I love maternal mortality. By that, of course, what I mean that I think it is a fascinating research question, one which has received far too little attention from researchers. Maternal mortality was common in both developed and developing countries as late the mid-1900s, but maternal mortality began to decline dramatically in most developed countries around the 1930s. Today maternal mortality is one of the most unjust and unequal measures of population health between the developed and developing world. Our best guess is that 99% of maternal deaths occur in developing countries.
I am reading a great book right now called “Death in Childbirth” by Irvine Loudon. Published in 1992, it is an international study of maternal mortality in the developed world from 1800-1950. I am a big fan of history, and think that understanding the declines in the developed world is key to developing more effective policies to reduce maternal mortality. Or at least, it is good to learn from our mistakes every now and again.
Eclampsia, known then as toxaemia, was among the leading causes of maternal death during the early twentieth century, then as now, the exact causes of eclampsia are largely unknown. I loved this quote regarding eclampsia:
“If the cause of a disease is unknown, renaming it not only reflects new theories, but produces an illusion of progress.”
Eclampsia is characterized by a period of increased blood pressure, known as pre-eclampsia, which may or may not lead to convulsions. It is relatively common, even today. At the time, blood pressure monitoring was not common and the disease was thought to be some sort of a toxic reaction to the placenta, hence the name. It eventually became known that high blood pressure was a predictor of this condition, so it was recommended that the blood pressure of women be monitored during pregnancy to screen for those who may develop eclampsia. From this recommendation, antenatal care was born.
Prior to this recommendation, antenatal care was rare. The use of antenatal care only became widespread during the period following the first world world, essentially during the 1920s. Antenatal care was instituted specifically to reduce maternal mortality from eclampsia, the other two major causes of maternal mortality at the time were puerperal sepsis and hemorrhage, both of which were mainly influenced by the care receiving during the delivery process. There was little evidence, however, that providing antenatal care did much to reduce maternal mortality, but as today, there was a feeling that it was necessary and providers were shunned if they did not provide such services.
Treatment of eclampsia, on the other hand, was a different ball game. Dozens of different treatments have been tried over the decades, from bleeding, to aspirin, to the Stronganoff treatment, which was fashionable throughout much of the early twentith century. It consisted of the following:
“The main features of the Stroganoff regime were very heavy sedation combined with magnesium sulphate, and the isolation of the patient in a darkened and totally quiet room where she was attended by staff tiptoeing in stockinged feet and peering in the dark. It was based on the theory that stimuli, auditory and visual, were the triggers of eclampsia. The method gained credence because it was so dramatic.”
Treatment today usually entails trying to lower the blood pressure of the mother, usually through the administration of a drug, such as magnesium sulphate, and early induction of labor. Eclampsia is harmful to both the mother and the child, and seems to resolve itself once the placenta is removed, so early labor is often induced, sometimes through caesarean section. Magnesium sulphate, one of the best drugs available to treat pre-eclampsia, is cheap and generally available. I have seen some research from Mexico recently that showed that it is rarely used appropriately in that setting.
If the screening for eclampsia is one of the main reasons for ensuring antenatal care, I would like to see more use of indicators to monitor how effective antenatal care is in addressing this issue. The DHS regularly collects data on whether the blood pressure of the mother was monitored, but I think it is whether pressure and urine were ever monitored, and reporting instead focuses on the number and timing of visits, and not whether these visits are high quality visits.Share on Facebook