kAtAnYa……

25 Jun

Blog itu katanya tempat ngomel…. nanti lama-lama jadi pinter nulis…..

Masa sih?…. let’s try….. anggap ini omelan saya yg pertama…

Starting from ZERO…….

KaNgEn NuLiS….

4 Jun

Sudah lama rasanya tidak menyentuh blog yang satu ini. Kepulangan ke tanah air paska kuliah di negeri dongeng telah menenggelamkanku dalam pekerjaan yang tidak ada hentinya. Kangen menulis… jadi kangen kuliah…. tapi apa daya… pengabdian pada negeri ini harus ku berikan sebelum merubah status menjadi “Scholarship Seeker” lagi… hehehe…..

PNS yang dihujani banyak pekerjaan mungkin terdengar aneh bagi sebagian besar orang…. apa bener PNS bisa sibuk? bukannya PNS datang jam 10, jalan-jalan ke mall jam 12, dan pulang jam 2 siang? Believe it or not….. itu tidak terjadi di kantor tempat saya bekerja.

Pekerjaan yang paling baru dilakukan adalah PSPK atau sensus “SAPI”. Sapi di sensus?, Gimana nanyanya? Pasti tuh hewan ga bisa jawab … (kalo ada sapi yang bisa jawab, cepat-cepat lari yaa… hehehe). Katanya tujuan kerjaan itu untuk menghitung stok daging sapi dan kerbau untuk persiapan swasembada daging nasional di tahun 2014. … akan tetapi, berita-berita yang berhubungan dengan sapi belakangan ini sangat menggelitik telinga saya…..

Ternyata sapi bisa membuat orang berurusan dengan lembaga yang “sangar”… KPK… Seorang anggota dewan yang TERHORMAT tersandung masalah korupsi pengadaan sapi impor… mungkin ini membuktikan bahwa pangsa pasar sapi sangat menguntungkan…tapi jangan ditiru ya oknum yang satu ini…

Dilain pihak salah satu pejabat kita bilang kalo “Australia masih menganggap kita sebagai pasar sapi yang utama”… hal ini tercetus ketika Australia mendapatkan protes dari warganya yang merupakan pencinta binatang. Mereka melakukan investigasi langsung dan menyatakan bahwa sapi-sapi yang diimpor dari australia, begitu sampai di rumah jagal di Indonesia, disiksa dulu sebelum dibunuh.. (masa sih???).  Walhasil pemerintah Australia membatasi eksport sapi ke Indonesia. Mungkin saya yang terlalu naif… tapi melihat perkembangan itu, sepertinya bapak Pejabat itu sangat takut bila pemerintah Australia menghentikan ekspor sapinya ke Indonesia… lahhhh…. katanya mau swasembada sapi… gimana sih…???

Mungkin memang saatnya kita berhenti bergantung pada negara pengekspor sapi (Australia)… bayangkan .. 20 tahun terakhir kita sudah mengimpor 6,5 juta sapi hidup dari Australia….. (Maaf ya negeri paman Cock…. walaupun saya alumni dari negerimu…. Negaraku yang paling utama… hehehe).

Anyway….. saat petugas pendata sapi bingung dengan teori dan cara2 mensensus sapi, Instruktur yang bicara panjang lebar sampai bibir kering, dan panitia yang tidak tidur 2 hari untuk membuat persiapan….. eee…si Sapi dengan nyamannya makan rumput dan memandang dengan lirikan penuh arti ke ruang pelatihan…dan dia cuma bilang…. “Moooooo”…… hehehehe… Selamat mensensus sapi buat rekan-rekan di BPS.

Maternal mortality and maternal morbidity form the major parts of women’s health problems in developing countries

8 Sep

Introduction

One of the biggest problems on women’s health in developing countries is maternal mortality. Rosenfield and Maine recognized the problem as “a neglected tragedy”, because it had been the major cause of death among women in reproductive ages (Rosenfield & Maine 1985, cited in McCarthy & Maine 1992, p. 23). WHO has stated that each year, 500,000 women die from complication of pregnancy and childbirth, and the reduction of maternal mortality to three quartes has been stated as one of the millennium development goal (WHO 2005, cited in Kvale, at.al. 2005, p. 141).

Recently several researches and interventions have supported the safe motherhood initiative to reduce the number of maternal mortality (McCarthy & Maine 1992, p. 23). They have addressed the causes which are associated with maternal mortality in several categories. Obstetric, health services, reproductive, socioeconomic and transportation are believed to be the causes of maternal mortality (Maine, at. al. 1987; Royston & Armstrong 1989, cited in McCarthy & Maine 1992, p. 23).

This essay will discuss the factors associated with maternal mortality and maternal morbidity in developing countries and tries to find suggestions to overcome maternal mortality and maternal morbidity, as main problems for maternal health.

Maternal Mortality and Maternal Morbidity in Developing Countries

A woman’s death can be classified as maternal death if that woman was pregnant and experienced “some complication of pregnancy or childbirth, or having a pre-existing health problem that is aggravated by pregnancy” (McCarthy & Maine 1992, p. 24). Maternal mortality is a risk that women must face while pregnant. It is estimated that women who die because complications of pregnancy and childbirth have reached 500,000 persons each year and 99% of these deaths take place in developing countries (WHO 2005, cited in Kvale, et.al. 2005). In developing countries, women have to face 45 times higher risk of dying from pregnancy related complications, compare to women in developed countries (www.rho.org 2005).

The Factors associated with Maternal Mortality and Maternal Morbidity

McCarthy and Maine have introduced a framework for analysing determinants of maternal mortality and morbidity. This framework is the answer the question about model for determinants of maternal mortality. The framework contains three general stages of the process of maternal mortality; distant determinants, intermediate determinants and outcomes. Women’s socioeconomic and cultural status has influenced maternal mortality in the greatest distance. It will affect women’s health status, reproductive, access to health services and health care behaviour (intermediate determinant). Thus, the 4 set of intermediate determinants plus a set of unknown factors will directly influence the outcomes stage (McCarthy & Maine 1992, p. 24).

There is no maternal mortality without pregnancy and pregnancy is the starting point of outcome stages leading to maternal death, which can be classified as direct and indirect obstetric (McCarthy & Maine 1992, p. 25). Direct obstetric, such as complications of pregnancy, delivery, postpartum period, and abortion complication, are the main causes of maternal mortality (WHO 1985, cited in McCarthy & Maine 1992, p. 25).

Another cause of maternal health is haemorrhage. Figure 1 show 25 percent of maternal mortality in the world is caused by haemorrhage. On the other hand, poor hygiene during delivery or of untreated sexually transmitted diseases (STDs) will cause sepsis/infection. Careful attention to clean delivery and detection of STDs during pregnancy can restrain sepsis/infection.

Figure1. Causes of Maternal Deaths: Global Estimates

Source: WHO 1999

In several studies, the distance from health facilities is believed to be one of the causes of maternal mortality (Fortney, et.al. 1985; Walker, et.al. 1985, cited in McCarthy & Maine 1992, p. 27). The access to health services not only the distance but also financial access. In developing countries, financial barriers contribute to high maternal mortality (Ekwempu, et.al. 1990; Omu 1981; WHO 1985, cited in McCarthy & Maine 1992, p. 27). There are issues in women’s health in developing countries which are associated with maternal mortality; “the three phases of delay” (Thaddeus, et.al. 1994, cited in Kvale et.al. 2005, p. 143). The first phase is “failure of a patient to seek appropriate medical care in time”. In developing countries, the awareness about the importance of pregnancy care is less. The second phase is “delay in reaching an adequate health care facility” (Kvale et.al. 2005, p. 143). Low quality of road and bad transport system usually occur in developing countries and it is also the factors which cause maternal mortality. The development of transport system and improvement of road qualities between peripheral areas and health facilities can reduce maternal mortality (WHO 1991, cited in Kvale et.al. 2005, p. 143). The last phase is “delay in receiving adequate health care at the facility, including delay in referral”. In some developing countries, circumstances where there are no adequate health facilities are often take place. These circumstances make people unwilling to spend their money for reaching another health facility if they know that facilities cannot help them (Kvale et.al. 2005, p. 143). It is believed that the improvement in health system is more important than socioeconomic factors for the declining of maternal mortality (Kvale et.al. 2005, p. 143).

In developing countries, the fundamental determinant of maternal mortality is low status and economic status of women. It will limit access of women to education, good nutrition and health services (WHO 1999, p. 15). On the next stage, it will lead to maternal death. Several pregnant women in developing countries who have low level of education seem less likely to understand their health.

Many women in developing countries use traditional birth attendant in delivery. Sometimes, they only assist by family, relatives or even alone. These situations will risk their health. The assistance of health personnel such as doctor or midwife is only used by 53 percent of women in developing countries. WHO estimates that life-threatening complications that require emergency care will be experienced by 15 percent of pregnant women in developing countries (WHO 1999, p.16).

Women’s status is not the only variable which can influence maternal health. Family status is another determinant in maternal health. In developing countries, sometimes woman cannot access health services because she and her family have not sufficient income. More over, women and their families in developing countries ussualy have low education which can influence maternal health. For example, if a husband had low level of education, then he was not understood the important of accessing health facilities for pregnant women and he would not advice his wife to access health services.

Strategies to Reduce Maternal Mortality in Developing Countries

Political commitments from developing country governments are needed to reduce maternal mortality. Families, communities, health systems, and good will from government at any levels can support the program for reducing maternal mortality. The resources can be mobilized and policy decisions can be made if the top level of decision makers has resolved to address maternal mortality (WHO 1999, p. 22). The government must provide appropriate health services, cheap essential drugs and good transportation to facilitate women to access health services. It is almost impossible to reduce maternal mortality if women have difficulties to pay services and essential drugs. The government also have to provide information and elucidation about the important of family planning program and sex education for adolescents, especially for girls. Family planning program is necessary to limit and postpone pregnancy. It is important for a woman to know that she have to face high risk of death when she gives birth for more than 5 times or having parity less than 2 years.

It is believed that the support form individuals and a wide range of groups are needed to address maternal health, because that kind of supports is needed by women in obtaining access to essential health care. In developing countries, many women give birth without a skilled attendant but with their family or a relative. It is important for the government to trained members of community, so that they can recognise danger sign of delivery and able to develop plans for emergency (WHO 1999, p. 25). The communities may organize communication tools, such as radios, telephones and transportation for emergency cases, and even they can provide it with their financial support. On the other hand, it is better for the government to distribute cheap and simple kits to pregnant women for home births (WHO 1999, p. 25). In Developing countries especially in remote areas, several women use traditional birth attendants to help their delivery. Maternal death will occur if a woman uses untrained traditional birth attendants. When health facilities do not available, it is important to provide health training for traditional birth attendants.

Good quality of health services is essential variable to reduce maternal mortality. Moreover, women will be suffered if they found that health service did not provide pre-delivery health care. Maternal death can be avoided if a pregnant woman gradually visited health services in order to have health baby. Health services must provide family planning information, so that women, men, and young people will realise the importance of family planning. The information about risks of maternal death must be informed to women and men. Information such as delaying pregnancy after 2 years and sufficient age for women to pregnant will help them to design their future family. Information about adequate ages for women to pregnant is also important for adolescent girls, so that they realise the risk for them if having pregnancy in their age.

Conclusion

Several researches have address that maternal mortality is the main problem of developing countries. The WHO has stated that maternal mortality is one of the eight millennium development goal, it show that maternal mortality is a main target to be solved. Direct obstetrics have been the main causes of maternal mortality. On the other hand, indirect obstetric such as women’s health status, reproductive status, access to health services, health care behaviour and women’s socioeconomic and cultural are important variables in addressing maternal mortality. Strategic actions must be developed to reduce maternal mortality. Policy actions, such as political commitment from the government are needed to address the problem, while the support of families and communities are also important.

In health sector actions, it is important to provide health training for traditional birth attendants. On the other hand, good quality of health services is essential variable to reduce maternal mortality. Family planning information and information about risks of maternal death will bring people’s understanding about maternal health.

REFERENCES LIST

Kvale, G, Olsen, B.E, Hinderaker, S.G, Ulstein, M and Bergsjo, P. 2005, ‘Maternal Deaths in Developing Countries: A Preventable Tragedy’, Norsk Epidemiology, Vol. 15, No. 2, pp. 141-149, viewed 21 May 2008, < http://www.ub.ntnu.no/journals/norepid/2005-2/052_06_Kvale.pdf&gt;.

McCarthy, J and Maine, D. 1992, ‘A Framework for Analyzing the Determinants of Maternal Mortality’, Population Sudies, Vol. 23, No. 1, pp. 211-226, viewed 20 May 2008, in Jstor Online Academic Research Library, <http://www.jstor.org.ezproxy.flinders.edu.au/stable/pdfplus/1966825.pdf&gt;.

RHO Cervical Cancer. 2005, ‘Overview and Lessons Learned’, Safe Motherhood, viewed 24 May 2008, < http://www.rho.org/html/sm_overview.htm&gt;.

WHO. 1999, ‘Reduction of Maternal Mortality’, A Joint WHO/UNFPA/UNICEF/World Bank Statement, viewed 18 May 2008, < http://www.who.int/reproductive-health/publications/reduction_of_maternal_mortality/e_rmm.pdf >.

Can, and should child labour be totally abolished?

8 Sep

Introduction

Child labour is a crucial problem, because it engages with economic growth, poverty and cultures. An estimation from International Labour Organisation (ILO) states that almost 246 million children age 5-17 years are engaged in child labour. Then, 171 million of them were dealing with dangerous jobs, such as pesticides and chemicals, while 73 million of them are children under 10 years old. (Unicef 2006, p.46). The larger consumer of child labour is agriculture sector. For example, in Africa, child labour becomes ‘an urban phenomenon’, because child labour is found in large number in farming areas (Canagarajah & Nielsen 1999, p. 1).

Addressing the economic sectors, children often become a victim as cheap worker. They are paid lower then adult worker and do not have bargaining power against the employers. On the other hand, sometimes child workers have to work using pesticides and other chemicals, which harm their health. Similarly, they are loosing opportunities to access education, because their time mostly has been used to work. Consequently, these tragic situations make child labour have low education, ill-health and disability, and also will destroy children’s future, or they even will never know the future because the death risk in child labour.

Child labour

Children in reality have four options. First, they attend school and do not work, as ‘normal’ children. Second, they work and attend school. The third option is neither work nor attends school. And the last option is they work but do not attend school (Maitra & Ray 2000, p. 4). Child labour cases usually happen in the last option, while they have to work and cannot attend school. Children from low family income usually are forces to enter employment world. Children usually have not right to make a decision wether he want to work or not, because the decision maker usually is the household head who allocated the time for all household members (Canagarajah & Nielsen 1999, p. 5).

Addressing the child labour, employers seem to value children as irreplaceable workers because of their ‘nimble fingers’. For example, it is easier for children to make fine, hand-knotted carpets, or pluck jasmine flowers without breaking branches, rather than adult worker. Furthermore, employers prone to believe that child workers are ‘cost-effective labours due to their low salary level’ (Canagarajah & Nielsen 1999, p. 4). The other reasons why employers still hire child workers are less difficult to manage, easier to be ordered and to less complaining, and trustworthy at work (Levison et.al 1996; Anker & Barge 1998, cited in Canagarajah & Nielsen 1999, pp. 4-5). However child labour will influence children’s health and also will cause injury or even death.

Figure 1. Children in Unconditional Worst Forms*

of Child Labour and Exploitation

(thousands; 2000)

Child Labour and Health

Child workers have higher health risks than adult workers. It is caused by ‘physiological and psychological immaturity and the biological process of children’s growth’, which make children easier to injury and make children more sensitive to noise, heat, lead, and radiation (Bequele & Myers 1995; Forastieri 1997; ILO 1998; Fassa et al 2000, cited in O’Donnel, et al 2003, p. 3). Moreover, children have to face other health risks, such as dangerous tools and machines, chemicals from pesticides and infections while working on a farm (O’Donnel, et al 2003, p. 3). The UNICEF (2006, pp. 46-47) also states that children are easier to have illness and injuries than adult because their physical immaturity.

Child workers not only work in agriculture sector, but also in construction and mining. According to UNICEF (2006, p. 47), child workers have higher risks of injury while working in construction and mining, rather than in farming. 25 percent of boy workers and 35 percent of girl workers who work in construction sector, suffer work related injuries and illness, while 16 percent of boy workers and 20 percent of girls workers who work in mining sector, have the same experiences (UNICEF 2006, p. 47). Health problems are not the only consequence of child labour. Children’s education and overall well-being will be influences by child labour.

Child Labour, Education and Children Well-being

It is believed that being poor will increase the children’s probability to work and at the next stage will decline the probability to attend school (Deb & Rosati 2004, p. 15). Parents form poor families cannot afford to send their children to access school and sometimes they have no other options but sending their children to work. In contras, parents think that school attendance is inefficient, because these learning processes at schools are foregone in favour of work (Canagarajah & Nielsen 1999, p. 2). These conditions will create illiterate children. Education will provide children with basic skills, which are needed to find better job and to avoid poverty. Illiterate children will have a weak position in the future employment as an adult (UNICEF 2006, pp. 47-48). Consequently, it will lead them to poverty and will create a similar ‘child labour problem’ for their kids.

In addition, child workers are also vulnerable to physical and psychological harm and sexual abuse. Base on research in El Savador, 66 percent of girl workers experienced physically or psychologically abused and many of them experienced sexual abuse by employers (UNUCEF 2006, p. 51). However, the most important thing is that child labour has lost leisure time as a child. Such information about the effects of child labour have rise the question weather child labour should be totally abolished or not.

Child Labour, Abolished or Not?

The International Labour Organisation (ILO) conventions 138 and 182 define that ‘hazardous work’ islabour that jeopardises the physical, mental or moral well-being of a child’, which is categorised to be abolished (ILO 2002, cited in Rosati & Lyon 2006, p.2). Child labour should be abolished if dealing with dangerous works. However, to totally abolished child labour, is not a good decision. In some cases, children voluntary work to help their poor parents or to earn money for their poor families. If child labour is totally abolished, poor family cannot continue their live. The wise child labour policies are needed to answer these conditions.

Conclusion

Child labour is a complicated problem. In one hand, it has link with economic development processes, but on the other hand, it will affect children’s wellbeing. Children will lose their leisure times and opportunity to access education while working. Unfortunately, their leisure times and education are children basic needs to have better future. Moreover, children will experience ill-health. It also will influence their future health or even they have to face death as the worse risk.

However, it is almost impossible to totally abolished child labour. Sometimes children must help their family by working to earn money, and without that their families cannot continue their live. The policies to manage child labour are needed, so that the risk of child labour could be minimised.

REFERENCES LIST

Canagarajah, S, and Nielsen, H.S. 1999, ‘Child Labor and Schooling in Africa: A Comparative Study’, Social Protection Discussion Paper Series, No. 9916, pp. 1-30, viewed 18 June 2008, <http://siteresources.worldbank.org/SOCIALPROTECTION/Resources/SP-Discussion-papers/Child-Labor-DP/9916.pdf&gt;.

Deb, P, and Rosati, F. 2004, ‘Determinants of Child Labor and School Attendance: The Role of Househould Unobservables, pp. 1-33, viewed 18 June 2008, <http://urban.hunter.cuny.edu/RePEc/htr/papers/household_effects_3.pdf&gt;.

Maitra, P, and Ray, R. 2000, ‘The Joint Estimation of Child Participation in Schooling and Employment: Comparative Evidence from Three Contiments’, pp. 1-39, viewed 18 June 2008, <http://www.utas.edu.au/ecofin/Library/discussion_papers/papers_00/2000-08.pdf&gt;.

O’Donnel, O, Van Doorslaer, E and Rosati, F.C. 2003, ‘Health Effects of Children’s Work: Evidence from Vietnam’, Understanding Children’s Work Project Working Paper Series, pp. 1-32, viewed 18 June 2008, <http://www.ucw-project.org/pdf/publications/standard_child_work_health_final.pdf&gt;.

Rosati, F.C and Lyon, S. 2006, ‘Tackling Child Labour: Policy options for Achieving Sustainable Reductions in Children at Work’, Understanding Children’s Work Project Working Paper Series, pp. 1-11, viewed 18 June 2008, <http://www.ucw-project.org/pdf/publications/standard_policy_primer_25sept2007.pdf&gt;.

UNICEF. 2006, ‘The State of the World’s Children 2006’, pp. 1-146, viewed 18 June 2008, < http://www.unicef.org/sowc06/pdfs/sowc06_fullreport.pdf>.

What makes it too far to walk for pregnant women to reach a medical/health facility?

8 Sep

Introduction

Maternal mortality had been the major cause of death among women in reproductive ages (Rosenfield & Maine 1985, cited in McCarthy & Maine 1992, p. 23) and the major causes of that is by direct obstetric (WHO 1999, p. 13). However, punctual medical treatment is believed will avoid such death. This essay will point to the causes of delaying to seek a health service by women in developing countries base on the three phases of delay and discuss the factors which influence each phase of delay.

The Three Phases of Delay

Addressing the issues why pregnant women in developing countries often delay to seek health facilities, Thaddeus & Maine introduce ‘The Three Phases of Delay’ as the lens to describe the issues (Thaddeus & Maine 1990, p. 4).

a. Phase 1 Delay

Thaddeus & Maine define phase 1 delay as ‘delay in deciding to seek care on the part of the individual, the family, or both’. Distances, cost and quality of care, are the main factors which is commonly discussed and studied (Thaddeus & Maine 1990, p. 4).

The important role in phase 1 delay is ‘distance’ between the woman’s house and health facility. A study of Southern Iraq shows when the distance to a health care increased 2-4 kilometres, consultation rate per 100 sickness episodes for all health services declined dramatically from 100 to 42. These conditions describe that the decision to reach health facility is influenced by the distance which they have to travel from their house to a health facility (Thaddeus & Maine 1990, p. 9).

The financial cost of treatment is another variable which is important to be consider. A study from Nigeria shows a sharp decrease in obstetric admissions from 7,450 to 5,473 in the period 1983-1985 when the Nigerian government increased fees for prenatal and delivery. Addressing ‘opportunity cost’, a woman in Indonesia, usually decided to visit health facility accompanied by her younger children because nobody else who can look after their kid at home. It will spend additional cost, not only transportation fares, but also the provision of snacks for all (Foster 1977, cited in Thaddeus & Maine 1990, p. 15). These examples describe that if financial cost increase then the eagerness to seek health facility will decrease.

The quality of care is considered to be the important factor in the decision to seek care. The evaluation wether a health facility has a good quality of care is depends on patient’s experience and it will influence their willingness to use the health facility (Thaddeus & Maine 1990, p. 16). In rural area of Kenya, patients for all illness who use government clinic were 19%, while 41% of patients used a mission clinic. It was caused by the successful treated at mission clinic which succeed to treat 87% of their patients (Mwabu 1986, cited in Thaddeus & Maine 1990, p. 16). These evidences show that the patients’ satisfaction with the health outcome influences the decision to seek care. On the other hand, the study in Ecuador shows patients who dissatisfy with the health service received, such as delays in admission and long waiting times, tent to reluctant to use hospital (Finerman 1983, cited in Thaddeus & Maine 1990, pp. 17-18).

Illness factors such as recognition of illness, severity of an illness and aetiology, are also important factors in the decision to seek care. If the patients do not recognise that their illness is disease which may harmful their live, then they will not seek for medical care. In Ethiopia, it was difficult to remind that tapeworm infection which was common in Ethiopia is a disease and it influenced their decision to seek care (Kloos, et.al 1987 cited in Thaddeus & Maine 1990, p. 21). Phase 1 delay creates delays in reaching an adequate health care facility in phase 2.

b. Phase 2 Delay

Phase 2 delay is defined as ‘delay in reaching an adequate health care facility’ (Thaddeus & Maine 1990, p. 4). This phase plays a dual role in the process. First role is a disincentive as discuss in phase 1 delay, which influences people’s decision, and the second role, it describes the time spent in seeking a health facilities. The second role contains physical accessibility factors, such as distribution of health facilities, travel distance, transportation, and death on the way to hospital (Thaddeus & Maine 1990, p. 35).

In developing countries, distribution of health facilities is concentrated in large towns and it plans to serve rural areas (Thaddeus & Maine 1990, p. 36). Unfortunately, it does not function as planned. Conversely, it creates another problem such as travel distance between women and the closest health facility, which may delay people to seek health care. Rural patients in Ethiopia had to walk form 15 to 18 kilometres to reach the nearest medical services (Thaddeus & Maine 1990, p. 38). Lack of transportation and poor quality roads also influence the delay of reaching health facility. In Kenya, the improvement of the main roads decreased travel distance and time to seek a health facility. However, the improved roads which shorted the distance did not demonstrate improvement in using health facility because of other barriers such as cost of treatment limited the advantages of shorter distances (Thaddeus & Maine 1990, pp. 10-11). On the other hand, 65% of people in a rural area in Kenya had to walk to get health facility and 40% of them had to walk for 5 kilometres to reach the closest health service (Thaddeus & Maine 1990, p. 38). Moreover, patients sometimes have to face death on the way to the hospital. The evidence from two mainly rural areas of Turki shows in period 1975-1983, 8% of maternal death occurred on the way to the hospital (Dervisoglu 1985, cited in Thaddeus & Maine 1990, p. 40). Phase 1 delay and phase 2 delay create delays in receiving needed treatment in phase 3.

c. Phase 3 Delay

Phase 3 delay is defined as ‘delay in receiving adequate care at the facility’ (Thaddeus & Maine 1990, p. 4), which includes ill-staffed facilities and ill-equipped facilities. Lack of medical and nursing personnel will lead to delays in patients’ receiving care (Thaddeus & Maine 1990, p. 42). In Lusaka’s UTH, staff delays in taking patients to the operating room were associated with 4 from 80 maternal deaths (Hickey & Kasonde 1977, cited in Thaddeus & Maine 1990, p. 44). Similarly, uncompleted equipment and supplies of essential drugs are also associated with delays in receiving needed treatment. In Vietnam, 20 % of maternal deaths were related to the lack of essential drugs.

Priority Phase of Delay

The ‘Three Phases of Delay’ creates variation impact on different countries. Addressing the priority phase of delay, it depends on the factors which affect utilisation in the country, so that a ‘goodness of fit’ between real conditions and the intervention plans will occur.

Conclusion

In developing countries, most maternal mortality could be avoided by punctual medical treatment. Delay in deciding, reaching and receiving adequate care at the facility become the major factor in maternal mortality in developing countries. However, the ‘Three Phases of Delay’ can be use to create plan to reduce maternal mortality in developing countries.

REFERENCES LIST

McCarty, J and Maine, D. 1992, ‘A Framework for Analyzing the Determinants of Maternal Mortality’, Population Sudies, Vol. 23, No. 1, pp. 211-226, viewed 20 May 2008, in Jstor Online Academic Research Library, <http://www.jstor.org.ezproxy.flinders.edu.au/stable/pdfplus/1966825.pdf&gt;.

Thaddeus, S and Maine, D. 1990, Too Far To Walk: Maternal Mortality Context (Findings from a Multidisciplinary Literature Review), Center for Population and Family Health. Columbia University.

WHO. 1999, ‘Reduction of Maternal Mortality’, A Joint WHO/UNFPA/UNICEF/World Bank Statement, viewed 18 May 2008, < http://www.who.int/reproductive-health/publications/reduction_of_maternal_mortality/e_rmm.pdf >.

How does the health of Australian indigenous women compare with that of women in developing countries?

8 Sep

Introduction

According to Australian Bureau of Statistics, 2.5% of the total Australian population (517,200 people) were Indigenous people (ABS 2008 cited in Health Info Net 2008, p. 1). There is no doubt that the health status of Indigenous people is worse than non-Indigenous people. Consequently, Indigenous people have higher death rates than non-Indigenous (Pink & Allbon 2008, p. 151). Addressing indigenous women’s health, they experience high rate of maternal mortality, high fertility rates, high infant deaths, and low expectation of life at birth. However, similar health status also happens in most developing countries, which 500,000 women each year die from complication of pregnancy and childbirth, and the reduction of maternal mortality (WHO 2005, cited in Kvale, at.al. 2005, p. 141).

Indigenous Women’s Health Status

The maternal mortality rate for Indigenous women in 2000-2002 was 45.9 per 100,000. It means maternal mortality rate for Indigenous women was five times higher than maternal mortality rates for non-Indigenous women (aihw 2007, p.2). However, Pink and Allbon believes that incomplete data for indigenous status in death is the cause of high rate of indigenous maternal mortality. (Pink & Allbon 2008, p. 82). Similarly, the Australian Bureau of Statistics (ABS) states that in 1996-2001, the life expectancy at birth for indigenous women was 64.8 years or 17 years less than women in total population (Health Info Net 2008, p. 2). This statistics shows that indigenous women have lower life expectancy at birth than the expectation of 82.0 years for all Australian females in the same period (Fredericks 2007, p. 99).

Furthermore, indigenous women have high infant deaths (12.2 per 1,000 live births) in the period 2001-2005, compared with 4.89 infant deaths per 1,000 live births of non-indigenous women (indexmundi.com). Several causes such as worse conditions in peri-natal period, symptoms, signs and ill-defined conditions, congenital malformations, respiratory diseases, injury and poisoning, and infectious and parasitic diseases, were believed have an important role in the high infant deaths among indigenous women (Pink & Allbon 2008, p. 93). Along the same lines, Indigenous women also experienced higher total fertility rate (2.1) compared to 1.8 of total fertility rate (TFR) for non-indigenous women (ABS 2007, cited in Health Info Net 2008, p. 1).

Table. 1. Expectation of life at birth for Indigenous people and the total population,

Australia and selected States, 1996-2001

Causes of Death among Indigenous Women

According to Fredericks, Indigenous women experience less healthy than non-Indigenous Australian. (Fredericks 2007, p. 98). It is believed that circulatory diseases, injury, diabetes, chronic kidney diseases, external causes of morbidity and mortality, intentional self harm including suicide, assault, neoplasm, and respiratory diseases are the leading causes of death for indigenous women (Fredericks 2007, p. 98). The Australian bureau of Statistics states that 19% of injury which was experienced by indigenous women, were caused by assault and 17% were caused by intentional self-harm including suicide (ABS 2005, cited in Health Info Net 2008, p. 3). Similarly, respiratory diseases after pregnancy were also attributed to causes of death among indigenous women.

Woman Health Status: Australian Indigenous and Developing Countries

Women in developing countries are also experience similar health status to indigenous women, even worse. According to UNFPA, the total fertility rate (TFR) in Indonesia is 2.7 lifetime births per woman. This figure is higher than 2.1 TFR for Australian indigenous women. However, 2.7 lifetime births per woman in Indonesia is the result of 50% decrease in TFR in 1970s (UNFPA n.d). Moreover, maternal mortality ratio (MMR) in Indonesia is currently 230 per 100,000 live births. Even though MMR in Indonesia is higher than 45.9 per 100,000 live births for indigenous women in 2000-2002, it is still lower than MMR for developing countries in general (450 per 100,000 live births). Indonesia has lower infant mortality (38.2 per 1,000 live births), compared to12.2 per 1,000 live births for indigenous. On the other hand, life expectancy at birth for female in Indonesia is 69.5 years, which is higher than life expectancy at birth for indigenous women 65 years (UNFPA n.d).

Conclusion

Indigenous woman’s health status is worse than non-Indigenous woman’s health. Indigenous women experience higher rate of maternal mortality, higher fertility rate, higher infant deaths, and lower expectation of life at birth compared to non-Indigenous woman. However, these conditions are better if compared to developing countries, which experience lower women’s health status.

REFERENCES LIST

Australian Indigenous HealthInfoNet. 2008, ‘Summary of Australian Indigenous health 2008’, pp. 1-8, viewed 25 June 2008, <http://www.healthinfonet.ecu.edu.au/html/html_keyfacts/2008Summary.pdf>

Australian Institute of Health and Welfare. 2007, ‘Maternal Mortality’, pp. 384-387, viewed 25 June 2008, http://www.aihw.gov.au/publications/ihw/atsihpf06r/atsihpf06r-c01-23.pdf

Fredericks, B. 2007, ‘Australian Aboriginal Women’s Health: Reflecting on the Past and Present’, Health and History, Vol. 9, No. 2, pp. 93-113, viewed 25 June 2008, <http://www.historycooperative.org/view.php>

Indexmundi, n.d, ‘Australia Infant mortality rate’, viewed 25 June 2008, <http://www.indexmundi.com/australia/infant_mortality_rate.html>

Kvale, G, Olsen, B.E, Hinderaker, S.G, Ulstein, M and Bergsjo, P. 2005, ‘Maternal Deaths in Developing Countries: A Preventable Tragedy’, Norsk Epidemiology, Vol. 15, No. 2, pp. 141-149, viewed 21 May 2008, <http://www.ub.ntnu.no/journals/norepid/2005-2/052_06_Kvale.pdf&gt;.

Pink, B and Allbon, P. 2008, ‘The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples 2008’, Australian Bureau of Statistics – Australian Institute of Health and Walfare, p. 1-291, viewed 24 June 2008, <http://www.aihw.gov.au/publications/ihw/hwaatsip08/hwaatsip08.pdf>.

UNFPA, n.d, ‘Overview Indonesia’, viewed 25 June 2008, <http://www.unfpa.org/worldwide/indicator.do?filter=getIndicatorValues>

Maternal Mortality in Developing Countries: The Unsolved Problem By: Ouceu Satyadipura

8 Sep

I. Introduction

Maternal mortality is one of the biggest problems on women’s health in developing countries. In 1985, Rosenfield and Maine called the problem as “a neglected tragedy”, because maternal mortality had been the major cause of death among women in reproductive ages (Rosenfield & Maine 1985, cited in McCarthy & Maine 1992, p. 23). WHO has predicted that 500,000 women each year die from complication of pregnancy and childbirth, and the reduction of maternal mortality to three quartes has been stated as one of the millennium development goal (WHO 2005, cited in Kvale, at.al. 2005, p. 141).

Recently the safe motherhood initiative, which is supported by researches and interventions to reduce the number of maternal mortality, has been provided by many organisations (McCarthy & Maine 1992, p. 23). Several researches have addressed the causes which are associated with maternal mortality in several categories. Obstetric, health services, reproductive, socioeconomic and transportation are believed to be the causes of maternal mortality (Maine, at. al. 1987; Royston & Armstrong 1989, cited in McCarthy & Maine 1992, p. 23). The others have stressed their focus on the pregnancy complication process and various factors that influence women in delaying to seek medical care (Thaddeus & Maine 1990, cited in McCarthy & Maine 1992, p. 24).

This essay will point to the causes of maternal mortality and maternal morbidity and tries to find suggestions to overcome maternal mortality and maternal morbidity, as main problems for maternal health. The focus on this essay will be on the situation in developing countries where maternal mortality is really high.

II. Maternal Mortality and Maternal Morbidity

There is a big gulf in maternal mortality ratio level between developing and developed countries. According to the World Health Organization (WHO),

“Maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes” (World Health Organization 1999, cited in Dyer 2006)”.

A woman’s death can be classified as maternal death if that woman was pregnant and experienced “some complication of pregnancy or childbirth, or having a pre-existing health problem that is aggravated by pregnancy” (McCarthy & Maine 1992, p. 24). Maternal mortality is a risk that women must face while pregnant. Pregnancy should be a joyful moment for a woman, but unfortunately it becomes a dangerous time and threatening situation when a woman has to face complications of pregnancy and childbirth. It is estimated that women who die because complications of pregnancy and childbirth have reached 500,000 persons each year and 99% of these deaths take place in developing countries (WHO 2005, cited in Kvale, et.al. 2005).

Table 1. Women’s Lifetime Risk of Death from Pregnancy, 2000

Region (United Nations regions)

Risk of Death

Africa

1 in 20

Asia

1 in 94

Latin American & Caribbean

1 in 160

Oceania

1 in 83

Europe

1 in 2,400

Less developed regions

1 in 61

More developed regions

1 in 2,800

Worldwide

1 in 74

Source: AbouZahr & Wardlaw 2000

These facts show that women in developing countries have to face 45 times higher risk of dying from pregnancy related complications, compare to women in developed countries (www.rho.org 2005). Table 1 show that 1 in 61 women from developing countries have to encounter the risk of death from pregnancy in the year of 2000. In contras, only 1 in 2,800 women in developed countries have the similar risk.

Table 2. Estimates of MMR, number of maternal deaths, lifetime risk, and range of uncertainty by United Nations MDG regions, 2005

Source: United Nations Population Fund 2004

The UNFPA has estimated that maternal mortality ratio (MMR) in developing countries in 2005 is 450 per 100,000 life birth (Table 2). On the other hand, the Indonesian government in 2006 announced that maternal mortality ratio (MMR) in Indonesia (307 per 100,000 live births) was the highest in Asia. It claimed that the high level of MMR was caused by low education among women, malnutrition, culture, and low effort from government to minimize the number of maternal death (Kompas Newspaper 2006, cited in http://www.situs.kesrepro.info 2006).

Many researchers have considered the factors which is associated with maternal death. Some researchers claim that obstetric, health service, reproductive, socioeconomic, and transportation factors are the causes of maternal death (Maine, et.al. 1987; Royson & Amstrong 1989, cited in McCarthy & Maine 1992, p. 23). On the other hand, other researchers have stated that the causes of maternal death are pregnancy complication and delaying in seek medical services (Thaddeus & Maine 1990, cited in McCarthy & Maine 1992, p. 24). However, they have not developed frameworks for maternal mortality’s determinants. The framework is really important to explain and describe what are the causes of maternal mortality in detail.

III. A Framework for Maternal Mortality

It is important to understand the determinants of maternal mortality. McCarthy and Maine have introduced a framework for analysing determinants of maternal mortality and morbidity.

This framework is the answer the question about model for determinants of maternal mortality. The framework contains three general stages of the process of maternal mortality; distant determinants, intermediate determinants and outcomes. Women’s socioeconomic and cultural status has influenced maternal mortality in the greatest distance. It will affect women’s health status, reproductive, access to health services and health care behaviour (intermediate determinant). Thus, the 4 set of intermediate determinants plus a set of unknown factors will directly influence the outcomes stage (McCarthy & Maine 1992, p. 24).

Figure 1. Framework for Maternal Mortality

Health status

Reproductive status

Access to health services

Health care behaviour/use of health service

Unknown or unpredicted factors

Complication

Death/ disability

Pregnancy

Socioeconomic

&

cultural factors

Distant determinants

Intermediate determinants

Outcomes

Source: McCarthy & Maine 1992

IV. Causes of Maternal Mortality

A. Outcomes Stage

There is no maternal mortality without pregnancy and pregnancy is the starting point of outcome stages leading to maternal death, which can be classified as direct and indirect obstetric (McCarthy & Maine 1992, p. 25). Direct obstetric, such as complications of pregnancy, delivery, postpartum period, and abortion complication, are the main causes of maternal mortality (WHO 1985, cited in McCarthy & Maine 1992, p. 25). On the other hand, indirect obstetric is women’s health status, which can influence their pregnancy and it will be discussed in intermediate stage.

The major cause of maternal health is haemorrhage. A joint statement from the WHO, UNFPA, UNICEF, and World Bank in 1999 stated that 80 percent of maternal death is caused by direct obstetric (WHO 1999, p. 13).

Figure 2. Causes of Maternal Deaths: Global Estimates

Source: WHO 1999

Figure 2 show 25 percent of maternal mortality in the world is caused by haemorrhage, which is more dangerous when a woman has anaemia. Anaemia will lead to blood loss, and without blood transfusion, drugs to control bleeding, or appropriate saving care, it will lead to death (WHO 1999, p. 13). On the other hand, poor hygiene during delivery or of untreated sexually transmitted diseases (STDs) will cause sepsis/infection. Careful attention to clean delivery and detection of STDs during pregnancy can restrain sepsis/infection. Hypertensive disorders are the third biggest factor (12%) which is associated with maternal death. Obstructed labour is another cause of maternal death and it occurs when malnutrition is endemic (WHO 1999, pp. 13-14)

Table 3. Causes of Maternal Death in 1997-2002 (%)

Morbidity

Africa

Asia

Latin America

Direct Obstetric

Haemorrhage

33.9

30.8

20.8

Hypertensive disorders

9.1

9.1

25.7

Obstructed labour

4.1

9.4

13.4

Sepsis/infection

9.7

11.6

7.7

Abortion

3.9

5.7

12.0

Others direct causes

4.9

1.6

3.8

Total Direct Obstetric

65.6

68.2

83.4

Total indirect Obstetric

34.4

31.8

16.6

Source: The WHO 2005

The same pattern has occurred in developing countries. Table 3 shows that in Africa (33.9%), Asia (30.8%) and Latin America (20.8%) in 1997-2002, haemorrhage was the major cause of maternal mortality. In total, more than 65 percent of maternal mortality in developing countries was caused by direct obstetric. It is predicted that every year 20 million unsafe abortion have happened and 90 percent of that abortion is in developing countries (Kvale, et.al. 2005, p. 143).

There are no extensive researches on pregnancy and childbirth related with disability in developing countries. However, it is believed that chronic urinary tract infection, uterine prolapse, and vaginal fistulae responsible for serious disability and these will influence women’s physical and social well-being (Maine, et.al. 1987; Royson & Amstrong 1989, cited in McCarthy & Maine 1992, p. 26).

B. Intermediate Determinants

Women’s health status will influence their surviving from complication during pregnancy. Malaria, hepatitis, anemia, and malnutrition are the leading causes for 25% of maternal deaths in developing countries (McCarthy & Maine 1992, p. 27). These indirect obstetric in some circumstances will set a higher risk of direct complications of pregnancy. For example, malaria will lead pregnant women to anemia, which in the next stage will reduce women’s chance of surviving a haemorrhage (McCarthy & Maine 1992, p. 27). Not only women’s health status but also reproductive health (ages, parity and marital status), can influence maternal mortality.

The classic “J-shaped” relation is known as a strong relation between maternal mortality and reproductive health. The relation describe that very young women, older women, women with no children, and women who have many children, have high risk of maternal mortality. Disability as results from pregnancy and childbirth usually occur in very young age women (McCarthy & Maine 1992, p. 27). On the other hand, unwanted pregnancy is also important determinant of maternal mortality. A woman is likely to have an abortion if she has unwanted pregnancy even if unsafe abortion is the only available procedure, and it will lead to increase high risk of death and disability (Kwast & Liff 1988, cited in McCarthy & Maine 1992, p. 27)

In several studies, the distance from health facilities is believed to be one of the causes of maternal mortality (Fortney, et.al. 1985; Walker, et.al. 1985, cited in McCarthy & Maine 1992, p. 27). The access to health services not only the distance but also financial access. In developing countries, financial barriers contribute to high maternal mortality (Ekwempu, et.al. 1990; Omu 1981; WHO 1985, cited in McCarthy & Maine 1992, p. 27)

There are issues in women’s health in developing countries which are associated with maternal mortality; “the three phases of delay” (Thaddeus, et.al. 1994, cited in Kvale et.al. 2005, p. 143). The first phase is “failure of a patient to seek appropriate medical care in time”. It is important to give education about the importance of pregnancy care to both men and women (Kvale et.al. 2005, p. 143). This action, hopefully, will reduce maternal mortality. The second phase is “delay in reaching an adequate health care facility” (Kvale et.al. 2005, p. 143). This is often caused by low quality of road and bad transport system. The development of transport system and improvement of road qualities between peripheral areas and health facilities can reduce maternal mortality (WHO 1991, cited in Kvale et.al. 2005, p. 143). The last phase is “delay in receiving adequate health care at the facility, including delay in referral”. The first and second delays are influenced by the third phase. In circumstances where there are no adequate health facilities, people will not spend their money for reaching another health facility if they know that facilities cannot help them (Kvale et.al. 2005, p. 143). It is believed that the improvement in health system is more important than socioeconomic factors for the declining of maternal mortality (Kvale et.al. 2005, p. 143).

It is important for pregnant women to use health services either for prenatal care or care during and after delivery. The use of prenatal care and family planning are the most important proximate determinant of fertility. In developing countries, contraceptive use has replaced the use of traditional methods, which usually harmful for pregnant women (Obuekwe & Marchie).

In some circumstances, unknown or unpredicted factor can lead to maternal mortality. Women who have high education, good income, advance health and reproductive status, and have access to health services, may have serious obstetric complications and it cannot be predicted or explained. Similar to developed countries, in developing countries, this case is also difficult to estimate. In Zaire 1987, a study found that 71 percent cases of obstructed labour happened in women with “no known risk factor” (Kasogo Project Team 1987, cited in McCarthy & Maine 1992, p. 28)

C. Socioeconomic and Cultural Factors

Women’s education level, occupation, and income are associated with their status in family and community. The fundamental determinant of maternal mortality is low status and economic status of women. It will limit access of women to education, good nutrition and health services (WHO 1999, p. 15). On the next stage, it will lead to maternal death. Several pregnant women in developing countries who have high level of education seem more likely to understand their health. It will force them to access health services to make sure that she and her future baby are in health condition.

In developing countries, many women use traditional birth attendant in delivery. Sometimes, they only assist by family, relatives or even alone. The assistance of health personnel such as doctor or midwife is only used by 53 percent of women in developing countries. WHO estimates that life-threatening complications that require emergency care will be experienced by 15 percent of pregnant women in developing countries (WHO 1999, p.16).

Women’s status is not the only variable which can influence maternal health. Family status is another determinant in maternal health. A woman cannot access health services if she and her family have not sufficient income. Education of others is another variable which can influence maternal health. For example, if a husband had low level of education, then he was not understood the important of accessing health facilities for pregnant women and he would not advice his wife to access health services. It will increase the risk of maternal mortality.

V. Strategies to Reduce Maternal Mortality

A. Policy Actions

Coordinated systems and long-term efforts are needed to reduce maternal mortality. Families, communities, health systems, and good will from government at any levels must support the program for reducing maternal mortality. Political commitment from the government is needed. The resources can be mobilized and policy decisions can be made if the top level of decision makers has resolved to address maternal mortality (WHO 1999, p. 22). The government must provide appropriate health services, cheap essential drugs and good transportation to facilitate women to access health services. It is almost impossible to reduce maternal mortality if women have difficulties to pay services and essential drugs. The government also have to provide information and elucidation about the important of family planning program and sex education for adolescents, especially for girls. Family planing program is necessary to limit and postpone pregnancy. It is important for a woman to know that she have to face high risk of death when she gives birth for more than 5 times or having parity less than 2 years. The government must conduct a program to inform about this kind of information.

B. Society and Community Interventions

One of the keys to reduce maternal mortality is the support of families and communities. It is believed that the support form individuals and a wide range of groups are needed to address maternal health, because that kind of supports is needed by women in obtaining access to essential health care. In developing countries, many women give birth without a skilled attendant but with their family or a relative. It is important for the government to trained members of community, so that they can recognise danger sign of delivery and able to develop plans for emergency (WHO 1999, p. 25). The communities may organize communication tools, such as radios, telephones and transportation for emergency cases, and even they can provide it with their financial support. On the other hand, it is better for the government to distribute cheap and simple kits to pregnant women for home births (WHO 1999, p. 25).

In Developing countries especially in remote areas, several women use traditional birth attendants to help their delivery. Maternal death will occur if a woman uses untrained traditional birth attendants. When health facilities do not available, it is important to provide health training for traditional birth attendants.

C. Health Sector Actions

Good quality of health services is essential variable to reduce maternal mortality. Health services must provide family planning information, so that women, men, and young people will realise the importance of family planning. The information about risks of maternal death must be informed to women and men. Information such as delaying pregnancy after 2 years and sufficient age for women to pregnant will help them to design their future family. Information about adequate ages for women to pregnant is also important for adolescent girls, so that they realise the risk for them if having pregnancy in their age. This action in the next stage will reduce the number of abortion.

Maternal health services have to provide counselling and health care for women who have had an abortion (WHO 1999, p. 29). In countries where abortion is legal, it is important to provide the counselling and health care to reduce the chance of complications after abortion. Basic antenatal and postpartum care are important variables (WHO 1999, p. 29). Good health services for women in pregnancy and after delivery are essential. Maternal death can be avoided if a pregnant woman gradually visited health services in order to have health baby. On the other hand, women will be suffered if they found that health service did not provide pre-delivery health care.

VI. Conclusion

Several researches have address that maternal mortality is the main problem of developing countries. The WHO has stated that maternal mortality is one of the eight millennium development goal, it show that maternal mortality is a main target to be solved. Direct obstetrics have been the main causes of maternal mortality. On the other hand, indirect obstetric such as women’s health status, reproductive status, access to health services, health care behaviour and women’s socioeconomic and cultural are important variables in addressing maternal mortality. Strategic actions must be developed to reduce maternal mortality. Policy actions, such as political commitment from the government are needed to address the problem, while the support of families and communities are also important.

In health sector actions, it is important to provide health training for traditional birth attendants. On the other hand, good quality of health services is essential variable to reduce maternal mortality. Family planning information and information about risks of maternal death will bring people’s understanding about maternal health.

REFERENCES LIST

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Kvale, G, Olsen, B.E, Hinderaker, S.G, Ulstein, M and Bergsjo, P. 2005, ‘Maternal Deaths in Developing Countries: A Preventable Tragedy’, Norsk Epidemiology, Vol. 15, No. 2, pp. 141-149, viewed 21 May 2008, < http://www.ub.ntnu.no/journals/norepid/2005-2/052_06_Kvale.pdf&gt;.

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RHO Cervical Cancer. 2005, ‘Overview and Lessons Learned’, Safe Motherhood, viewed 24 May 2008, < http://www.rho.org/html/sm_overview.htm&gt;.

UNFPA. 2004, ‘Maternal Mortality Figures Show Limited Progress in Making Motherhood Safer’, Maternal Mortality Statistics, viewed 19 May 2008, <http://www.unfpa.org/mothers/statistics.htm&gt;.

WHO. 1999, ‘Reduction of Maternal Mortality’, A Joint WHO/UNFPA/UNICEF/World Bank Statement, viewed 18 May 2008, < http://www.who.int/reproductive-health/publications/reduction_of_maternal_mortality/e_rmm.pdf >.

WHO. 2005, ‘Causes of Maternal Death’, Epidemiology, viewed 18 May 2008, <http://www.who.int/reproductive-health/MNBH/epidemiology.html&gt;.