Evidence - All-Party Parliamentary Group

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Columbia University, Mailman School of Public Health /
Averting Maternal Death and Disability Program / RAISE Initiative
Submission to UK All Party Parliamentary Group on
Population, Development and Reproductive Health
New Inquiry: Maternal Morbidity
September 2008
SUMMARY
Over 500,000 maternal deaths occur each year around the world. Maternal mortality,
however, represents merely the “tip of the iceberg.” For every woman who dies as a
result of pregnancy or childbirth, between 16 and 20 more suffer illness or injury.
One oft-overlooked maternal morbidity is uterine prolapse, whereby a woman’s pelvic
musculature is damaged or weakened to the extent that it can no longer support the
uterus. Among women of reproductive age, the prevalence of uterine prolapse ranges
from 2% to 20%. Women’s experiences with prolapse tend to be characterised by
discomfort and pain, although sequelae can also include life-threatening complications
such as maternal sepsis. Due to these and other complications, women often cannot
perform even simple daily activities like sitting, standing, walking, and lifting. In addition
to its physical repercussions, uterine prolapse can have negative consequences for
women’s family and social lives.
In Nepal, the prevalence of uterine prolapse is strikingly high; recent estimates suggest
that between 600,000 and more than one million women suffer from the condition. In
this region, heavy work and heavy lifting, particularly during pregnancy and the
postpartum period, represent major risk factors for prolapse. Frequent pregnancy, high
parity, early marriage and childbirth, malnutrition, and certain traditional birthing
practices also contribute to the frequency of the problem.
Fistula is one of many conditions that can lead to uterine prolapse. Recent estimates
suggest that approximately two million women are living with fistula around the world,
with between 50,000 and 100,000 new cases emerging each year. Obstetric fistula is a
direct maternal complication; it most often results when women experience obstructed
labour and do not have access to medical care. While obstetric fistula has become
increasingly prominent, however, traumatic fistula is a problem that remains relatively
unknown. Traumatic fistula is the result of violent rape, including the forced insertion of
foreign objects, such as guns, broken bottles, and sticks, into the vagina. In such cases,
a hole develops in the wall between a woman’s vagina and her bladder, rectum, or both,
leading to incontinence and complications like infertility, nerve damage, and infection.
Due to incontinence, the woman is often ostracised by her community and family; in the
case of traumatic fistula the situation is made yet worse due to the additional stigma of
rape.
The single most important task of organisations seeking to decrease death and disability
due to pregnancy and childbirth, including both uterine prolapse and fistula, is to
strengthen health systems at all levels. A crucial component of this task is to focus on
the systematic implementation of emergency obstetric care (EmOC) services, with
equitable distribution to all women. The charge to strengthen health systems and all its
1
components necessitates additional funding; organisations such as DFID will be crucial
to its success. Further, organisations must ensure that refugee and internally displaced
women are included in the prioritisation of services for women in developing countries.
Finally, donors must also promote increased accountability at all levels of the health care
system.
1. AGENCY OVERVIEW
1.1 Columbia University’s Mailman School of Public Health is a leading institution of
higher learning in the United States and in the world. Its research, education, and
service agenda addresses the critical and complex public health issues that affect
millions of people locally and globally. The Mailman School is especially known for its
pioneering work on women’s reproductive health and human rights.
1.2 The Averting Maternal Death and Disability Program (AMDD), based at the
Mailman School, was established in 1999 to reduce maternal mortality and morbidity in
the developing world by improving the availability, quality, and utilisation of emergency
obstetric care (EmOC). AMDD believes that sustained reductions in maternal mortality
can only be achieved through systemic country-wide improvements to heath systems,
inclusive of EmOC.
2. BACKGROUND
2.1 One-third of the burden of disease experienced by women globally is the result of
reproductive ill-health.1 A significant proportion of this burden is due to complications of
pregnancy and childbirth; approximately 15% of all pregnant women will suffer a direct
obstetric complication, either during pregnancy, delivery, or the postpartum period, all of
which could lead to death or disability if left untreated.2 Stark inequities are evident
between developed countries and developing countries with regards to this disease
burden. A woman’s chance of dying a maternal death in the developing world, for
example, is one in 61, and in the developed world, one in 2,800.3 The major reason for
these discrepancies is the lack of appropriate care available in developing countries.
Even within countries, differential access to care is often determined by degrees of
social disadvantage, including those of educational level, wealth, urban versus rural
residence, religion, ethnicity, and forced displacement status.
2.2 Over 500,000 maternal deaths occur each year around the world.4 Maternal
mortality, however, represents merely the “tip of the iceberg.” Estimates of the number
of women experiencing maternal morbidity, defined as any “complications that have
arisen during the pregnancy, delivery or postpartum period,” range from eight million to
50 million.5,6 Major types of maternal morbidity in developing countries can be classified
by length of duration. Short-term complications include anaemia, preeclampsia,
eclampsia, haemorrhage, ectopic pregnancy, sepsis, obstructed labour, depression, and
uterine rupture. Long-term complications include uterine prolapse, vaginal fistula,
incontinence, dyspareunia, and infertility. In the absence of proper care, however, shortterm complications often lead to long-term morbidity.7,8,9
2.3 Educational attainment and wealth are closely associated with a woman’s risk of
maternal morbidity. Further risk factors include pregnancy and childbirth at young ages,
2
high parity, low utilisation of family planning, and lack of access to health services,
including safe abortion services where legal. In addition to physical injury and illness,
maternal morbidity can lead to long-lasting and significant emotional, social, and
economic consequences, not only for women, but also for their children and families. 10,11
2.4 Some obstetric complications, such as those due to unsafe abortion, can be
prevented. Most, however, cannot be foreseen or prevented, but only treated. For this
reason, access to EmOC† and the presence of skilled attendants during delivery are
indispensable in the fight to reduce maternal morbidity and mortality.12
3. UTERINE PROLAPSE
3.1 Maternal morbidities are often overlooked in regions where maternal mortality is
high. This is particularly true of uterine prolapse, or “fallen womb.” With untold millions
of women suffering from this condition, the public health community can no longer afford
this oversight. In uterine prolapse, a woman’s pelvic musculature is damaged or
weakened to the extent that it can no longer support the uterus. In first degree prolapse,
the cervix descends into the vaginal opening primarily when the woman is bearing down.
In second degree prolapse, the cervix descends into the woman’s vulva. Finally, in third
degree prolapse, the cervix, and often the uterus, descend beyond the vulva, and often
outside the body entirely.13,14,15
3.2 Among women of reproductive age, the prevalence of uterine prolapse ranges
from 2% to 20%. The condition most often develops following childbirth, although
intrapartum prolapse does occur in rare cases. Women’s experiences with prolapse tend
to be characterised by abdominal pressure and pain, back pain, pain during sexual
intercourse, and discomfort urinating and defecating. Many women with uterine
prolapse experience abnormal vaginal discharge, reproductive and urinary tract
infections, and infertility. Internal tissues, when outside the body, can become dry and
cracked, leading to bleeding and ulcers, and, eventually, infection. Due to these
complications, women often cannot perform even simple daily activities like sitting,
standing, walking, and lifting. Intrapartum prolapse poses additional health threats,
including spontaneous abortion, premature labour, and maternal sepsis.16,17,18,19,20
3.3 Frequent pregnancy and high parity are common causes of uterine prolapse.
Certain direct obstetric complications can also lead to uterine prolapse; perineal
damage, prolonged and obstructed labour, and delivery of a large infant can all result in
significant pelvic floor damage. Heavy work and heavy lifting, particularly during
†
EmOC is a standard set of medical interventions for treating direct obstetric complications and,
accordingly, preventing maternal death and disability. Basic EmOC comprises the following
interventions, or “signal functions”: 1) administration of parenteral antibiotics, 2) administration of
uterotonic drugs (e.g. parenteral oxytocics, misoprostol), 3) administration of parenteral
anticonvulsants (e.g. magnesium sulphate), 5) removal of retained products (e.g. manual vacuum
aspiration), 6) assisted vaginal delivery (e.g. vacuum extraction), and 7) neonatal resuscitation
(e.g. with bag and mask). Comprehensive EmOC includes all of the above interventions, as well
as surgery, including caesarean sections, and blood transfusion. To provide the signal functions,
facilities must have the requisite medications, supplies, and functioning equipment, and staff must
be trained, competent, and authorised to provide the intervention.
3
pregnancy and the postpartum period, are major risk factors for prolapse. Malnutrition,
hypertension, constipation, and chronic cough, including from smoking, can increase
women’s risk of prolapse. Women who have had a vaginal hysterectomy can be at a
greater risk of uterine prolapse, as can women with an abdominal mass or a history of
fistula. Post-menopausal women are at risk for prolapse; as they start to lose oestrogen,
their pelvic floor weakens, leading to prolapse. Prolapse also occurs at younger ages,
particularly where women marry and have children early in life. Genetics may play a role
as well; prevalence varies between ethnic groups. 21,22,23,24,25,26,27
3.4 Case Study: Nepal
Nepal is one country in which the United Kingdom has invested substantial resources in
maternal health. Despite significant progress, however, poor health indicators persist.
There, a woman’s lifetime risk of dying as a result of pregnancy or childbirth is one in 31.
In the United Kingdom, that number is one in 3,800. In Nepal, between 11% and 19% of
births are attended by skilled personnel, and only one in 20 women with life-threatening
obstetric complications are able to access EmOC.28,29,30
3.5 In Nepal, the prevalence of uterine prolapse is strikingly high, representing the
most frequent cause of poor health among women of reproductive and post-menopausal
age, and one of the most frequent among lower caste and rural women. 31 Recent
estimates suggest that between 600,000 and more than one million women suffer from
the condition; prevalence rates range from 10% to 40%.32,33,34,35
3.6 Several factors contribute to high rates of uterine prolapse in Nepal. Women
traditionally engage in extremely hard work, including heavy lifting, with little or no rest
during pregnancy or the postpartum period. Their workload is, on average, 12% to 22%
greater than men’s. Early marriage and childbirth, malnutrition, and certain traditional
birthing practices can present risk factors for prolapse as well. In some areas, for
example, an attendant pushes on the woman’s belly from the outside during labour,
causing pelvic floor damage.36,37,38,39
3.7 In addition to its physical sequelae, uterine prolapse causes serious problems in
women’s family and social lives. In Nepal, high value is placed on women’s ability to
work and to bear children. Uterine prolapse threatens their ability to do both, and it is
not uncommon for women suffering from the condition to be abandoned by their
husbands and ostracised by their families and communities.40,41,42
3.8 Treatment for uterine prolapse depends on the degree of severity. For the most
mild cases, some physicians recommend a regimen of Kegel exercises to strengthen the
pelvic floor. More commonly, however, women with first or second degree prolapse are
prescribed a pessary to stabilise the uterus. The cost of the pessary is approximately
£0.38, but must be replaced every 3 months, which can be challenging when access to
health care is limited and extreme poverty is widespread. Severe cases of prolapse can
be treated only through surgery, most often a hysterectomy. Surgery costs
approximately £110, an exorbitant sum for women in less developed countries. 43,44,45
3.9 In addition to cost, weak health systems and lack of awareness about treatment
options are major barriers to women receiving needed care. Social stigma attached to
reproductive morbidity, traditional gender roles, and cultural beliefs also prevent women
4
from seeking care. Women often do not make decisions about their own health care,
and working with male doctors makes many women uncomfortable.46,47,48
3.10 As with other maternal morbidities, in order to begin to make real progress toward
reducing the prevalence of uterine prolapse, health systems in developing countries
must be strengthened, including increasing skilled attendance at birth and improving
access to and utilisation of family planning and EmOC.49 Specific steps recommended
by programme data include improving access to health education, screening,
counselling, and early treatment.50,51,52 Inter-sectoral collaboration is also essential in
order to improve the status of women within society, leading to a more equitable
distribution of work, improved access to health care and education, and the opportunity
to control the number of spacing of their children.
4. FISTULA
4.1 Today, nearly 60 million people around the world are living displaced by conflict
and other humanitarian emergencies. Women living in crisis settings suffer from the
same reproductive morbidities as women living in more stable settings, compounded by
complications like sexual violence and lack of access to health care. As a result, women
living in countries with ongoing and recent conflicts have consistently poor maternal
health.53
4.2 Fistula is one of many conditions that can lead to uterine prolapse. Obstetric
fistula is a direct maternal complication; it most often results when women experience
obstructed labour and do not have access to medical care. In such cases, a hole
develops in the wall between a woman’s vagina and bladder (a vesicovaginal fistula) or
the rectum (a rectovaginal fistula) or both. In these situations, the foetus often dies, and
the woman is left leaking urine, faeces, or both. Additionally, women with fistula can
develop complications that include uterine prolapse, infertility, ulcerations, infection,
kidney disease, spontaneous abortion, and severe nerve damage. Due to their
incontinence, women are often shunned by their families and communities.54,55
4.3 While obstetric fistula has become increasingly prominent as a public health
concern, traumatic fistula remains relatively unknown. Traumatic fistula is defined as “an
abnormal opening between the reproductive tract of a woman or girl and one or more
body cavities or surfaces, caused by sexual violence, usually but not always in conflict
and post-conflict settings.” 56 Such trauma is caused by violent rape and the forced
insertion of foreign objects, including guns, broken bottles, and sticks, into the vagina.
Due to the stigma of incontinence, coupled with the additional stigma of rape, women
with traumatic fistula are frequently ostracised by their families and communities.57,58
4.4 Unlike obstetric fistula, traumatic fistula cannot be considered a true maternal
morbidity unless it happens to occur during pregnancy or the immediate postpartum
period. Its consequences, however, are the same, and have a significant impact on
reproductive and maternal health. Recent estimates suggest that approximately two
million women are living with obstetric or traumatic fistula around the world, with
between 50,000 and 100,000 new cases emerging each year. Sexual violence has
persisted, and, some reports indicate, even escalated, in recent conflicts, resulting in its
definition as a war crime. Regions with particularly high numbers of traumatic fistula
5
survivors include Burundi, Chad, the Democratic Republic of Congo (DRC), Sudan,
Rwanda, Sierra Leone, Kenya, and Northern Uganda. Violent rape has been a
particularly salient feature of the ongoing war in the DRC, where nearly 15% of all
fistulae are the result of trauma. 59,60
4.5 Obstetric fistula can be prevented only by ensuring skilled attendance at birth and
increasing access to and utilisation of comprehensive EmOC, particularly Caesarean
sections. EmOC services cannot be provided without adequate numbers and levels of
staff who are appropriately trained, posted, and retained. One solution to the problem of
insufficient staff, or inappropriate distribution of staff, is the expansion of mid-level
providers’ capacity and authority to provide EmOC services. This strategy of training
mid-level providers has been extremely successful in countries such as Mozambique,
Tanzania, and Malawi. In Mozambique, for example, surgical technicians perform more
than half of major obstetric surgeries in the country, including nearly all such surgeries in
rural hospitals, and with outcomes comparable to procedures performed by
physicians.61,62,63,64,65
4.6 Surgery can repair both obstetric and traumatic fistulae. In uncomplicated cases,
as many as nine in ten such surgeries are successful, although in complicated cases,
this number drops to six in ten. Unfortunately, with a cost of £160, surgical intervention
can be prohibitively expensive for many women. Urostomy, a procedure in which urine
is collected in a bag to prevent leakage, is an option for women who cannot afford
surgery and for women for whom surgery is not successful. However, the majority of
women living with fistula receive no treatment whatsoever, due to lack of knowledge or
lack of access to services. As is the case with other maternal morbidity, treatment of
fistula will only be attained through strengthened health systems.66,67
REQUIRED ACTIONS
5.1 The single most important task of organisations seeking to decrease death and
disability due to pregnancy and childbirth is to strengthen health systems at all levels –
especially at sub-national levels. A crucial component of this task will be to focus on the
systematic implementation of EmOC services, with equitable distribution to all women.
Only when this is achieved will the reduction of maternal morbidity and mortality become
a reality. AMDD, for example, has been able to help upgrade hundreds of existing
facilities to increase met need for EmOC and to significantly reduce direct obstetric case
fatality rates over the course of only a few years, through effective partnerships and a
systematic focus on improving facility, district, and national systems.68,69,70,71,72
5.2 Organisations must ensure that refugee and internally displaced women are
included in the prioritisation of services for women in developing countries. DFID is an
important donor to United Nations agencies and to humanitarian relief organisations, and
as such should encourage these organisations to include women in emergency settings
in plans for strengthening health systems. As a crucial component of this effort, safe
abortion services should be made available to women who have experienced sexual
violence in all areas in which rape constitutes grounds for abortion.
5.3 Needs assessments have shown that in many places, facilities exist but lack the
trained staff, essential drugs, equipment, and supplies to make them function as EmOC
6
facilities. In order to effectively strengthen health systems, donor agencies must
encourage the systematic upgrading of existing health centres and hospitals to provide
the full range of life-saving signal functions.73
5.4 Donors should encourage national governments, implementing organisations, and
policy-making bodies to expand the role of mid-level providers to provide good quality
EmOC, with requisite training and support, and within strengthened health systems.
5.5 DFID’s maternal health strategy appropriately focuses on the most critical
elements of maternal morbidity and mortality reduction, notably EmOC. Moreover, DFID
is a leader in this field, together with its partners in the International Health Partnership.
It is crucial that DFID maintain this evidence-based focus on what is needed to reduce
maternal morbidity and mortality. It is also crucial that DFID maintain, or expand, its
global leadership in maternal health.
5.6 Funding
The charge to strengthen health systems and all its components necessitates additional
funding; organisations such as DFID will be crucial to the success of the process of
strengthening health systems. There are several ways in which donor agencies can be
most efficient. First, they can make commitments to long-term investments. Second,
they can provide funding which complements national health programmes and ensures
donor harmonisation. Finally, stakeholders at every level should be included in plans for
funding. 74 DFID’s participation in the International Health Partnership will help to
accomplish these goals, and DFID should continue to pursue such collaborations.
5.7 In the 2007-2008 fiscal year, DFID spent nearly £3 billion on its Bilateral
Programme. Over £500 million, or 18%, of this was spent on the health sector,
representing an increase in funding from previous fiscal years.75 DFID has taken an
important step by pledging more than £50 million of funding to maternal health
programmes in 2008. However, the health sector requires additional support. Given
DFID’s strong strategy and leadership position, further spending is called for; DFID has
recognised that more than £7 billion are needed in order to provide basic health services
for all.76 In addition, ensuring that maternal health programmes are adequately funded
within the health system will help to prioritise services such as EmOC, family planning,
and safe abortion. Without additional funding and attention from DFID and other donors,
little, if any, progress will be made toward Millennium Development Goal 5, which calls
for the improvement of maternal health.
5.8 Donors have the obligation to challenge governments of countries suffering from
high maternal morbidity and mortality to redouble their efforts to improve maternal health
and reduce maternal death and disability. International organisations must work in
concert with national and sub-national actors in order to effect real change in maternal
morbidity and mortality.
5.9 Health care is not only a service provided to individuals, but also a basic human
right. As such, donors must support national governments in their progressive
realisation of this right, which includes involving civil society organisations and ensuring
that all women have access to good-quality pregnancy-related care.
7
5.10 Donors must also promote increased accountability at all levels of the health care
system, from health workers to donor agencies, in order to reach the common goal of
maternal morbidity reduction. DFID has made important progress toward this goal
through its participation in the International Initiative on Maternal Mortality and Human
Rights (IIMMHR). Further progress can be made through supporting non-governmental
organizations and networks that, like IIMMHR, focus on building constructive
accountability mechanisms related to maternal mortality and morbidity. As noted in the
Task Force on Child Health and Maternal Health’s progress report, “Accountability
should lie at the heart of the MDG initiative.” 77
Contact Details
Linda P. Fried, MD, MPH
Dean, Mailman School of Public Health
Columbia University
722 West 168th Street, 14th Floor
New York, NY 10032
Tel: +1 212-305-9300
Email: [email protected]
Allan Rosenfield, MD
Dean Emeritus, Mailman School of Public Health
Columbia University
722 West 168th Street
New York, NY 10032
Tel: +1 212-305-3929
Email: [email protected]
Lynn P. Freedman, JD, MPH
Professor of Clinical Population and Family Health
Director, Averting Maternal Death and Disability Program
Mailman School of Public Health, Columbia University
60 Haven Avenue, B3
New York, NY 10032
Tel: +1 212-304-5281
Email: [email protected]
Therese McGinn, DrPH
Director, RAISE Initiative
Associate Professor of Clinical Population and Family Health
Mailman School of Public Health Columbia University
60 Haven Avenue, B3
New York, NY 10032
Tel: +1 212-304-5224
Email: [email protected]
8
References
1
Bonetti, T. R., A. Erpelding, et al. (2004). "Listening to "felt needs": investigating genital prolapse
in western Nepal." Reprod Health Matters. 12(23): 166-75.
2 Bailey, P., A. Paxton, et al. (2006). "Measuring progress towards the MDG for maternal health:
including a measure of the health system's capacity to treat obstetric complications." Int J
Gynaecol Obstet. 93(3): 292-9. Epub 2006 Mar 6.
3 WHO, Unicef, & UNFPA (2004). "Maternal Mortality in 2000: Estimates developed by WHO,
Unicef, UNFPA." Geneva.
4 WHO, Unicef, & UNFPA (2004). "Maternal Mortality in 2000: Estimates developed by WHO,
Unicef, UNFPA." Geneva.
5 Vallely, L., Y. Ahmed, et al. (2005). "Postpartum maternal morbidity requiring hospital admission
in Lusaka, Zambia - a descriptive study." BMC Pregnancy Childbirth. 5(1): 1.
6 Liskin, L. S. (1992). "Maternal morbidity in developing countries: a review and comments." Int J
Gynaecol Obstet. 37(2): 77-87.
7 Ibid.
8 UNFPA. "Surviving Childbirth, But Enduring Chronic Ill-Health." Retrieved 16 September 2008,
from http://www.unfpa.org/mothers/morbidity.htm.
9 Vallely, L., Y. Ahmed, et al. (2005). "Postpartum maternal morbidity requiring hospital admission
in Lusaka, Zambia - a descriptive study." BMC Pregnancy Childbirth. 5(1): 1.
10 Mutyaba, S. T. and F. A. Mmiro (2001). "Maternal morbidity during labor in Mulago hospital." Int
J Gynaecol Obstet. 75(1): 79-80.
11 UNFPA. "Surviving Childbirth, But Enduring Chronic Ill-Health." Retrieved 16 September
2008, from http://www.unfpa.org/mothers/morbidity.htm.
12 Bailey, P., A. Paxton, et al. (2006). "Measuring progress towards the MDG for maternal health:
including a measure of the health system's capacity to treat obstetric complications." Int J
Gynaecol Obstet. 93(3): 292-9. Epub 2006 Mar 6.
13 UNFPA. "Surviving Childbirth, But Enduring Chronic Ill-Health." Retrieved 16 September
2008, from http://www.unfpa.org/mothers/morbidity.htm.
14 Earth, B. and S. Sthapit (2002). "Uterine prolapse in rural Nepal: gender and human rights
implications. A mandate for development." Culture, Health & Sexuality 4(3): 281-296.
15 Bonetti, T. R., A. Erpelding, et al. (2004). "Listening to "felt needs": investigating genital
prolapse in western Nepal." Reprod Health Matters. 12(23): 166-75.
16 Ibid.
17 Guariglia, L., B. Carducci, et al. (2005). "Uterine prolapse in pregnancy." Gynecol Obstet
Invest. 60(4): 192-4. Epub 2005 Jul 13.
18 Daskalakis, G., E. Lymberopoulos, et al. (2007). "Uterine prolapse complicating pregnancy."
Arch Gynecol Obstet. 276(4): 391-2. Epub 2007 Apr 4.
19 Earth, B. and S. Sthapit (2002). "Uterine prolapse in rural Nepal: gender and human rights
implications. A mandate for development." Culture, Health & Sexuality 4(3): 281-296.
20 Liskin, L. S. (1992). "Maternal morbidity in developing countries: a review and comments." Int J
Gynaecol Obstet. 37(2): 77-87.
21 Earth, B. and S. Sthapit (2002). "Uterine prolapse in rural Nepal: gender and human rights
implications. A mandate for development." Culture, Health & Sexuality 4(3): 281-296.
22 Bodner-Adler, B., C. Shrivastava, et al. (2007). "Risk factors for uterine prolapse in Nepal." Int
Urogynecol J Pelvic Floor Dysfunct. 18(11): 1343-6. Epub 2007 Mar 1.
23 Buchsbaum, G. M., E. E. Duecy, et al. (2006). "Pelvic organ prolapse in nulliparous women and
their parous sisters." Obstet Gynecol. 108(6): 1388-93.
24 Liskin, L. S. (1992). "Maternal morbidity in developing countries: a review and comments." Int J
Gynaecol Obstet. 37(2): 77-87.
25 Bonetti, T. R., A. Erpelding, et al. (2004). "Listening to "felt needs": investigating genital
prolapse in western Nepal." Reprod Health Matters. 12(23): 166-75.
9
26
Sze, E. H., G. B. Sherard, 3rd, et al. (2002). "Pregnancy, labor, delivery, and pelvic organ
prolapse." Obstet Gynecol. 100(5 Pt 1): 981-6.
27 UNFPA. "Traumatic Fistula – a factsheet." Retrieved 18 September 2008, from
http://www.google.com/url?sa=t&source=web&ct=res&cd=1&url=http%3A%2F%2Fwww.unfpa.or
g%2F16days%2Fdocuments%2Fpl_traumaticfistula.doc&ei=YXDSSLnmJaLSet6NI0K&usg=AFQjCNFwGWaLaD8zAvAIoJzLf3m9PGGfeA&sig2=5ELStPWzNuylZXW6ykt5LQ.
28 Rana, T. G., B. D. Chataut, et al. (2007). "Strengthening emergency obstetric care in Nepal:
The Women's Right to Life and Health Project (WRLHP)." Int J Gynaecol Obstet. 98(3): 271-7.
Epub 2007 Jun 29.
29 Unicef (2008). Tracking Progress in Maternal, Newborn & Child Survival: The 2008 Report.
New York.
30 WHO, U., & UNFPA (2004). Maternal Mortality in 2000: Estimates developed by WHO, Unicef,
and UNFPA. Geneva.
31 IRIN. "NEPAL: More than 600,000 women suffer uterine prolapses " Retrieved 17 September
2008, from http://www.irinnews.org/report.aspx?ReportId=71244.
32 Bodner-Adler, B., C. Shrivastava, et al. (2007). "Risk factors for uterine prolapse in Nepal." Int
Urogynecol J Pelvic Floor Dysfunct. 18(11): 1343-6. Epub 2007 Mar 1.
33 Bhusal, K. (2007). Prolapse Is Leading Cause of Poor Health in Women. The Press Institute for
Women in the Developing World.
34 Liskin, L. S. (1992). "Maternal morbidity in developing countries: a review and comments." Int J
Gynaecol Obstet. 37(2): 77-87.
35 UNFPA. "Surviving Childbirth, But Enduring Chronic Ill-Health." Retrieved 16 September
2008, from http://www.unfpa.org/mothers/morbidity.htm.
36 Earth, B. and S. Sthapit (2002). "Uterine prolapse in rural Nepal: gender and human rights
implications. A mandate for development." Culture, Health & Sexuality 4(3): 281-296.
37 Bodner-Adler, B., C. Shrivastava, et al. (2007). "Risk factors for uterine prolapse in Nepal." Int
Urogynecol J Pelvic Floor Dysfunct. 18(11): 1343-6. Epub 2007 Mar 1.
38 Bhusal, K. (2007). Prolapse Is Leading Cause of Poor Health in Women. The Press Institute for
Women in the Developing World.
39 Bonetti, T. R., A. Erpelding, et al. (2004). "Listening to "felt needs": investigating genital
prolapse in western Nepal." Reprod Health Matters. 12(23): 166-75.
40 Ibid.
41 IRIN. "NEPAL: More than 600,000 women suffer uterine prolapses " Retrieved 17 September
2008, from http://www.irinnews.org/report.aspx?ReportId=71244.
42 UNFPA. "Surviving Childbirth, But Enduring Chronic Ill-Health." Retrieved 16 September
2008, from http://www.unfpa.org/mothers/morbidity.htm.
43 Ibid.
44 Earth, B. and S. Sthapit (2002). "Uterine prolapse in rural Nepal: gender and human rights
implications. A mandate for development." Culture, Health & Sexuality 4(3): 281-296.
45 Bhusal, K. (2007). Prolapse Is Leading Cause of Poor Health in Women. The Press Institute for
Women in the Developing World.
46 Ibid.
47 Earth, B. and S. Sthapit (2002). "Uterine prolapse in rural Nepal: gender and human rights
implications. A mandate for development." Culture, Health & Sexuality 4(3): 281-296.
48 Bodner-Adler, B., C. Shrivastava, et al. (2007). "Risk factors for uterine prolapse in Nepal." Int
Urogynecol J Pelvic Floor Dysfunct. 18(11): 1343-6. Epub 2007 Mar 1.
49 IRIN. "NEPAL: More than 600,000 women suffer uterine prolapses " Retrieved 17 September
2008, from http://www.irinnews.org/report.aspx?ReportId=71244.
50 Fortney, J. A. and J. B. Smith (1999). Measuring Maternal Morbidity. Safe Motherhood
initiatives: critical issues. M. Berer and T. S. Ravindran. Oxford, England, Blackwell Science
(Reproductive Health Matters): 43-50.
51 Bonetti, T. R., A. Erpelding, et al. (2004). "Listening to "felt needs": investigating genital
prolapse in western Nepal." Reprod Health Matters. 12(23): 166-75.
10
52
Bodner-Adler, B., C. Shrivastava, et al. (2007). "Risk factors for uterine prolapse in Nepal." Int
Urogynecol J Pelvic Floor Dysfunct. 18(11): 1343-6. Epub 2007 Mar 1.
53 Save the Children (2002). State of the World's Mothers 2002: Mothers & Children in War &
Conflict. Washington, DC.
54 UNFPA. "Traumatic Fistula – a factsheet." Retrieved 18 September 2008, from
http://www.google.com/url?sa=t&source=web&ct=res&cd=1&url=http%3A%2F%2Fwww.unfpa.or
g%2F16days%2Fdocuments%2Fpl_traumaticfistula.doc&ei=YXDSSLnmJaLSet6NI0K&usg=AFQjCNFwGWaLaD8zAvAIoJzLf3m9PGGfeA&sig2=5ELStPWzNuylZXW6ykt5LQ.
55 Campain to End Fistula. "Frequently Asked Questions." Retrieved 18 September 2008, from
http://www.endfistula.org/q_a.htm.
56 UNFPA. "Traumatic Fistula – a factsheet." Retrieved 18 September 2008, from
http://www.google.com/url?sa=t&source=web&ct=res&cd=1&url=http%3A%2F%2Fwww.unfpa.or
g%2F16days%2Fdocuments%2Fpl_traumaticfistula.doc&ei=YXDSSLnmJaLSet6NI0K&usg=AFQjCNFwGWaLaD8zAvAIoJzLf3m9PGGfeA&sig2=5ELStPWzNuylZXW6ykt5LQ.
57 Ibid.
58 Campain to End Fistula. "Frequently Asked Questions." Retrieved 18 September 2008, from
http://www.endfistula.org/q_a.htm.
59 UNFPA. "Traumatic Fistula – a factsheet." Retrieved 18 September 2008, from
http://www.google.com/url?sa=t&source=web&ct=res&cd=1&url=http%3A%2F%2Fwww.unfpa.or
g%2F16days%2Fdocuments%2Fpl_traumaticfistula.doc&ei=YXDSSLnmJaLSet6NI0K&usg=AFQjCNFwGWaLaD8zAvAIoJzLf3m9PGGfeA&sig2=5ELStPWzNuylZXW6ykt5LQ.
60 Ibid.
61 Dovlo, D. (2004). "Using mid-level cadres as substitutes for internationally mobile health
professionals in Africa. A desk review." Hum Resour Health. 2(1): 7.
62 Chilopora, G., C. Pereira, et al. (2007). "Postoperative outcome of caesarean sections and
other major emergency obstetric surgery by clinical officers and medical officers in Malawi." Ibid.
5: 17.
63 Vaz, F., S. Bergstrom, et al. (1999). "Training medical assistants for surgery." Bull World Health
Organ. 77(8): 688-91.
64 Pereira, C., A. Cumbi, et al. (2007). "Meeting the need for emergency obstetric care in
Mozambique: work performance and histories of medical doctors and assistant medical officers."
Br J Obstet Gynaecol. In Press (DOI:10.1111/j.1471-0528.2007.01489.x).
65 Kruk, M. E., C. Pereira, et al. (2007). "Economic evaluation of surgically trained assistant
medical officers in performing major obstetric surgery in Mozambique." Br J Obstet Gynaecol
114: 1253-1260.
66 Campain to End Fistula. "Frequently Asked Questions." Retrieved 18 September 2008, from
http://www.endfistula.org/q_a.htm.
67 UNFPA. "Traumatic Fistula – a factsheet." Retrieved 18 September 2008, from
http://www.google.com/url?sa=t&source=web&ct=res&cd=1&url=http%3A%2F%2Fwww.unfpa.or
g%2F16days%2Fdocuments%2Fpl_traumaticfistula.doc&ei=YXDSSLnmJaLSet6NI0K&usg=AFQjCNFwGWaLaD8zAvAIoJzLf3m9PGGfeA&sig2=5ELStPWzNuylZXW6ykt5LQ.
68 AMDD (2006). "Averting Maternal Death and Disability Program Report 1999-2005." New York.
69 UN Millennium Project Task Force on Child Health and Maternal Health. (2005). “Who's got the
power? Transforming health systems for women and children." New York, UNDP.
70 Rana, T. G., B. D. Chataut, et al. (2007). "Strengthening emergency obstetric care in Nepal:
The Women's Right to Life and Health Project (WRLHP)." Int J Gynaecol Obstet. 98(3): 271-7.
Epub 2007 Jun 29.
71 Santos, C., D. Diante, Jr., et al. (2006). "Improving emergency obstetric care in Mozambique:
the story of Sofala." Ibid. 94(2): 190-201. Epub 2006 Jul 18.
72 Kayongo, M., E. Esquiche, et al. (2006). "Strengthening emergency obstetric care in Ayacucho,
Peru." 92(3): 299-307. Epub 2006 Jan 25.
73 Rosenfield, A., C. J. Min, et al. (2007). "Making motherhood safe in developing countries." N
Engl J Med. 356(14): 1395-7.
11
74
UN Millennium Project Task Force on Child Health and Maternal Health. (2005). "Who's got the
power? Transforming health systems for women and children." New York, UNDP.
75 DFID (2008). "DFID Annual Report 2008: Making It Happen." London.
76 International Development Committee (2008). Maternal Health: Fifth Report of Session 2007–
08. London, House of Commons.
77 UN Millennium Project Task Force on Child Health and Maternal Health. (2005). "Who's got the
power? Transforming health systems for women and children." New York, UNDP.
12
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