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Is child survival enough?

Of the 200 million pregnancies which occur each year, at least 23 million develop serious complications such as post-partum haemorrhage, hypertensive disorders, eclampsia, puerperal sepsis, and abortion. Half a million of these complications result in the death of the mother. Over 20 million women undergo unsafe abortions with the attendant risks to life and health. Some 20 million women survive, but with a range of long-term disabilities including obstetric fistula, anaemia, uterine prolapse, endometritis, pelvic inflammatory disease, secondary infertility, paralysis, and kidney failure. The factors which cause these maternal deaths and disabilities are the same as, or greatly overlap with, those which cause the deaths and disabilities of newborn infants. Women and infants go through the drama of delivery together. Woman and fetus, mother and infant, should be seen as a dyad or duality—two units treated as one. The fate of the newborn is inextricably linked to the health of the mother before, and during pregnancy and delivery. Of the 3.9 million deaths of infants aged less than 1 month each year, 2.8 million occur within 1 week of delivery, largely as a consequence of poorly managed pregnancies and deliveries (Fig. 1). Poor maternal health and nutrition before and during pregnancy may result in low birth weight which puts the baby at risk of infection, hypothermia and asphyxia, and impeded growth and development. Inadequate care during pregnancy, especially failure to manage genital tract infections and sexually transmitted diseases can result in prematurity. Inappropriate management during delivery is a major cause of hypoxia. Nearly 4 million newborns suffer moderate to severe birth asphyxia resulting in some 800000 deaths with at least an equal number suffering complications or sequelae such as epilepsy, mental retardation, cerebral palsy, and learning disabilities. Poor hygiene during delivery and cord care can lead to neonatal tetanus which claims the lives of some 430000 newborns annually. Failure to maintain warmth of the newborn baby can lead to hypothermia and death (Fig. 2).