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Compiled by Carol Aloysius

Why women die - Maternal mortality: local scenario

Available data from recent studies in Sri Lanka estimates the prevalence of anaemia in pregnancy to be in the region of 55 to 60 per cent.

The adverse effects on maternal and foetal well being as well as its significant contribution towards maternal mortality has led the Ministry of Health and Women's Affairs to tackle the problem of anaemia among pregnant women head on.A comprehensive strategy has now been formulated to prevent and control anaemia in pregnancy. Provision has also been made to consider the problem of anaemia in adolescent girls, working women and poor mothers.

Under this prevention program the Health Ministry will distribute high protein energy meals and iron folate tablets to all underprivileged mothers and create awareness on the dangers of anaemia among the local community.

For years preventable problems arising during pregnancy and childbirth have been the single greatest cause of premature death and disability among women of reproductive age in the developing world. Today, the most recent figures available show that among adult women globally, maternal deaths are second only to deaths caused by AIDS. In Sri Lanka 1 out of 230 women face a life time risk of maternal death, according to a WHO Report.

A maternal death is defined as "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes." Three measures are commonly used to measure maternal deaths:

. The maternal mortality ratio is the number of maternal deaths per 100,000 live births.

It indicates the risk of maternal death among pregnant women and those who have recently delivered and is also sometimes referred to as the 'obstetric risk.'

. The maternal mortality rate is the number of deaths per 100,000 women aged 15 to 49 in a given period. It reflects both a woman's risk of dying from pregnancy-related causes and her risk of being pregnant at a particular period in time - both are components of risk. The lifetime risk indicates the probability of death over a woman's reproductive life.

It takes into account the fact that most women have more than one pregnancy in their lifetime and it is therefore a more realistic assessment of the risk an individual woman faces because of her reproductive capacity.

A lifetime risk of 1 in 3,000 means that 1 out of every 3,000 women will die and represents a low risk, while 1 in 100 means one per cent of women will die and is a high risk.Any woman can develop complications, even if she is educated, healthy and has access to prenatal care.

Yet most of the deaths, disabilities and ill health are preventable.

Women die or become ill during pregnancy and childbirth for many reasons.

Improving women's nutrition, general health and socio-economic status will reduce the maternal mortality and morbidity rates.

So will access to contraceptives, to safe, legal abortion services, to tetanus toxoid vaccination, to iron supplementation and other simple technologies. Appropriate maternity care during delivery will both prevent emergencies and save lives.

The biggest direct cause of maternal death is severe bleeding.

Indirect causes are the next most common - they result from women being already in very poor health and anaemic or suffering from conditions such as malaria or HIV while pregnant. The other main causes are infection, unsafe abortion and eclampsia.

Main causes of maternal death

1. Severe bleeding or post partum haemorrhage has a number of causes - a small piece of placenta being retained in the uterus, or the uterus failing to contract, for example.

2. Indirect causes include anaemia, malaria and heart disease.

3. Infection or sepsis is caused by unclean delivery practices. It can also arise without being introduced from outside the woman's body - from damaged tissue.

4. Unsafe abortion is defined as a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both.

5. Eclampsia refers to convulsions and coma occurring during pregnancy, labour or soon after childbirth. Pre-eclampsia - a condition in pregnancy manifested by oedema (fluid retention of the ankles, hands or face) also kills women. Both can be associated with hypertension (raised blood pressure).

6. Obstructed labour occurs when the foetus cannot descend through the birth canal. It is usually caused by malpresentation of the foetus or too narrow a pelvis as a result of childhood malnutrition.

7. Other direct causes include ectopic pregnancy - when the fertilised egg becomes implanted and begins to develop outside of the uterus, usually in a fallopian tube. This can occur as a result of damage caused by a reproductive tract infection; embolism - the formation of obstructive blood clots dangerous to health; and deaths related to the use of anaesthesia.

8. Anaemia, which is a leading cause by maternal morbidity and mortality. Anaemia causes babies to be born prematurely and with a low birth weight, both of which hugely increase their chances of dying before they are a year old, and cause serious maternal illness. Severe anaemia can kill pregnant women by causing heart failure.

The heart of a severely anaemic woman has to pump harder to get oxygen around the body. A woman may experience palpitations and dizziness. She will become profoundly tired, pale (especially on the palms of the hands and inside the eyelids) and breathless. Eventually her heart will give up. Anaemic women are also much more vulnerable to the effects of any haemorrhage or infection that might occur after giving birth. Food sources of iron are unlikely to meet the increased needs of pregnant women, therefore iron tablets (usually combined with folic acid, a vitamin necessary for blood synthesis) should be part of all prenatal care regimes.

Malaria and anaemia

Pregnant women with malaria are particularly vulnerable to anaemia. A woman struggling with mild anaemia who then has an episode of malaria can find that her anaemia suddenly worsens and the condition becomes critical. Almost a fifth of severe anaemia in pregnancy is thought to be due to malaria.

Malaria in pregnancy is also a major cause of miscarriage, premature delivery, low birthweight and newborn death.Forty per cent of the world's pregnant women are at risk of malaria infection during pregnancy.

On account of these growing number of maternal deaths, emergency obstetric care will always be necessary, however much women's social status, nutrition and freedom to plan their pregnancies improve.

The result of such case can cause a decline in maternal deaths.

Basic essential obstetric care (EOC) can be provided by midwives, doctors or nurses with midwifery training.

They include:

1. Parenteral (intravenous or intramuscular) antibiotics to prevent or treat infection.

Parenteral oxytocic (drugs which make the uterus contract to stop bleeding)

Parenteral sedatives or anticonvulsants for eclampsia

Manual removal of placenta (in cases of haemorrhage)

Removal of retained products of contraceptive (to prevent bleeding and infection).

Courtesy: 'Birth Rights - new approaches to safe Motherhood' by PANOS)

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Is your child's behaviour unusual?

Most children show isolated psychological symptoms at one time or another and, to a considerable extent, these are a normal part of growing up. However, some children suffer from psychological disorders that interfere with normal development. Accordingly, one of the first tasks when a child is referred to a psychologist is to assess whether the child has a disorder.

In this context, a psychological disorder can be defined as behavioural or emotional symptoms that are so prolonged or so severe as to cause suffering to the child or to others, social restriction or impairment of normal development. Some symptoms, such as fire setting or deliberate self-harm, are so extreme that they need only occurs once to be regarded as abnormal. Most symptoms are only abnormal, however, if they persist and if they are seen in several situations, and should be regarded as a disorder only if they lead to impairment.

Emotional Disorders

Most emotional disorders of childhood are exaggerations of normal development trends. The onset is usually during the developmentally appropriate age period. For example, it is normal for infants to show a degree of anxiety over separation from people they are attached. When this anxiety becomes severe, or persists in to later childhood or adolescence, it is termed separation anxiety disorder. Similarly, when anxiety persists beyond the preschool years, the diagnosis of social anxiety disorder is justified.

Anxiety disorders are among the commonest psychological problems in childhood and occurring in about 3 per cent of 10 year olds. Genetic factors are important. The parents are often anxious and communicate their anxiety by behaviours such as over protectiveness. Some cases of anxiety, particularly specific fears, are precipitated by stress.

Management consists of the reduction of stress, behavioral therapy for specific symptoms (e.g. graded exposure to the fearful situation) and general treatment such as relaxation. Medication may be helpful for severe cases, but should not be prescribed for long periods.

Mood disorders

Depressive disorders occur in prepubertal children but are uncommon. The main clinical features are similar to adults. But somatic complaints and anxieties are more common in small children than in adolescence.

Mania is uncommon. Infants who have been severely deprived or abused sometimes show a state of withdrawal and retarded development.

Management - consists of reducing this adversity, and the use of individual psychological interventions (e.g. cognitive behavioral therapy, which can be administered to children over 10 years) and family therapy. Medications should be used cautiously for adolescence due to the risk of overdose. Most recover within few months but relapse can occur.

Conduct disorders are characterised by repetitive anti-social behaviour that lasts for at least for 6 months. In young children, the clinical picture is dominated by markedly opposition behaviour (e.g. defiance, hostility, and disruptiveness) that is clearly outside the normal range. In older groups' behaviours such as stealing truancy, fighting, lying and running away is seen. In severe cases, fire setting or cruelty to animals and other children are seen.

Conduct disorders are usually associated with poor peer relationships. Conduct disorders occur more in towns than in rural areas. More in boys than girls. There is a strong link with discordant interfamilial relationships and abuse Parents are often inconsistent in applying rules and may be critical and rejecting the child. About 30 per cent have reading difficulties and few have organic brain disease.

Management depend, on the presenting problem and the commitment of the parents. Behavioral methods are effective for young children. Medication is of little value.

Hyperkinetic Disorders

Hyperkinetic behaviours are overactive behaviours and inattention. Diagnosis depends on these two problems in more than one situation (e.g. home, clinic, classroom), and long-term persistence of the behaviour. The diagnosis is difficult in less than 5 years due to wide normal variations. Several other abnormalities are associated with the disorder, including impulsiveness, conduct disorders and learning difficulties.

Management Counsel the parents of the biological factors. Changing the environment, for example by moving to a house with a garden, is helpful. Behavioural programs, may be helpful. Stimulant medications may be helpful in severe cases.

Enuresis

By 5 years of age 10 per cent of children will still wet at night and 3 per cent will wet during the day. Enuresis (inappropriate emptying of the bladder in the absence of organic disease) in a child over 5 years may be at night or during daytime or both.

The most common cause is an inherited delay in maturation of the nervous pathways that control micturition. But there is increased level of behavioral problems in these children especially in girls. Management - children should be reassured that they are not the only ones to suffer from the problem. Parents should be advised not to punish the child. But rather to encourage the appropriate toilet habit.

Dr. R.A.R. Perera

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Coping with the loss of a loved one...

Have you recently suffered the loss of a loved one? Are you still struggling to deal with your pain? If the answer is 'Yes' then this article sent by reader Neville Perera, an Assistant Medical Officer, can help you......

Death comes in a thousand forms. We know that it is inevitable. The most common forms of death is heart failure and cancer. It is estimated that a psychologically healthy person needs almost two years to recover from the effects of the death of a loved one.

The great majority of bereaved people are supported by their families and to a certain extent, by their friends and neighbours during the trauma of the first few days after a death. The most difficult loss to cope with is the death of a spouse.

Often the bereaved person gains strength from the people who come to the service. It encourages them when they see that their sense of sorrow and deprivation is shared by many others. Very often the real grieving begins at or after the funeral.

Time, we are told, is the great healer. There is some truth in that saying.

The two enemies of recovery are loneliness and deprivation. If the bereaved person has lost a constant companion like a spouse - then the loneliness can be like physical pain. Prayer can counter loneliness by reminding us not only of the presence of God but also of the continuing link that believers have through Him with those who have died.

Internal loneliness is a bitter and corrosive thing.

Again, friends must watch out for the symptoms and help the bereaved person achieve a sensible balance of activity.

They should do something more relaxing, such as reading a book, watching television or going for a walk. As you work at these physical exercises, you also alleviate heartache over your loss. Other emotional helps are to read poetry, write down personal thoughts about anything, listening to music or playing a musical instrument.

All these can calm the emotions and ease sadness.

Anniversaries and birthdays can also stir up memories.

It is probably better to anticipate them than to allow them to creep up on you. Perhaps inviting a few relatives or friends to a meal can remove the sting before it strikes.

Some find a visit to the cemetery or memorial a help, provided it is not unbearably painful.

Open and close each day with prayer from your bed.

Let us remember that the bereaved in our midst need our love which everyone of us possesses.

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You and Our Doctor

Diabetes is fast becoming the most widespread disease in the world. Our family physician Dr. S.R. Nanayakkara discusses some questions relating to this life-threatening illness.

Shortness of vision in diabetes is a danger signal!

Q: Can a diabetic patient go blind suddenly? If your answer is yes, then please brief us how it occurs and how to prevent it.

A: Vision of a diabetic could be affected by two factors.

1. Cataract

2. Diabetic Retinopathy.

Cataract as you know, is a condition where the lens of the eye becomes hazy and less transparent to the light rays. It does not occur suddenly but as a gradual process.

Retinopathy is more dangerous and one may go totally blind if not treated at the correct time. The distal inner surface of the eye ball is called Retina which corresponds to the film of a camera where the image is formed.

Retina is a very complex tissue, formed by a large number of tiny blood vessels and neurones. Changes occur in those blood vessels causing minute bleeding into the retina and changing the structure of the retinal tissue, which may be first noticed as a shortness of vision and later into blindness. Therefore, any diabetic person who develops vision problems must go immediately an ophthalmologist (the eye specialist doctor) but not to an optometrist to change your glasses.

Various new techniques including the laser treatment have greatly improved the outlook of this condition if detected early.

Diabetic foot

Q: Being a diabetic for nearly 10 years I have some fear in my mind about my future. I am 48 year old male. Four of my close friends who are also diabetics lost their feet and toes by amputation. I was made to understand by a TV program, that in the Colombo National Hospital alone, the amputation rate is increasing gradually. May I kindly suggest you, to give us an account on this crippling problem and what preventive measure you could advice me to take.

A: Diabetic foot problem is certainly preventable. All diabetic patients do not get it. I can't see any reason why people have let their diabetic state to progress into such a complication. The prevention of such complication is not that difficult, if you know how to control your blood glucose level.

Most frequently we see diabetic foot problems in the elderly, but about 30 per cent is found in people below 50 years as well. The basic lesion is found in the nerves and blood vessels of the legs. The commonly expressed symptom at the beginning is loss or impaired sensation of the skin at the periphery of the legs. This is the commonest warning sign. If one desires to prevent diabetic foot problems, one must identify this symptom early and seek medical advice, immediately. This condition is called Diabetic Neuropathy. Later the skin of the affected area becomes dry due to the loss of sweating etc. One may not feel pain in that area when mildly injured by pressure due to walking or wearing tight shoes.

All these factors increase the risk of foot ulceration. Subsequently Bacteria can invade the ulcer slowly and silently causing an infected ulcer.

Apart from the above reasons there may be some changes occurring in the small blood vessels causing occlusion to the blood flow, there by slowly blocking the blood flow beyond that level. This would further delay the healing of the ulcer, eventually causing the death of the tissues. This condition is called gangrene. Once a gangrene is formed, the only answer to save the life is amputation.

The prevention of this condition is very simple.

First step is keeping your blood glucose level within normal range of 80mg - 115mg, throughout the whole 365 days of the year. How? by diet, and exercise with or without drugs. If you are unable to keep your blood glucose level within that range, obviously you are not going to prevent loosing your toes one day.

After having controlled your blood glucose level the following steps could be observed.

1. Clean and wash your feet and toewebs with soap and water every night before going to bed. Look for any skin changes, discolouration, nail changes. If found report to your doctor on the next day itself.

2. Look for any impairment loss of sensation on the skin. You may seek assistance from your spouse. But examine your toe nails very carefully without injuring the skin edges.

3. Stop smoking immediately

4. Select correct type of shoes. Don't use tight fitting closed shoes, soft padded shoes are ideal to off load your body weight under the foot.

5. Do not walk barefoot.

6. Exercise daily. Walking especially is very good to keep you fit.

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