A Thematic Review of Challenges and Solutions
ringing down maternal morbidity and mortality rates and thereby improving reproductive health services has been a major concern in developing nations for the past few decades. In spite of adopting on the various measures and implementing new strategies, the adversity in maternal health has not been managed entirely. This thematic review is an attempt to briefly elaborate on the various challenges encountered in improving obstetrical critical care and also to outline potential solutions to these maternal health challenges.
Introduction and Epidemiological Evidence
Maternal mortality is a major concern in developing nations in
spite of various advancements in the medical field (Bajwa SK et al. 2010,
2012). WHO has laid down 2015 as the target year to bring down substantially
the level of maternal mortality in developing nations, though achieving this
objective so soon seems impossible.
in obstetrical critical care in developing countries is reflected in the fact
that these nations account for 99% of overall maternal mortality. The scenario is
worst in African and South Asian countries, where incidences of maternal deaths
reach almost two thirds of all the maternal deaths in the world. Only 0.2–0.9%
of total obstetrical patients may require intensive care unit (ICU) admission
in the US, which corresponds roughly to 40,000-120,000 women in association with
4.3 million births per year (Munnur U et al. 2005; Madan I et al. 2009). Similar
data from developing nations is difficult to derive but results from isolated
studies have shown very high mortality of obstetric patients admitted to the
ICU. Developing countries’ governments from time to time have implemented
numerous reproductive health policies and reproductive health programmes;
however, the statistical figures released by WHO for 2008 in relation to
emergency obstetrical critical care have portrayed a dismal picture. Emergency
medicine is still in its infancy days in South Asian and other developing
countries compared with developed nations like Australia, Canada, the US and
the UK (Fell DB et al. 2005; Fowler SJ 2005; Germain SJ et al. 2006; Madan I et
al. 2009). Improvement of obstetrical critical care in developing nations is studded
with numerous challenges and the implementation of concrete solutions is needed
(Tang LC et al. 1997; Dias de Souza et al. 2002; Karnad DR et al. 2004).
Challenges in Improving Obstetrical Critical Care
Numerous guidelines have been published by various international obstetrical and critical care societies but the successful application of these guidelines has been very difficult in developing nations (Bajwa SK et al. 2010; Bajwa SK et al. 2012). Also, to date there is no universal consensus on the adoption of a particular scoring system for critically ill obstetric patients (El-Solh AA et al. 1996; Penny G et al. 2007). The partial to complete failure of these implemented measures can be attributed to various factors, such as the following:
• Shortage of Quality Manpower
A poor patient to doctor ratio is a common dismal scenario in many
developing countries. At present, specialist intensive care services are
available only in few of the urban health centers of developing nations (Bajwa
SK et al. 2010). The concept of a dedicated obstetrical critical care unit has
come up recently and is yet to take momentum in these nations (Gupta S et al.
• Economic Constraints and Poverty
Countries of South Asia are experiencing a very bad gross domestic
product (GDP) ratio and poverty is discouraging an early treatment seeking
behaviour. It is only when a clinical condition gets out of control that people
in these poverty stricken populations approach medical service providers for
treatment (Bajwa SK et al. 2010). Many of these patients are so poor that
earning daily bread is a huge struggle let alone the bearing of expenses
incurred on critical care services.
• Illiteracy and Attitude
The lower literacy rate among populations of developing nations
has further increased the obstacles for delivering effective obstetrical
critical care services. The status of woman and the existence of gender bias in
these societies, with families strongly desiring a male baby, chiefly reflect
the mental attitude of the majority of the inhabitants of South Asia. This
discriminatory ideology of gender preference is responsible for a higher
incidence of septic abortions and other pregnancy related complications (Bajwa
SK et al. 2010).
• Lack of Clinical Awareness
Clinical awareness about the various ailments of pregnancy is
lacking in both literate and illiterate urban and rural populations. The
majority of these people do not take any symptom or disease during pregnancy
seriously and only when it reaches alarming proportions do they seek medical
advice (Perez A et al. 2006; Faponle AF et al. 2007; Baloch R et al. 2010).
This leads to delays in managing critically ill obstetric patients, thereby
increasing morbidity and mortality. These complications can be further enhanced
if such patients are treated by quacks which can create irreversible
• Transport and Communication Snags
Many villages and remote areas of both African and South Asian
countries are not properly connected with cities. As such, it becomes highly
difficult to transport critically ill obstetric patients to health centres for
timely intervention (Okafor UV et al. 2005; Baloch R et al. 2010). At times,
low affordability of communication gadgets and networks also
hampers the timely delivery of critical care health services (Guise JM 2007).
• Customs, Traditions and Socio-Behavioural Factors
Developing nations exhibit a wide variety of cultural and social
practices, which somehow are largely contradictory to evidence based approaches for management of pregnant patients. Due to these socio
behavioural attitudes, urgent medical and obstetrical care may suffer.
• Health Policies
In spite of these countries implementing various reproductive
health policies, not much visible improvement has been seen (Baloch R et al.
2010; Bajwa SK et al. 2010). Failure of these
policies can be attributed to various administrative, social, attitudinal,
economic and political factors, which are difficult to elaborate on in this
thematic review. These health policies and programmes should be reviewed
periodically in order to incorporate new plans and strategies.
• Lack of Coordinated Activities
One of the biggest reasons for partial to complete failure of
these health policies includes gross incoordination among different health
providers. The unavailability of clear-cut guidelines and protocols related to
obstetrical critical care is one of the major reasons for this. As such, treatment patterns are very
subjective and vary widely among different
setups. This is highly detrimental in
providing quality reproductive health
• Poor Antenatal Care
Various physiological and pathological fluctuations can be
experienced in the antenatal period. This mandates regular check-ups to ensure
a healthy mother and the delivery of a healthy baby. In the majority of
instances, parturients present to the health centres only during the late
stages of labour, without any previous antenatal check-up (Perez A et al. 2006;
Faponle AF et al. 2007). Such patients can have high morbidity and mortality if
they have comorbid diseases and obstetrical complications (Guise JM et al.
2007). In countries like India, one third of pregnant females never present
themselves for any kind of antenatal check-up. Statistical figures of National
Health and Family Survey, 2006, report that astonishingly a mere 7% of pregnant
females come for third trimester antenatal check-ups.
• Inadequate Medical Facilities
Besides shortages of qualified manpower and poor antenatal care,
inadequate medical facilities further compound the problem. In rural areas,
apathy is highlighted by the fact that not many facilities and drugs for
managing critically ill obstetric patients are available at the majority of
• Inadequate Infrastructure
The majority of the population in developing nations resides in
rural areas, but most tertiary care centers and bigger hospitals and institutes
are located in urban areas. As such, rural health infrastructure is grossly
deficient in managing critically ill patients. It is difficult for the
respective governments to set-up ICU’s amid the circumstances that prevail in
• Attitudinal Differences
Attitudinal differences are prevalent in all strata of society,
whether among the general public, opinion makers, policy makers, doctors or
paramedical staff. They arise because of previously mentioned factors such as
poverty, illiteracy, economic constraints, shortage of manpower and so on, and
they can be highly detrimental to delivering quality critical care services.
• Under-Reporting and Non-Reporting of Obstetrical Data
Developed nations have been able to adopt appropriate measures to
improve reproductive health services on the basis of data from observational,
retrospective and randomised prospective trials (Harris CM et al. 2002; Zeeman
GG et al. 2003). On the other hand, scarce and sporadic data from developing
nations has not been helpful in bringing any significant improvement in
reproductive health services as it reveals only partial to minimal information
regarding the actual state of obstetrical critical care. It becomes extremely
difficult for health administrators and policy makers to formulate and
implement appropriate corrective measures to bring an improvement in overall
The higher incidence of maternal mortality in developing nations is mainly due to severity of comorbid medical and surgical disorders which can complicate pregnancy by inflicting direct insults or leading to intensive care admissions. Various cardiac pathologies, respiratory disorders, haematological disturbances, endocrinological disorders, sepsis, altered metabolic profiles, neurological diseases, cerebro- vascular accidents, renal diseases, hepatic disorders, trauma and so on can be devastating to both mother and the foetus if not timely diagnosed and appropriately managed.
• ICU Challenges
Critically ill obstetric patients are usually young and have a good prognosis if timely therapeutic interventions are administered. This requires dedicated efforts from teams of obstetricians, anaesthesiologists, intensivists and pediatricians to plan and design the various structural and functional aspects of the obstetrical ICU.
• Political Unrest
The political situation of a country can have a direct and
indirect impact on the health services of these developing nations. The
ever-present political turmoil in South Asian and some African countries has
gradually upset the provision of qualitative delivery of obstetrical critical
Potential and Possible Solutions
To fulfill the targets set by WHO in decreasing maternal morbidity and mortality throughout the globe, concrete measures have to be taken, particularly in the developing nations with the highest maternal deaths. A multidisciplinary approach, coordinated and dedicated efforts from government officials, doctors, paramedical staff and most importantly active participation of society and the general public are required. Shortages of manpower can possibly be overcome by:
• Recruiting new specialists by giving various incentives;
• Implementing a rotation policy so as to deploy specialist doctors for a compulsory spell of at least two to three years in rural areas;.
• Giving higher pay scales and salaries to doctors posted in rural areas;
• Providing accommodation and other facilities at a minimum cost to doctors posted in rural areas;
• Regularly posting postgraduate students to these peripheral health centres on a monthly basis, under the supervision of a senior doctor; and
• Governments permitting the opening of new medical colleges only in rural areas.
times of economic recession and crisis, governmental responsibility to improve
health services is immense. Budget reallocation has to be done so as to direct
maximum funds towards the management of critical care services.
A higher literacy rate in society definitely contributes towards
reproductive health. Moreover, it becomes easy for doctors to make obstetrical patients
clinically aware about their present condition during an antenatal visit. All
patients with systemic diseases should be made aware of potential complications
associated with them. Diagnostic aids, prophylactic measures and therapeutic
interventions should be planned solely during these antenatal visits. Giving
the contact number of doctors can be of great help in case of an emergency. Looking
at customs, traditions and superstitions from a scientific angle can only be
achieved by spreading literacy levels throughout society.
Means of transportation and communication can be improved with
initiatives from the government. Free ambulances can be deployed at various
critical focal points, facilitating attendance to critically ill patients in
the shortest possible time. These ambulances should be equipped with facilities
for deliveries and neonatal resuscitation. Maternal and foetal monitoring
during transportation can have a significant positive impact on outcome
(Elliott JP et al. 1987). In addition, helpline numbers could be displayed on
the roadside, in newspapers and on television. Overall, improving logistical
operations and communication networks can bring significant change.
There is an acute need to strengthen health infrastructure at grass root levels so as to ensure timely implementation of the appropriate interventions. Simple early initiatives, close monitoring and symptomatic care can help drastically in reducing maternal morbidity and mortality. To improve obstetrical critical care health services, planning should involve representatives from both developed and developing nations. They should develop new consensus with the involvement of various international communities and societies that work for the improvement of reproductive health, in which they review prevailing health scenarios, socio-political circumstances and the availability of resources. The practical and feasible application of universal guidelines could be enabled, thus aiding the provision of quality care in high risk obstetrical emergencies.