Where was the ‘M’ in tropical medicine?

Since the inception of the discipline ‘tropical’ medicine, its textbooks almost never paid any discernible attention to maternal health per se, even if it was obvious to all ‘tropical’ doctors that obstetric problems were – and are – extremely common and that the toll taken by maternal and neonatal ill health in the “tropics” was – and is – enormous . For decades, textbooks in tropical medicine have notoriously omitted obstetrics. This is strange as the vast majority of all maternal and perinatal deaths occur in ‘tropical’ countries.

As a ‘tropical’ doctor 40 years ago during the war in Angola (1975–76), the author discovered that studying textbooks in tropical medicine never gave any information on issues that are very prevalent in the ‘tropics’ such as eclampsia, obstructed labour, postpartum haemorrhage, maternal mortality or stillbirth. We can, for instance, certainly assume that any world epidemiology map of eclampsia incidence would be reasonably similar to the corresponding map of, for example, malaria. Still the word ‘eclampsia’ could never be encountered under ‘e’ in the index of textbooks in ‘tropical’ medicine.

From the beginning, specialists of ‘tropical’ medicine in European countries were not specialists in medical problems in the tropics but rather merely experts in ‘travel medicine’, essentially taking care of (homecoming) Europeans’ ‘tropical’ diseases. Of course, there were no homecoming travellers with eclampsia, obstructed labour or postpartum haemorrhage. So this bias is an important reminder of the character of textbooks in ‘tropical’ medicine 40–50 years ago and very often even today.

In fact, it is well known that several countries in the tropics – such as Cuba – have a ‘tropical’ disease pattern quite different from other countries at similar latitudes. At the same time, we know that in some currently high-income countries very far from the tropics, for example, Sweden, malaria, leprosy, cholera, etc. were rampant 200–300 years back, making these diseases hardly ‘tropical’ but rather diseases of poverty. The expression ‘pathology of poverty’ has been coined to illustrate this association . The difference in perception – considering today’s Cuba and historical Sweden – also represents an attitudinal shift in understanding the complexity of ‘tropical’ diseases caught in the rhetoric question: ‘their latitudes or our attitudes?’ .

Currently, the perception of ‘global’ medicine has widened the scope not only geographically but also discipline-wise, and maternal and neonatal health has entered the field in an appropriate way . We have turned our attention from the tropics to the planet as a whole, and by that maternal and neonatal health has appeared as two obvious priority fields of intervention.

Where was the ‘M’ in the ‘baby bomb’ era?

Looking backwards, it is obvious that the late recognition in low-income countries of maternal and neonatal ill health in general has to do with the powerful setting of priorities by influential donor countries and international organizations. The demographic focus on ‘the population explosion’ rather undermined any donor interest to reduce maternal mortality or to pay attention to maternal and neonatal health . One particularly revealing example is from a meeting of all Scandinavian professors of obstetrics and gynaecology in Uppsala, Sweden, in the late 1980s. When the author lectured on the need to reduce maternal mortality, a question came from one of the most prominent Swedish professors in obstetrics and gynaecology at the time: ‘Would not reducing maternal mortality imply that the population explosion will worsen?’ He was not alone in seeing enhanced maternal survival as potentially dangerous and problematic. But he was ignorant about the fertility trends showing, already then, the levelling off of global population growth. Notwithstanding this, the mere expression of doubt whether it would be wise to save mothers’ lives is of course ethically unacceptable by any standard.

In the 1980s, the ‘M’ was also virtually invisible in research priorities supported by major international donors. Less than 5% of the funding in ‘reproductive health’ research in the HRP (Special Programme on Research in Human Reproduction) was spent on maternal health; the remaining bulk supported contraceptive research (Sterky, personal communication).

The Swedish professor’s questioning of the wisdom of reducing maternal mortality is a thought-provoking illustration of the famous statement by Professor Mahmoud Fathalla, quoted innumerable times:

‘Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.’

At the same time, powerful donors, such as the World Bank, had not yet started to see the value of financial support to curb maternal and neonatal morbidity and mortality. It came later, particularly evident in 1994, in the ground-breaking annual report: ‘Investing in Health’ . Before that, in the 1970s and 1980s, the World Bank invested overwhelmingly in ‘population’, a very unclear concept – implicitly but not explicitly – implying simply population control or provision of contraceptives.

India is a thought-provoking example, thoroughly investigated by the Norwegian researcher Synnøve Engh . Sweden was one of the most prominent donors even before the violent population control-oriented ‘emergency’ was declared in 1975. Sweden entered after the emergency, with the World Bank, in a second big population control project but abolished its participation in 1980 due to the absence of maternal health in it . In India, maternal health had – seemingly – been on the agenda already in the early 1970s by the remarkable legalization of induced abortion in 1971, but it had a demographic motivation, which is obvious when analysing the absence of other commitments to improve maternal health and to reduce maternal and neonatal mortality.

Globally, some of the most prominent causes of maternal mortality – also in India – were already at that time postpartum complications such as bleeding from an atonic uterus, uterine rupture and childbed fever. Interestingly, already 50 years ago the postpartum period was given attention in India. In Engh’s scientific work [8, p. 194], it is stated that the postpartum programme

had grown out of an international project started in 1966 by the Population Council, an American philanthropic organisation working with population control and family planning, which two Indian hospitals participated in. In 1969, the GoI set up its own nationwide Post Partum Programme, based on the international programme .

But the postpartum programme had nothing to do with obstetric care at birth and was totally geared towards exerting pressure on postpartum women to accept tubal ligation or other birth control methods . In itself, such a focus was (and is) of course uncontroversial. What is interesting here, however, is that this programme had no maternal health objective but only a demographic one, disguised in an allegedly maternal health costume.

The demographic objective soon became dismantled in the ‘emergency’ and signified a virtual abolition of any efforts to enhance maternal and neonatal survival . Engh states:

In June 1975, Indira Gandhi declared a national emergency, which lasted until January 1977. During this period, most of her principal opponents were arrested, civil rights were abrogated, and many organisations were banned. The press was heavily censored, journalists were jailed, and foreign correspondents expelled. On 16 April 1976 a new National Population Policy was announced, which contained a range of comprehensive measures, the most extreme being the permission to State legislatures to pass laws for compulsory sterilization . [8, p. 215]

The notion that high parity per se is detrimental to women’s health is unproven. Observations from Nigeria indicate that high parity is not associated with high mortality per se. Rather, if the investigated mothers are stratified socio-economically, it emerges that it is not parity but poverty that kills . In an overview of poverty-stricken, historical Sweden regarding the degree of risk attributable to multiparity per se for adverse pregnancy outcome, we found essentially the same thing: that grand multiparity is not a risk factor for maternal death . A similar approach was used in Bangladesh where birth intervals per se were not found to be associated with increased risk of maternal mortality .

In retrospective, the era of the ‘baby bomb’ hoax made maternal and neonatal survival a low-priority issue, which delayed the recognition of the ‘M’ in its own right. Notwithstanding the importance of contraceptive access as a tool for women’s emancipation and freedom, the non-recognition of maternal health as a human right implied a delay in recognizing the ‘M’ during this era . Attention was consequently drawn to ‘reproductive health’ as a wider concept than ‘family planning’ and subsequently ‘family welfare’, the latter representing essentially a new name for population control in India . In fact, the concept ‘reproductive health’ was coined for the first time only in 1985 .

Where was the ‘M’ in the ‘baby bomb’ era?

Looking backwards, it is obvious that the late recognition in low-income countries of maternal and neonatal ill health in general has to do with the powerful setting of priorities by influential donor countries and international organizations. The demographic focus on ‘the population explosion’ rather undermined any donor interest to reduce maternal mortality or to pay attention to maternal and neonatal health . One particularly revealing example is from a meeting of all Scandinavian professors of obstetrics and gynaecology in Uppsala, Sweden, in the late 1980s. When the author lectured on the need to reduce maternal mortality, a question came from one of the most prominent Swedish professors in obstetrics and gynaecology at the time: ‘Would not reducing maternal mortality imply that the population explosion will worsen?’ He was not alone in seeing enhanced maternal survival as potentially dangerous and problematic. But he was ignorant about the fertility trends showing, already then, the levelling off of global population growth. Notwithstanding this, the mere expression of doubt whether it would be wise to save mothers’ lives is of course ethically unacceptable by any standard.

In the 1980s, the ‘M’ was also virtually invisible in research priorities supported by major international donors. Less than 5% of the funding in ‘reproductive health’ research in the HRP (Special Programme on Research in Human Reproduction) was spent on maternal health; the remaining bulk supported contraceptive research (Sterky, personal communication).

The Swedish professor’s questioning of the wisdom of reducing maternal mortality is a thought-provoking illustration of the famous statement by Professor Mahmoud Fathalla, quoted innumerable times:

‘Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.’

At the same time, powerful donors, such as the World Bank, had not yet started to see the value of financial support to curb maternal and neonatal morbidity and mortality. It came later, particularly evident in 1994, in the ground-breaking annual report: ‘Investing in Health’ . Before that, in the 1970s and 1980s, the World Bank invested overwhelmingly in ‘population’, a very unclear concept – implicitly but not explicitly – implying simply population control or provision of contraceptives.

India is a thought-provoking example, thoroughly investigated by the Norwegian researcher Synnøve Engh . Sweden was one of the most prominent donors even before the violent population control-oriented ‘emergency’ was declared in 1975. Sweden entered after the emergency, with the World Bank, in a second big population control project but abolished its participation in 1980 due to the absence of maternal health in it . In India, maternal health had – seemingly – been on the agenda already in the early 1970s by the remarkable legalization of induced abortion in 1971, but it had a demographic motivation, which is obvious when analysing the absence of other commitments to improve maternal health and to reduce maternal and neonatal mortality.

Globally, some of the most prominent causes of maternal mortality – also in India – were already at that time postpartum complications such as bleeding from an atonic uterus, uterine rupture and childbed fever. Interestingly, already 50 years ago the postpartum period was given attention in India. In Engh’s scientific work [8, p. 194], it is stated that the postpartum programme

had grown out of an international project started in 1966 by the Population Council, an American philanthropic organisation working with population control and family planning, which two Indian hospitals participated in. In 1969, the GoI set up its own nationwide Post Partum Programme, based on the international programme .

But the postpartum programme had nothing to do with obstetric care at birth and was totally geared towards exerting pressure on postpartum women to accept tubal ligation or other birth control methods . In itself, such a focus was (and is) of course uncontroversial. What is interesting here, however, is that this programme had no maternal health objective but only a demographic one, disguised in an allegedly maternal health costume.

The demographic objective soon became dismantled in the ‘emergency’ and signified a virtual abolition of any efforts to enhance maternal and neonatal survival . Engh states:

In June 1975, Indira Gandhi declared a national emergency, which lasted until January 1977. During this period, most of her principal opponents were arrested, civil rights were abrogated, and many organisations were banned. The press was heavily censored, journalists were jailed, and foreign correspondents expelled. On 16 April 1976 a new National Population Policy was announced, which contained a range of comprehensive measures, the most extreme being the permission to State legislatures to pass laws for compulsory sterilization . [8, p. 215]

The notion that high parity per se is detrimental to women’s health is unproven. Observations from Nigeria indicate that high parity is not associated with high mortality per se. Rather, if the investigated mothers are stratified socio-economically, it emerges that it is not parity but poverty that kills . In an overview of poverty-stricken, historical Sweden regarding the degree of risk attributable to multiparity per se for adverse pregnancy outcome, we found essentially the same thing: that grand multiparity is not a risk factor for maternal death . A similar approach was used in Bangladesh where birth intervals per se were not found to be associated with increased risk of maternal mortality .

In retrospective, the era of the ‘baby bomb’ hoax made maternal and neonatal survival a low-priority issue, which delayed the recognition of the ‘M’ in its own right. Notwithstanding the importance of contraceptive access as a tool for women’s emancipation and freedom, the non-recognition of maternal health as a human right implied a delay in recognizing the ‘M’ during this era . Attention was consequently drawn to ‘reproductive health’ as a wider concept than ‘family planning’ and subsequently ‘family welfare’, the latter representing essentially a new name for population control in India . In fact, the concept ‘reproductive health’ was coined for the first time only in 1985 .

Where was the ‘M’ in MCH?

After the Alma Ata conference in 1978, primary healthcare gained recognition and the concept MCH was created as a parole. Save the Children (founded already in 1919), UNICEF (founded in 1946) and other organizations working for children had gained momentum over several decades and the woman with the baby on her back became the incarnation proper of the MCH concept. But the ‘C’ became much more prominent than the ‘M’, the latter being more a carrier (of the ‘C’) than an individual in its own right. Also, the Asian focus on the threatening ‘baby bomb’, during the emergency in India, presumably added to the perception of the burden of many babies. For obstetricians, the background position of the ‘M’ became gradually an eye-opener .

In the same year, incidentally, Rosenfield and Maine published their now famous article: ‘Maternal mortality – a neglected tragedy – Where is the M in MCH?’ . The article challenged the obstetricians to be more proactive and show more initiative. The authors stated:

It is difficult to understand why maternal mortality receives so little serious attention from health professionals, policy makers, and politicians. The world’s obstetricians are particularly neglectful of their duty in this regard. Instead of drawing attention to the problem and lobbying for major programmes and changes in priorities, most obstetricians concentrate on subspecialties that put emphasis on high technology . [1, p 83]

Alluding to the World Bank’s focus on population control and unclear focus on maternal health, they concluded:

We suggest that the Bank makes maternity care one of its priorities. A programme for the prevention of maternal deaths could be built around the building of maternity centres in rural areas, the recruitment and training of staff for the centres, and the provision of supplies and drugs. The programme could be phased so that governments would take over these expenses in time. Loans for these purposes should be seen as an acceptable long-term investment in improving the health of women . [1, p 85]

Two years after Rosenfield’s and Maine’s article, the first Safe Motherhood Conference took place in Nairobi in 1987 and maternal health, for the first time, was given global attention. Motherhood- and pregnancy-related health became emerging priorities. Morbidity and mortality around birth (perinatal) became important issues to address. Perinatal medicine emerged as an earlier overlooked and neglected discipline. From becoming a paediatric subspecialty, it had more and more an obstetric identity, though, like in the case of MCH, ‘M’ was again subordinate to ‘C’. The fact that about 70% of maternal deaths occur in the perinatal period raised a rhetoric question similar to the one raised by Rosenfield and Maine: ‘Is there an “M” in perinatal medicine?’ .

The seven years from Nairobi (1987) to the Cairo ICPD International Conference on Population and Development (1994) visualized further that the ‘M’ had finally gained more visible recognition. Several other global conferences in the early 1990s took the challenges of the Safe Motherhood Conference seriously and formulated the goal of halving maternal mortality by the year 2000 . One of the most important events was the ‘ World Summit for Children’ in 1991 (with more than 120 heads of state and presidents present), which predated the Cairo commitment of reducing maternal mortality by half by the turn of the century .

The MCH concept was useful to draw attention to the importance of the mother for the survival and well-being of the newborn. But the picture that we associate with the MCH concept is incomplete. It says nothing of maternal health and hides one brutal aspect of the mother: when the woman is dying a maternal death, the baby is never on her back.

The simplistic shortcut: antenatal classification of the high-risk mother

In the 1970s, the World Health Organization (WHO) had launched ‘the risk approach’ as a strategy in antenatal care to identify risk factors for undesirable outcomes, with care to be delivered according to individual needs. A WHO compilation on coverage of maternity care showed that while almost all pregnant women in high-income countries attend antenatal care, most of them from the first trimester onwards, less than two-thirds receive antenatal care in most countries in low-income countries .

Over the last decades, a number of trials have addressed the question if any antenatal care model is superior to the others. One randomized controlled trial in Zimbabwe tested a model of fewer but more objectively oriented visits and fewer procedures per visit . Women in the new programme had fewer visits, less antenatal referrals and significantly less preterm deliveries, and there were no differences in other outcome indicators.

It is obvious that there are categories of women with foreseeable problems at a forthcoming birth. Examples comprise those with short stature, diabetes, hypertension, previous caesarean section, etc. But it is likewise true that among the vast majority of women who actually die, the prevalence of conventional ‘risk’ factors is low and most women dying a maternal death are, in fact, low-risk women . This implies that screening for ‘high risk’ is a necessary but not sufficient precondition for making pregnancy safer.

In 1997 in Colombo, there was a celebration of the tenth anniversary of the Safe Motherhood Initiative in Nairobi. This celebration conference shaped the important conclusion: ‘every pregnancy faces risk’ , thereby admitting that the problem of maternal mortality is dependent, in the majority of cases, on factors and circumstances occurring very suddenly, without warning also, in otherwise healthy individuals . The need for emergency obstetric care with proper management of such ‘bolts from the blue’ became obvious. For instance, with active management of the third stage of labour the risk of massive postpartum haemorrhage can be reduced. However, if it occurs, unexpectedly, both external compression of the abdominal aorta and applying the intrauterine condom tamponade technique (with or without retained placenta) will stop bleeding in most cases and save the woman’s life . For another ‘bolt from the blue’, eclampsia, a similar emergency regimen is needed. Even if mostly preceded by pre-eclampsia, some eclampsia cases have short prodromal stages. It has its ‘management of choice’ with magnesium sulphate in bolus and maintenance doses and with clinical control of patellar reflexes, respiratory rate and hourly urinary output. Both these ‘bolts’ can be handled by a midwife in a small peripheral unit and both categories can, but only if needed, be referred to the first referral level.

Pregnancy has two ‘actors’: the carrier and the passenger. And safe motherhood also comprises the safe birth of a live passenger. Looking backwards, it is thought-provoking that the attention paid to stillbirths and early neonatal deaths has been so limited. Even the global burden of disease concept long overlooked ‘stillbirth’ as an entity. In the ‘Global Burden of Disease’ of 2004, the concept ‘stillbirth’ was not even mentioned at all , in spite of the fact that more than three million stillbirths occur annually . In addition, each year approximately three million newborns die before they are 1 month old, contributing to about 40% of all deaths of children under 5 years of age and 60% of all infant mortalities .