Limitations of maternal care to improve maternal health

In a presentation at the 1991 Berzelius Symposium in Sweden, a Population Council researcher described the limitations of healthcare systems, specifically during pregnancy, in terms of their effect on maternal health status. These limitations stem from an inability to improve health because of social conditions—poverty and illiteracy, overwork, inequality in sexual relationships—that cannot be solved by medical interventions. Maternal ill health originates before pregnancy and endures beyond it, whereas the window of contact with women during pregnancy is small. Nevertheless, recent evaluations suggest that the impact of prenatal care is in the caring process more than any specific aspect of care. The presentation concludes that wide extension of caregiving systems and access to some level of care may be more important than assessment and implementation of specific interventions for deprived populations who are in great need

Maternal risk

This presentation to the 1991 Berzelius Symposium, Stockholm, Sweden, explores the issue of maternal risk—the probability or chance of dying or being seriously injured in pregnancy—as it is used in maternal health care. This concept of risk has been a useful tool for research and medical and epidemiological education, but its use as a tool for service delivery design has been more problematic. In order to construct a risk system, one has to have reliable data on the relationships between individual characteristics and the outcome being studied—something that is difficult to develop with regard to maternal health. Furthermore the system must be easily taught to those who will use it. Finally, there are psychological issues related to being labeled a “high-risk” individual. The presentation proposes a change in vocabulary and perception, from managing risks to identifying problems that can be solved and thus help more women

Celebrating mother and child on the fortieth day: The Sfax Tunisia postpartum program

This edition of Quality/Calidad/Qualité gives information about a postnatal family planning program in the Sfax Center of the Tunisia Maternity and Newborns Hospital. This program, developed jointly by the national family planning program and the Maternity staff, has had extraordinary success in getting more mothers to return after six weeks for their postnatal visit. During the visit, the period between births is discussed; and family planning services are offered as an important means for achieving both the recovery and good health of the mother, as well as the physical and mental development of the infant. The report describes a few of the plans that the Sfax Center is considering to increase the options that can be offered to clients in the postnatal state. These are, in effect, a part of the permanent evaluation of program services; and it is through this evaluation that they look for better ways to respond to the needs of the clients of the Center to protect their reproductive health

Acceptability of first trimester medical abortion

Unwanted pregnancy is a serious and stressful problem for women. As stated in this paper, technologies that afford safe and effective abortion are well accepted and provide relief from a great difficulty. Many women fear surgery and will go far to avoid it. There is substantial apprehension about general anesthesia during surgery and also fear that local anesthesia may not prevent pain. This leads to a high demand for a medical abortion alternative. Some women consider that the quick and definitive surgical alternative is easier; some find that swallowing a pill is easier. Privacy is greatly valued. Medical abortion technology seems to meet this need more than surgical abortion, especially if the surgical alternative mandates hospital admission and absence from home. The high values placed on privacy, autonomy, and the wish to be able to be at home combine, in at least some settings, to create a demand for a self-administered home treatment for early abortion. Given a choice between surgery and any of several medical abortion methods, most eligible women appear to prefer the medical method

Rethinking postpartum health care

These proceedings come from papers and discussions as part of the Population Council invitational seminar entited Rethinking Postpartum Health Care, in 1992. The seminar on postpartum reproductive health was the fifth in a series of seminars convened by the Population Council as part of its Robert H. Ebert Program on Critical Issues in Reproductive Health and Population. The program focuses on four topics: 1) improving and devising new approaches to postpartum care; 2) improving the quality of care in family planning and reproductive health services; 3) managing unwanted pregnancy and preventing the consequences of unsafe abortion; and 4) bringing attention to sexually transmitted diseases, including AIDS. The purpose of the seminar on postpartum health care was to raise the level of interest in an often neglected period of women\u27s reproductive life

Misoprostol in the management of the third stage of labour in the home delivery setting in rural Gambia: a randomised controlled trial.

OBJECTIVE: To assess the effectiveness of 600 microg oral misoprostol on postpartum haemorrhage (PPH) and postpartum anaemia in a low income country home birth situation. DESIGN: Double blind randomised controlled trial. SETTING: Twenty-six villages in rural Gambia with 52 traditional birth attendants (TBAs). SAMPLE: One thousand, two hundred and twenty-nine women delivering at home under the guidance of a trained TBA. METHODS: Active management of the third stage of labour using three 200-microg misoprostol tablets and placebo or four 0.5-mg ergometrine tablets (standard treatment) and placebo. Tablets were taken orally immediately after delivery. MAIN OUTCOME MEASURES: Measured blood loss, postpartum haemoglobin (Hb), difference between Hb at the last antenatal care visit and three to five days postpartum. RESULTS: The misoprostol group experienced lower incidence of measured blood loss > or =500 mL and postpartum Hb or = 2 g/dL was 16.4% with misoprostol and 21.2% with ergometrine [relative risk 0.77; 95% confidence interval (CI) 0.60-0.98; P= 0.02]. Shivering was significantly more common with misoprostol, while vomiting was more common with ergometrine. Only transient side effects were observed. CONCLUSIONS: Six hundred micrograms of oral misoprostol is a promising drug to prevent life-threatening PPH in this setting

Misoprostol: An emerging technology for women\u27s health—Report of a seminar

On May 7–8, 2001, the Population Council and the Center for Reproductive Health Research & Policy of the University of California, San Francisco, convened a technical seminar in New York City on the use of misoprostol for women’s health indications. The seminar was designed to provide a forum for researchers, providers, women’s health advocates, and educators to exchange information with the goal of advancing the potential of misoprostol to improve women’s health. Participants discussed the state of the art in research, examined current clinical use of misoprostol, and created strategies for the future. The first day focused on scientific and clinical aspects of misoprostol use. The second day’s discussion centered on the future of misoprostol for women’s health, including identifying priorities for research and the role of provider groups and women’s health and advocacy organizations in helping to ensure misoprostol’s continued, appropriate use. At the end of each session, the group had an opportunity to share ideas and discuss unanswered questions. This report covers the key issues raised by each speaker and highlights general areas of discussion among participants

First-trimester medical abortion with mifepristone 200 mg and misoprostol: a systematic review.

BACKGROUND: The dose of mifepristone approved by most government agencies for medical abortion is 600 mg. Our aim was to summarize extant data on the effectiveness and safety of regimens using the widely recommended lower mifepristone dose, 200 mg, followed by misoprostol in early pregnancy and to explore potential correlates of abortion failure. STUDY DESIGN: To identify eligible reports, we searched Medline, reviewed reference lists of published reports, and contacted experts to identify all prospective trials of any design of medical abortion using 200 mg mifepristone followed by misoprostol in women with viable pregnancies up to 63 days' gestation. Two authors independently extracted data from each study. We used logistic regression models to explore associations between 15 characteristics of the trial groups and, separately, the rates of medical abortion failure and of ongoing pregnancy. RESULTS: We identified 87 trials that collectively included 120 groups of women treated with a regimen of interest. Of the 47,283 treated subjects in these groups, abortion outcome data were reported for 45,528 (96%). Treatment failure occurred in 2,192 (4.8%) of these evaluable subjects. Ongoing pregnancy was reported in 1.1% (499/45,150) of the evaluable subjects in the 117 trial groups reporting this outcome. The risk of medical abortion failure was higher among trial groups in which at least 25% of subjects had gestational age >8 weeks, the specified interval between mifepristone and misoprostol was less than 24 h, the total misoprostol dose was 400 mcg (rather than higher), or the misoprostol was administered by the oral route (rather than by vaginal, buccal, or sublingual routes). Across all trials, 119 evaluable subjects (0.3%) were hospitalized, and 45 (0.1%) received blood transfusions. CONCLUSIONS: Early medical abortion with mifepristone 200 mg followed by misoprostol is highly effective and safe

Misoprostol and teratogenicity: Reviewing the evidence

Misoprostol, a prostaglandin E1 analog marketed as Cytotec® for the prevention and treatment of gastric ulcers, is inexpensive and registered for use in over 80 countries. Many scientific articles show the preparation to be safe and effective for various reproductive health indications, including cervical softening and early pregnancy termination. Owing to the extensive body of published literature on these indications, misoprostol is now widely used for several reproductive health indications. The abortifacient properties of misoprostol are well known to medical professionals and frequently to the public. As noted in this meeting report, because the drug is available at low cost, many women have opted for self-administration of the method to terminate their pregnancies. The pharmaceutical industry and the public health community have raised the concern that if such an abortion attempt fails and the pregnancy results in a live birth, exposure of the fetus to misoprostol in utero could increase the risk of birth anomalies. The most extensively documented accounts of self-medication with misoprostol for induced abortion have come from Brazil, thus the case of Brazil provides a unique opportunity for studying the potential teratogenicity of misoprostol