Nearly every minute, a woman dies somewhere in the world from complications arising during pregnancy and childbirth. This accounts for 350,000 to 500,000 maternal deaths each year, many of which are preventable (1,2). More women’s lives are lost every year during childbirth than deaths that resulted from the 2004 Asian tsunami and the 2010 Haitian earthquake combined. Yet unlike natural disasters, maternal mortality receives relatively little media attention. Maternal mortality remains a silent disaster of wide-scale proportion. This chapter seeks to call attention to this silent crisis by offering a discussion of maternal death, the roles and challenges of anesthesia provision, and the impact of current anesthesia outreach projects and educational missions. In an effort to promote greater understanding throughout this discussion, the following key terms are defined, as they are pertinent to this offering of global perspectives on obstetric anesthesia.

Maternal mortality is considered a basic health indicator that reflects the overall adequacy of a country’s healthcare system. While maternal mortality has dramatically decreased in industrialized nations over the past 80 years, this has not occurred in many low- and middle-income countries (LMICs). The disparity between countries is extreme (Fig. 47-1) (1,2). The MMR is <25/100,000 in the United States, Canada, and UK; 280/100,000 in South Central Asia; 640/100,000 in sub-Saharan Africa; and an overwhelming 1,400/100,000 in Afghanistan resulting in a range of lifetime risk of maternal death of 1 in 7,600 compared to 1 in 11 (Table 47-1) (2).

In 2008, eleven countries including Afghanistan, Bangladesh, the Democratic Republic of Congo, Ethiopia, India, Indonesia, Kenya, Nigeria, Pakistan, Sudan, and Tanzania comprised 65% of all maternal deaths (2). Over the past decade, the worldwide distribution pattern of maternal mortality has remained relatively consistent, although the absolute numbers have declined since 1990 (Fig. 47-2) (1,2). This is somewhat unclear, however, because gross underestimates of maternal death are likely in countries where death rates are the highest due to poorly developed data collection and death registration systems (3).

For every maternal death, it is estimated that 30 women suffer morbidity such as chronic anemia, stress incontinence, infertility, vaginal fistulae, chronic pelvic pain, emotional depression, and/or physical exhaustion. Maternal death is also frequently associated with fetal and neonatal death, with conservative worldwide estimates predicting approximately 3.7 million neonatal deaths and 3.3 million stillbirths each year (4). The persistence of high maternal mortality and morbidity in developing countries represents a pervasive neglect of women’s most fundamental human rights. Such neglect primarily affects poor, disadvantaged, and powerless women in a continuum of pain and suffering.

Maternal mortality is not just a woman’s problem. In many circumstances, women financially support and maintain the cultural traditions of their families. The premature death of a mother deeply penetrates into a community’s social and cultural fiber, placing burden not only on the individual family but also on society as a whole. Maternal death in dependent societies often negatively impacts other vulnerable family members such as infants, young children, and the elderly.

In September 2000, a declaration was adopted by 189 nations during the United Nations Millennium Summit to heighten awareness of global economic and health disparity. Eight Millennium Development Goals (MDGs) were created to be achieved by 2015 (Fig. 47-3). MDG 5 calls for a 75% reduction of maternal death by 2015—which would require an annual 5.5% decline. Globally, this decline has only been 2.5% since 1990 (5). Among countries with the highest MMR, 30 have made poor progress; 23 of these are in sub-Saharan Africa. One challenge has been in obtaining accurate data. A number of agencies, including the World Health Organization (WHO), the United Nations International Children’s Fund (UNICEF), the United Nations Fund for Population Activities (UNFPA), and the World Bank are collaborating to provide accurate statistics.

The UN Millennium Project identified four broad categories to explain why countries are failing to meet MDGs. These include poor governance, poverty traps, poverty pockets, and policy neglect (6). With poor governance, low-income countries fail to provide citizens equal protection under the law. Corruption, mismanagement, and economic instability are rampant. Even many well-intentioned governments have insufficient human resources and infrastructure to maintain effective public services that include healthcare.

Second, poverty traps prevent society from carrying out initiatives to overcome hunger, disease, and infrastructure frailty
in order to achieve economic stability. A vicious cycle ensues whereby poverty results in low rates of savings, tax revenues, and foreign investment and simultaneously high rates of violence, brain drain, population growth, and environmental degradation. Poverty traps are common where geographical conditions are unfavorable. In sub-Saharan Africa, for example, poor road infrastructure, through difficult terrain, produces high transportation cost that limits commerce. Tropical diseases (such as malaria) and agricultural compromise, due to rain dependence in arid regions, are also problematic. One
key to ending the poverty trap is for high-income countries to help LMIC make the necessary investments in health, education, and basic infrastructure (6). Sustainability of advancement is difficult, however, since developing countries usually lack scientific and technologic communities. Scientists, physicians, and engineers, chronically underfunded, emigrate in search of better employment opportunities elsewhere (7,8). Moreover, private companies focus their innovation activities on the problems and projects of high-income countries, where the financial returns are more likely.

Third, many countries are failing to achieve MDGs because of persistent poverty pockets. This occurs primarily in large middle-income countries such as Brazil, China, and Mexico that have extensive regional and ethnic diversities. Here governments fail to ensure that critical investments in infrastructure, human resources, and public services are channeled to rural areas or slums; therefore, these social groups are excluded from the political process and economic benefits.

Fourth, some MDGs are falling short due to policy neglect. Policymakers are either unaware of the challenges and solutions or neglect core public issues. Throughout the developing world, neglect is especially common with girls and women in regards to education, healthcare, and legal protection against violence. Reaching the MDGs would bring tremendous benefits worldwide (6).

Maternal deaths are described as direct when they result from conditions that are unique to pregnancy, or indirect when they arise from diseases that develop before or during pregnancy that are aggravated by the pregnant state (2). A new WHO classification system also includes unanticipated complications of management and unknown as causes of maternal death (9). Consistently, more than two-thirds of deaths result from direct causes including hemorrhage, preeclampsia, sepsis, unsafe abortion, and obstructed labor/uterine rupture (Fig. 47-4) (10). Another 20% arise from indirect causes related to preexisting conditions such as malaria causing severe anemia, human immunodeficiency virus (HIV), and hepatitis. Women are most susceptible to complications and death during the third trimester through the week following delivery; however, risk is highest between delivery and the second postpartum day (10). These statistics suggest that supervision and care during this critical time period may help reduce maternal death.

In many urban areas, maternal deaths occur in hospitals. Three typical presenting scenarios include: (i) Women arrive moribund, too late to benefit from any emergency care; (ii) women arrive with complications that could have been prevented had they received timely and effective interventions; and (iii) women arrive for normal delivery that subsequently develop
serious complications, either naturally or through iatrogenic factors, and die with or without having received emergency care (10). The latter two scenarios raise concerns regarding the quality of hospital care. Numerous studies have shown that delays in recognition and treatment of life-threatening complications, as well as substandard practices, contribute directly to maternal deaths (11,12). In cases where women arrive in a moribund state, it is likely that problems exist with referrals between facilities, or there are community barriers—which might be physical, cultural, or financial—to accessing care (10,13).

Community barriers include late recognition, by women and families of the need to seek care that is either intentional or unintentional, and transportation difficulties in reaching hospitals (13). Most women labor in their houses for several days and go to hospital only as a last resort because delivery is considered “natural,” not as an “illness” requiring hospitalization. Unfortunately, death during labor or delivery may also be accepted as normal and inevitable (13). In addition, a lack of health education and/or poor reputation of health care facilities leave many patients unconvinced or frankly afraid of the value of modern obstetric management (13,14). A woman may deliberately stay in the house hoping to achieve normal vaginal delivery. A random questionnaire administered to a group of rural women in the Akosombo district of Ghana revealed that about 70% of women associated hospital confinement with severe discomfort, especially related to cesarean delivery (14). Others have a natural disinclination toward cesarean delivery because their peer groups insult them openly if they have been unable to deliver vaginally, considered the “natural” way (14). A lack of support and privacy in the hospital is a factor keeping some away and women may associate surgery with mortality (13). Furthermore, it is a status symbol to have large families and women believe that cesarean delivery will limit the number of children that they may bear (14). In some cultures, a pregnant woman with complications or a woman in labor cannot be taken to the hospital without the husband’s consent, further delaying care (13,14). These social issues, along with the physical impediments of travel to referral centers, put lives of the mother and the fetus in peril.

The poorest and most remote communities illustrate the highest magnitude of delay (Fig. 47-5). Elements we take for granted, such as a passable road or gas to power a vehicle, are frequently absent and represent insurmountable barriers that result in untimely deaths. Some maternal deaths are so remote that the women are not even given the justice of becoming a statistic to be analyzed. In Egypt, the MMR was more than twice as high in the nomadic Frontier region than in the Metropolitan area (120 vs. 48 deaths per 100,000) (15). In Afghanistan, the differences are most striking, with mortality being 418/100,000 in the capital city of Kabul compared with 6,507/100,000 in the remote district of Ragh (16).

The enormity of this global crisis can be overwhelming to the point of creating inactivity. When one dissects the layers of problems, however, it boils down to few common needs: Access to a suitable facility to receive care, a sufficient number of competently trained medical staff, and a sustainable source of supplies and equipment.

The importance of trained anesthesia providers for achieving MDG 5 becomes apparent when one recognizes the necessity of surgery in managing obstetric emergencies. Obstetric anesthesia as a subspecialty does not exist in most developing countries, yet hospitals within most countries treat obstetric complications that require surgery, including obstructed labor, ruptured uterus, eclampsia, and hemorrhage (17). The WHO recommends a cesarean delivery rate of 5% to 10%; however, in sub-Saharan Africa, the rate is frequently less than 1%, due in part to poor availability of anesthesia personnel (18,19). In many parts of Asia and Africa, anesthesia is administered by the surgeon or inadequately trained nonphysician providers working alone (14,18). The most dire example is described in Afghanistan where maternal mortality rates are among the highest in the world (1,400 maternal deaths per 100,000 live births). In an article by Hill, an obstetrician practicing in Afghanistan, a single photo of her operating theater paints a big picture (Fig. 47-6) (20). Strikingly absent is the complete lack of anesthesia equipment. Anesthesia for cesarean delivery may simply consist of local infiltration by the surgeon with some physical and chemical (ketamine ± benzodiazepine) restrain provided by midwives or nurses (14,20).

As a medical specialty, anesthesia does not command much clout worldwide (17,19). Anesthesia providers are in extreme shortage throughout much of Africa and Asia (Fig. 47-7), and even within rural areas of developed countries (19,21,22,23,24). Physician anesthesiologists in developing countries often leave in search of more lucrative opportunities abroad (19,21) creating a situation known as “brain drain.” Currently in Uganda, for example, there are 14 physician anesthesiologists in a population of 30 million—approximately one anesthesiologist per every 2 million people (19). By comparison, in the United States, the ratio is 1:4,000 and in UK, 1:5,000. Most Ugandan anesthesia providers work in cities, in conditions that would still be considered austere by Western standards. Postgraduate training programs in Uganda remain unfilled because of difficulty recruiting and funding trainees. In 2010, there were only 12 anesthesia residents in training although 47 positions were available (21). The annual cost of training is approximately $3,500, nearly 10 times the estimated mean annual household income in Uganda (21). In neighboring Kenya (population 32 million), there are 120 anesthesiologists, but only 13 of these are employed in the public sector. The remainder works in private practice in the capital, Nairobi. There are several hundred surgeons at Kenyatta National Hospital, the national referral and teaching hospital, but only nine anesthesiologists (21).

In LMIC, the response to the critical shortage of anesthesia providers has varied. In general, it is common to reduce the required training period for medical practitioners or to create opportunities for nonmedical personnel to conduct anesthesia. As a result, the backgrounds of anesthesia providers across the world vary dramatically. In Africa, anesthesia is predominantly provided by nonphysicians, usually as nurse anesthetists or clinical officers, some with up to 2 years of clinical training and others with no formal training—just on the job experience (14,19,22,24). China has a large portion of its care given by nurse anesthetists (50% to 90%). In some areas of central Asia (e.g., Mongolia), physician anesthesiologists are the norm and paramedical providers virtually unheard of (24). India is unique because subspecialty trained anesthesiologists can provide services for liver transplant a few miles away from a sparsely staffed community health center where anesthesia is given by the surgeon either in the form of local infiltration or a spinal, then monitored by an untrained nurse (25). India has not allowed training of nurse anesthetists or medical officers, despite a critical shortage of anesthesia providers in rural areas. India has an MMR of 540/100,000 live births. Given the enormous Indian population, this country alone may represent more than 20% of all maternal deaths (25).

Many global initiatives are striving to improve emergency obstetrical services, and these, by necessity, should also include a model of safe anesthesia care (18,23,26,27,28). Anesthesia significantly contributes to maternal mortality and is associated with as many as 3% to 9% of hospital-based maternal deaths each year in developing countries (12,22,23,26,29,30,31). Considering the high number of maternal deaths in many countries, the impact of anesthesia is real.