Q:1- One of the causes for maternal death is abortions inspite of having well organized family planning services in srilanka

Maternal Death

Definition:-

Maternal  death is the death of women while pregnant or within 42days of termination of pregnancy, irrespective of the duration and site of  pregnancy, from any cause related to or management but not from accidental or  incidental causes.

Abortion:-  It is the ending of pregnancy by removing a fetus or embryo before it can survive outside the uterus. An abortion that occurs spontaneously is also known as a miscarriage. An abortion may be caused purposely and is then called an induced abortion,or less frequently,”induced miscarriage”.

Introduction

Pregnancy places a women at some risk for illness and death.This risk may be  gladly assumed with the desired pregnancy.Unwanted pregnancy places  a  women at additional risk if she seeks abortion as safe services are not available.This risk may be varying from morbidity such as infertility to mortality.

Unsafe abortion is the 3^rd leading cause of maternal mortality worldwide. The World Health Organization identifies safe abortion care as one seven necessary intreventions to ensure quality reproductive, maternal and child health care. Ending death and injury from unsafe abortion is also one of the easiest goals to achieve – early-term abortion is a simple procedure and, when done by a trained provider, remarkably safe. 

The world health organization estimates that 25 to 50 percent of the 500,000 maternal deaths that occur every year result from illegal  abortion.Most of these deaths occur in undeveloped countries.     The data on preventable morbidity and mortality from septic abortion are staggering and documented.In srilanka,the maternal maortality ratio(MMR)- the number of maternal deaths per 100,000 live births in a given period was 32 in 2013.By contrast,the MMRs of some the country’s closest neighbors were much higher.

Mortality and morbidity from septic abortions are frequent in countries where the induced abortions are illegal or inaccessible. In srilanka induced abortion can be done legally only to save the life of the mother. Abortion related deaths primarily from sepsis. Infection usually begins as endometritis and involves the endometrium and any retained products of conception. If not treated,the infection may spread further into the myometrium and parametrium.The patient may develop bacteremia and sepsis at any stage of septic abortion. In this case, presence of highly virulent pseudomonas infection in the uterus can act as a focus of infection releasing endotoxins and exotoxins. This will cause systemic inflammatory response as a reaction to bacterial infection. Further release of vasoactive substances is associated with organ dysfuntion, hypoperfusion or hypotension, metabolic abnormalities, and microcirculatory failure leading to septic shock.

Methods of  unsafe abortion,

-Trying to break the amniotic sac inside the womb with a sharp object or wire.

-Pumping toxic mixures, such as chili peppers and chemicals like alum,lysol, permanganate, or plant poison into the body of women.

-Inducing an abortion without medical supervision by self-administering abortifacient over-the-counter drugs or drugs obtained illegally or by using drugs not indicated for abortion but known to result in miscarriage or uterine contraction.

Primary prevention of septic abortion,

-Provision of effective and acceptable contraception

-Provision of safe, legal abortion services in the case of contraceptive failure;and appropriate medical management  of abortion.

Secondary prevention,

Includes early detection and prompt treatment of disease, for example, acute cardiac care or myocardial infarction.

Tertiary prevention (rehabilitation),

Mitigates disability, an example being coronary artery bypass grafting.

In general, primary prevention is preferable to secondary and tertiary prevention in terms of both cost and compassion: immunising against poliomyelitis is better than building iron in lungs. Primary prevention includes reduction in the need for unsafe abortion through contraception, legalisation of abortion on request, the use of safer techniques, and improvement of provider skills. Access to safe, effective contraception can subtantially reduce- but never eliminate the need for abortion to reulate infertility.

Conclusion

Serious complications are resulted from illegal abortion causing mortality and morbidity. Reducing maternal mortality by preventing illegal abortion is a challenge. Mostly ethical, religious  and political obligations prevent discussion on health values to prevent maternal deaths from illegal abortions. Therefore we need to initiate a discussion among medical and legal community to reduce the number of maternal deaths from illegal abortions.

Q2:- Discuss existing maternal care model and the package in srilanka?

Antenatal care model currently used in Sri Lanka is the traditional multi-visit model; once a month up to 28weeks, fortnightly during 28-36weeks and weekly thereafter. The domiciliary care also follows the same model. Pregnant women are simultaneously receiving maternal care services at multiple settings example. Field clinic, hospital clinic, specialized care unit, and some even visits to obstetricians in the private sector. Therefore, altogether pregnant woman received 12-18 clinic visits and 8-10 home visits during antenatal period as more than 90% of women registered for antenatal care before 12 weeks. Postnatal care model consists of two home visits during 1st 10 days, one visit between 11-28 days, and one visit around 42 days (altogether 4 visits). This model also includes a postnatal clinic visit at 4-6 weeks. However, in contrast to antenatal clinic and domiciliary care coverage which is almost universal, only 80% of women receive at least one postnatal home visit. Postnatal clinic care is not well established in the country.

Though Sri Lanka has achieved effective service coverage in MCH/FP, the quality of service delivery needs further improvement in order to attain further reductions of maternal mortality and morbidity.

After considering the existing health policies and health care system in the country, achievements and gaps, ability of packaging evidence based interventions, client and service providers’ satisfaction, development in transport and communication, cost effectiveness and expectation of the public, the following model was developed to deliver evidence based interventions to reduce maternal and child mortality and mortality.

 

References:

-www.medrives.com

-world health organization.

-Maternal martality surveillance system in srilanka(Family Health Bureau)

-Maternal care package A guide to field Health care workers (Family Health Bureau-2011