Wednesday, August 31, 2011

Stop Belittling Maternal Deaths

The anti-RH group called Filipinos For Life defended Sen. Tito Sotto’s unfortunate attacks and caustic remarks on the information that an average of 11 maternal deaths occur daily, by claiming that the accurate figure is 4.8 to 8.3. In its statement [1], the anti-RH group cautioned “against the excessive emotional use of the outdated statistic to influence Philippine government policy” and explained their lower figure as follows:

"Based on our own estimates, the correct figure is 4.8 maternal deaths a day, based on 2008 data from the National Statistics Office and the National Statistical Coordination Board. This assumes a maternal mortality ratio (MMR) of 99 per 100,000 live births and 1.784 million live births in 2008. Assuming a high MMR of 169 per 100,000 live births, the figure is 8.3."

The group produced a lower figure by using registered live births (1.784 M in 2008) for its calculation. The National Statistics Office (NSO) itself clearly flags the fact that this figure is lower than the actual number of live births due to late and non-registration [2], and the Filipinos For Life should have heeded the NSO’s caveat. 

A concrete indicator of the huge scale of underregistration is the 2007 population census, which counted a total of 2.07 M infants [3] (under age 1). Though already a lot higher than the registered births of the following year, the census figure is still lower than the actual number of live births since some 2.5% of infants die before reaching age one [4] and would not have been counted by the census.

On 7 September 2010, the National Statistical Coordination Board (NSCB)[5] approved a new maternal mortality ratio (MMR) estimation methodology and the resulting MMR estimates for 1990 and 2000-2010 as “interim estimates for planning and policy/decision-making purposes until such time that the results of population censuses and surveys and updated data from the civil registration system are made available.” The MMR estimate for 2010 is 95 to 163 maternal deaths for every 100,000 live births[6].

Combining available NSO data on fertility rates and the female population of reproductive age with the new NSCB estimate, the number of maternal deaths in 2010 falls within the range of 2,370 to 4,067 or an average of 6.5 to 11.1 deaths per day (see annex tables for details).

Whether the exact figure is at the lower, central or upper part of the estimate, the important point is to responsibly create policies that would eliminate preventable maternal deaths. Low to high income countries have shown this to be doable. Falsely accusing RH advocates of using outdated data, quibbling about the numbers or callously asking for death certificates as proof will only obstruct the crafting of workable solutions to maternal deaths. 

Family planning—whether using natural or artificial methods—can reduce maternal deaths by promoting safer timing of pregnancies or enabling mothers who do not want to get pregnant anymore to fulfill their wishes. A non-pregnant woman has zero risk of complications and maternal death. Skilled birth attendants and emergency obstetric and neonatal care can reduce maternal deaths by providing proper, life-saving interventions to women who do want to get pregnant, or those who get pregnant unintentionally. Humane treatment and counseling for women with post-abortion complications will enable health practitioners to promote and provide natural or artificial family planning so that abortions—which cause a significant proportion of maternal deaths—are minimized if not eliminated. Sexuality education in schools will reduce or delay sexual experimentation among young people, thereby reducing unintended pregnancies and the risk of maternal complications and death. 

All of these five measures that can eliminate preventable maternal deaths are in the RH bill. Opponents should be responsible enough to unequivocally point out the parts they can support and the parts they cannot, and engage constructively with the goal of reducing maternal deaths. Belittling maternal deaths contributes nothing and is a grave insult to the millions of mothers who yearly face risks to give new life. ■

Annex: Estimating the Number of Maternal Deaths

I. Using New NSCB MMR, High Assumption
ABCDEFG
Age GroupProjected Female Population, 2010Age-Specific Fertility Rates, 2008 (live births per 1,000 women)Estimated Total Live Births, 2010MMR 2010, (maternal deaths per 100,000 live births)Total Maternal Deaths per YearAverage Maternal Deaths per Day
15-194,702,40054 253,930 163 414  1.1 
20-244,378,900163 713,761  1,163  3.2 
25-293,951,200172 679,606  1,108  3.0 
30-343,526,600136 479,618  782  2.1 
35-392,995,20084 251,597  410  1.1 
40-442,704,70038 102,779  168  0.5 
45-492,325,4006 13,952  23  0.1 
TOTAL24,584,4002,495,243 4,067  11.1 

II. Using New NSCB MMR, Low Assumption
ABCDEFG
Age GroupProjected Female Population, 2010Age-Specific Fertility Rates, 2008 (live births per 1,000 women)Estimated Total Live Births, 2010MMR 2010, (maternal deaths per 100,000 live births)Total Maternal Deaths per YearAverage Maternal Deaths per Day
15-194,702,40054 253,930 95 241  0.7 
20-244,378,900163 713,761  678  1.9 
25-293,951,200172 679,606  646  1.8 
30-343,526,600136 479,618  456  1.2 
35-392,995,20084 251,597  239  0.7 
40-442,704,70038 102,779  98  0.3 
45-492,325,4006 13,952  13  0.0 
TOTAL24,584,4002,495,243 2,370  6.5 

Table Notes:
1. Column D was calculated by dividing Column B with 1,000 and multiplying the result with Column C.
2. Column F was calculated by dividing Column D with 100,000 and multiplying the result with Column E.

Table Sources:        
Column A: National Statistics Office. Projected Populations by Five-Year Age Group and Sex, by Region and Province, and by Five-Calendar Years: 2000-2040 (Medium Series). See http://www.census.gov.ph/data/sectordata/popproj_tab4r.html
Column C: National Statistics Office (NSO) [Philippines], and ICF Macro. 2009. National Demographic and Health Survey 2008. p. 40. Calverton, Maryland: National Statistics Office and ICF Macro.
Column E: National Statistical Coordination Board. Interim Estimates of National-Level Maternal Mortality Ratios: 1990 and 2000-2010. Available at http://www.nscb.gov.ph/resolutions/2010/11_10annex2.pdf 


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Endnotes
[2] From the NSO web page that published the 2008 registered live births: “Statistics presented include only those births which occurred in 2008 and were registered from January 2008 to March 2009. Births that were registered after March 2009 and those that were not registered at all were not included.” See http://www.census.gov.ph/data/pressrelease/2011/pr1153tx.html 
[4] National Statistics Office and ICF Macro. 2009. National Demographic and Health Survey 2008. Calverton, Maryland: National Statistics Office and ICF Macro. p. 96.
[5] National Statistical Coordination Board. Board Resolution No. 11-10. Available at http://www.nscb.gov.ph/resolutions/2010/11.asp
[6] National Statistical Coordination Board. Interim Estimates of National-Level Maternal Mortality Ratios: 1990 and 2000-2010. Available at http://www.nscb.gov.ph/resolutions/2010/11_10annex2.pdf 

Medical Experts' Declaration on the Action of Contraceptives

By Alberto Romualdez, M.D.
Wednesday, 24 August 2011

Below is part of the report from an expert group convened recently by the Universal Health Care Study Group of the University of the Philippines Manila: 

On Monday, 8 August 2011, 21 experts from diverse scientific fields including biochemistry, physiology, pharmacology, obstetrics and gynecology, reproductive endocrinology and infertility, internal medicine, demography, and public health gathered to examine raging questions on pregnancy and contraception applying scientific and evidence-based analysis.

These are our conclusions: 

1. Conception is not an exact scientific term. For some it means implantation; for others it is an event that occurs at some time after fertilization. No one at the meeting equates conception with fertilization.

2. Fertilization encompasses the process of penetration of the egg cell by the sperm cell and the combination of their genetic material to form the fertilized egg or the zygote. The process is estimated to take about 24 hours. At present, there is no accepted laboratory or clinical method of determining if and exactly when natural fertilization has taken place, but we accept that it has occurred after a pregnancy has been detected. 
Natural losses occur all the time; 33%-50% of all fertilized eggs never implant without the woman doing or taking anything.

3. All contraceptives, including hormonal contraceptives and IUDs, have been demonstrated by laboratory and clinical studies, to act primarily prior to fertilization. Hormonal contraceptives prevent ovulation and make cervical mucus impenetrable to sperm. Medicated IUDs act like hormonal contraceptives. Copper T IUDs incapacitate sperm and prevent fertilization.

4. The thickening or thinning of the endometrium (inner lining of the uterus) associated with the use of hormonal contraceptives has not been demonstrated to exert contraceptive action, i.e. if ovulation happens and there is fertilization, the developing fertilized egg (blastocyst) will implant and result in a pregnancy (contraceptive failure). In fact, blastocysts have been shown to implant in inhospitable sites without an endometrium, such as in Fallopian tubes.

5. Pregnancy can be detected and established using currently available laboratory and clinical tests – e.g. blood and urine levels of HCG (Human Chorionic Gonadotrophin) and ultrasound – only after implantation of the blastocyst. While there are efforts to study chemical factors associated with fertilization, currently there is no test establishing if and when it occurs.

6. Abortion is the termination of an established pregnancy before fetal viability (the fetus' ability to exist independently of the mother). Aside from the 50% of zygotes that are naturally unable to implant, an additional wastage of about 20% of all fertilized eggs occurs due to spontaneous abortions (miscarriages).

7. Abortifacient drugs have different chemical properties and actions from contraceptives. Abortifacients terminate an established pregnancy, while contraceptives prevent pregnancy by preventing fertilization.

8. Like all medical products and interventions, contraceptives must first be approved for safety and effectiveness by drug regulatory agencies. Like all approved drugs, contraceptives have “side effects” and adverse reactions, which warrant their use based on risk-benefit balance and the principles of Rational Drug Use. Risk-benefit balance also applies when doing nothing or not providing medicines, which can result in greater morbidities and death. 

In the case of contraceptives, which are 50-year-old medicines, the Medical Eligibility Criteria (MEC) developed by the WHO is the comprehensive clinicians’ reference guiding the advisability of contraceptives for particular medical conditions. 

9. The benefits of the rational use of contraceptives far outweigh the risks. The risk of dying from pregnancy and childbirth complications is high (1 to 2 per 1000 live births, repeated with every pregnancy). Compared to women nonsmokers aged below 35 who use contraceptives, the risk of dying from pregnancy and delivery complications is about 2,700 times higher.

10. The risk of cardiovascular complications from the appropriate use of hormonal contraceptives is low. While the risk for venous thrombo-embolism (blood clotting in the veins) among oral contraceptive users is increased, the risk of dying is low, 900 times lower than the risk of dying from pregnancy and childbirth complications. Heart attack and stroke are also rare in women of reproductive age and occur in women using hormonal contraceptives only in the presence of risk factors –like smoking, hypertension, and diabetes. The MEC will guide providers in handling patients with cardiovascular conditions. 

11. The risk of breast cancer from the use of combined hormonal pills (exogenous estrogen or estrogen from external sources) is lower than the risk from prolonged exposure to endogenous estrogens (hormones naturally present in the body). Current users of oral contraceptives have a risk of 1.2 compared to 1.9 among women who had early menarche (first menstruation) and late menopause, and 3.0 among women who had their first child after age 35. The risk of breast cancer from oral contraceptive use also completely disappears after 10 years of discontinuing use.

12. Combined hormonal pills are known to have protective effects against ovarian, endometrial and colorectal cancer. 

13. The safety and efficacy of contraceptives which passed the scientific scrutiny of the most stringent drug regulatory agencies, including the US FDA, warranted their inclusion in the WHO's "core list" of Essential Medicines since 1977. The core list enumerates "minimum medicine needs for a basic health care system listing the most efficacious, safe and cost-effective medicines for priority conditions."

14. Contraceptives are included in the Universal Health package of the Department of Health.

15. The use of contraceptives in family planning programs is known to reduce maternal mortality by 35% through the elimination of unintended pregnancy and unsafe induced abortions.