Tag Archive | "risk reduction"

Crossing Streets and Maternal Death Risks (part 2)


Hong Kong footbridgeOf around 3.37 M pregnancies that occurred in 2008, 17% led to induced abortions and 14% to unwanted births—more than a million pregnancies that women did not want. Some 92% of these occurred while using no method of family planning, or relying on a traditional one like the withdrawal or rhythm.

The fist half of this article likened maternal risks to similar risks when crossing busy streets. Risk reduction can be done two ways. One, make the process safer. Two, avoid it whenever possible.

Family planning (FP) is the second way. Using artificial or natural methods, it is a means to avoid unintended pregnancies. Using the road crossing analogy, effective FP methods are like overpass walkways that government builds to keep people away from harm. In turn, people need to learn and choose to use them to be of any good.

Relative Risks

An overpass is safer for most people, but is not risk-free. Nothing in life is. The overpass stairs may be slippery. Snatchers may declare the site as their emerging market. Civil engineers may have been sloppy. An earthquake, lightning or bullet from a cop’s warning shot may just strike while you’re in the middle of it. You simply compare all these with the risk of matching your footwork with running vehicles.

The same weighing of risks and benefits apply to all FP methods. For example, users of combined pills do have an increased risk of venous thromboembolism (VTE), a blood clot in veins deep inside the body that is 1–2% fatal. Anti-RH folks have often used this to scare people. What they fail to mention is that drug regulatory agencies have concluded that the increase in absolute risk is small, and that pregnancy confers higher risks of getting VTE than pill use:

Condition Risk of VTE
Not using pills, not pregnant 5–10 cases per 100 000 women-years
Using the most common pill
(low-dose ethinylestradiol + levonorgestrel)
20 cases per 100 000 women-years of use
Pregnant 60 cases per 100 000 pregnancies

 

Contraindications

Using an overpass is also not safe for everyone. Someone on wheelchairs who will try the atrociously steep ramp at the Quezon Avenue-EDSA overpass will probably careen down and break more bones. Urging someone with fear of heights or an asthmatic attack to climb up is courting trouble. Other more sensible methods should simply be made available.

For FP methods and all other medicines, the user may have a condition which makes the drug or procedure riskier than usual. If the risks outweigh the benefits, the medicine is contraindicated, meaning not recommended for use. Since people have unique genetics, medical histories and current conditions, the decision can only be done on a case to case basis.

For example, natural family planning (NFP) is effective for motivated couples. If one or both do not want to use it, the method is contraindicated. The risk of pregnancy would be too high. If the husband is violently uncooperative, the woman gets no benefit at all while risking a whole range of harm. Using the same principles, combined pills are not prescribed to women with pre-existing hypertension because of increased risk of heart attack and stroke; or to women with pre-existing breast cancer because both natural and synthetic estrogens stimulate the proliferation of breast cells.

Policy Choices

“An ounce of prevention is worth a pound of cure” is something we learn in elementary school. When anti-RH folks profess to support safety through maternal care services and in the same breath denigrate the value of family planning, I yearn for the simple lessons of our grade school teachers. The anti-RH position is akin to banning overpass walkways, insisting that people rely on the natural ebb and flow of traffic to safely cross streets, and allaying their fears by saying there will be more hospitals to save and mend broken bodies.

The RH bill’s safe motherhood proposal is simple. Women who are pregnant by choice or circumstance should get the standard care that has made maternal deaths a rarity in many parts of the world. Women who do not want more children or want to postpone the next pregnancy should get the family planning method of their choice to avoid maternal risks altogether.

Make the process safer. Avoid risks whenever possible. Both are needed, both should be done.

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Crossing Streets and Maternal Death Risks


Busy street in ManilaCrossing a busy street and testing one’s agility against vehicles has inherent risks. To minimize these risks, we create structures and social rules such as traffic lights, pedestrian lanes, speed bumps and so on. We also minimize the frequency of exposure to risks. Using overpass walkways, avoiding unnecessary trips and creating better planned neighborhoods are some of the ways we reduce the number of times people and vehicles cross paths.

The reproductive health (RH) bill’s approach to reducing maternal deaths follows the same dual strategy: minimize risks and minimize exposure to risks.

A woman’s lifetime risk of maternal death is a product of two factors: the risk of death from each pregnancy and birth, and the number of times she gets pregnant. The most successful countries in the world have managed to bring down both, and some of our ASEAN neighbors are on the way to making maternal death a rare possibility in a woman’s lifetime (see chart below).

Lifetime risk of maternal death

Source: World Health Organization, UNICEF, UNFPA and The World Bank,
“Trends in maternal mortality: 1990 to 2008”, Annex 1 & Appendix 14, 2010.

 

To reduce the risk of death from each pregnancy, the RH bill mandates:

  • sufficient number of skilled birth attendants (SBAs, referring to midwives, nurses or doctors) that can provide antenatal, birthing and postnatal services (Sec. 5 in both House and Senate versions);
  • enough facilities, equipment, supplies and health personnel to provide emergency obstetric and neonatal care (Sec. 6 in both House and Senate versions);
  • the maximum level of PhilHealth benefits for women with obstetric complications (Sec. 14 in House version and 11 in Senate); and
  • a review process to learn lessons from maternal deaths that do occur (Sec. 9 in House version and 8 in Senate).

Opponents of RH have expressed mixed reactions to this aspect of the bill. Some have accepted it as beneficial and have focused instead on their key issues of contraception, abortion and sex education. Others have branded it as unnecessary or a mere sweetener because the government has been doing maternal health programs without a law; or maternal death is not among the top-10 causes of deaths; or both. To check these claims, let us look at a key indicator of safety during pregnancy and birth: skilled birth attendance.

If women lack access to SBAs, they rely on the hilot (traditional birth attendants) to manage their childbirth and the immediate period after delivery. Unfortunately, around three quarters of all maternal deaths occur during these critical times. A hilot does not have the skills or resources to save women from the usual complications like severe bleeding, convulsions, sepsis and obstructed labor. How a hilot can totally mess up with diagnosing a complication and acting promptly to forestall death can be seen in the documentary Olivia’s Story. Only 37 years old, she died on May 2, 2009 in a poor community in Malabon (yes, hilots ply their trade even in a city in the country’s metropolis) after delivering her tenth child at home.

In 1999, a special session of the UN General Assembly agreed to work towards raising the use of SBAs to 80% by 2005, 85% by 2010 and 90% by 2015. What has the Philippines achieved? In 2008, actual use of SBAs by all women was only 62%, and the poorest women had use rates of only 26% (see chart below).

Percentage use of SBA, Philippines

Source: Macro International Inc, 2011. MEASURE DHS STATcompiler.
http://www.measuredhs.com, June 14 2011.

 

Was the UN target too ambitious? No. Some of our ASEAN neighbors have proven that middle-income countries can attain the goal. Malaysia, Thailand and Vietnam have met or exceeded the target. Indonesia is behind but has performed better than the Philippines (see chart below).

Percentage use of SBAs, selected countries
Source: WHO, Women and Health, Health Service Coverage,
Global Health Observatory Data Repository, June 16, 2001.

The average Filipina receives less skilled maternal care than some of her ASEAN neighbors. Those who are poor receive hardly any care at all.

Yes, the country does have a maternal care program which has been in place since perhaps the elder Aquino government, which merely reinforces the point that “business as usual” won’t be enough. Having something going on does not mean policymakers cannot make it better funded and more effective, equitable and enforceable. It would be both wise and charitable for the anti-RH forces to concede this issue in the RH bill debates.

Part 2: Family Planning and Reducing Exposure to Risks

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