- Severe bleeding
- Unsafe abortion
- Obstructed labor
- Obstetric fistula
Severe bleeding in pregnancy is defined as any blood loss of more than 500mL within 24 hours after birth. It results from failure of the uterus to contract, genital tract trauma, rupture of the uterus, retained placental tissue, or maternal bleeding disorders. While there is no dearth to the medical management of PPH, there will be cases of severe bleeding that will ultimately require surgical management with considerable success rate.
Unsafe abortion is the “termination of unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both”. Each year, 42 million pregnancies are voluntarily terminated, 22 million within the legal system, and 20 million outside of it. In the latter case, abortions are performed by unskilled attendants or in unhygienic conditions. Only one in three abortions in developing countries occurs in safe conditions while 98% are unsafe. One in four of unsafe abortions will likely result in severe complications, even death.
The WHO and Guttmacher estimates that every year, 68,000 women die from unsafe abortions and between two to seven million women suffer from long-term damage of reproductive organs or disease. The WHO recognizes unsafe abortion as an entirely preventable major public health problem, due largely to unmet need for family planning, contraceptive failure, lack of information on contraception, and no access to safe abortion services, both medical and surgical.
An obstructed labor occurs when the passage of the fetus through the pelvis is impeded. Among the most common causes are: a large fetal head passing through a small pelvis, wrong position of the fetus while going through the birth canal, and fetal defects. Obstructed labor is a major cause of maternal mortality, accounting for 1–5 deaths/1000 live births. It is more common in developing countries due to lack of adequate health care delivery facilities, poor nutrition resulting in small pelves, poverty, and socioeconomic and cultural factors that are against traditional antenatal care and delivery. Obstructed labor causes significant morbidity and mortality both in the short-term and in the long-term. Fetal death is common. Obstructed labor requires emergency cesarean section, otherwise, the mother risks losing the baby and developing an obstetric fistula.
Obstetric fistula. An important long-term consequence of prolonged and obstructed labor is the development of an obstetric fistula, which is an abnormal opening between the vagina and urinary bladder or rectal wall. In the developing world, the true incidence of obstetric fistulas is unknown, as many patients suffer in silence and isolation. The WHO estimates that 50,000 to 100,000 women develop obstetric fistulas each year and that over two million women currently live with this disorder.
Obstetric fistulas can be treated with surgical reconstruction with a 90% success rate for uncomplicated cases and 60% success rate for complicated cases. The challenges involved in obstetric fistulas include the high volume of cases, access to facilities, and the cost of treatment. UNFPA estimates that the total cost for the procedure including post-operative care and rehabilitation support is USD 300. Another important challenge is informing women that treatment is available. Most women who develop fistulas isolate themselves from society for shame and embarrassment of their condition.