母体死亡への対策急務 年50万人の妊娠出産時死亡

　妊娠出産中の死亡がここ20年変化なく50万人が死亡している。2015年までに75%減少させようという目標を達成するには緊急な対策が必要である。毎年2000万の危険な流産があり、1000ｰ2000万人が障害を負っている。ハーバード大の試算では母体死亡率の低下はここ15年間、年率1%未満にすぎない。目標達成には61億ドルの資金が必要と推定される。
　2005年に、母体死亡は535,900人あり、母体死亡率は10万出生当たり 402(216～654)と推定される。ほとんどはサハラ以南(270,500, 50%)とアジア(240,600, 45%)である。1990と2005の間ですべての国で年率2.5%の死亡率の低下があるが、サハラ以南地域では減少したという証拠がない。2015年Millennium Development Goal(MDG5)目標を達成するには発展途上国の妊娠出産ケアの改善が急務である。
　危険な流産が母胎死亡の大きな原因であり、意図しない妊娠と危険な流産を減らし、安全な流産へのアクセスを増大させることに取り組む必要がある。1995年には4600万だったが、2003年には4200万流産が推計される。15-44才の人口1000人当たりの人工流産の頻度は1995年に35であったが2003年には29に減少した。西欧が最も低く12、北欧が17、南欧が18、北米が21であった。流産のうち48%が危険なもので、危険な流産の97%は発展途上国で起きている。100出生に対し31流産あり、東欧が100出生に対し105流産と最も高い。全体の流産率は世界で差は少ないが、危険な流産は発展途上国に集中している。避妊と安全な流産の保証が母体死亡を減らし母体の健康を保つことになる。
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Last Updated: Friday, 12 October 2007, 00:46 GMT 01:46 UK
Action needed on maternal deaths
http://news.bbc.co.uk/2/hi/health/7039647.stm
Women at a clinic in Uganda
Sub-Saharan Africa has the highest rates of mortality in childbirth

Experts have condemned the "appalling" lack of progress made in reducing the number of women worldwide dying during pregnancy and childbirth.

Analysis in The Lancet medical journal shows half a million women die every year - little change from 20 years ago.
And 20 million unsafe abortions - a major factor in maternal deaths and illness - are done annually.
A key global target of a 75% reduction in maternal deaths by 2015 will not be met without urgent action, they warned.

The general message is we still have the situation we had 20 years ago - that half a million women die every year from the complications of childbirth and 10-20 million women suffer disability
Ann Starrs, Family Care International

Dr Richard Horton, editor of the Lancet, said women were too often seen as "containers" for babies and nothing more.
He said there should be no more excuses or delay in attempts to dramatically cut the number of deaths by three-quarters, as was set out in the Millennium Development Goals.
A study by Professor Ken Hill from Harvard University showed that maternal deaths fell by less than 1% a year between 1990 and 2005, although some countries showed better results.
Half of maternal deaths occur in sub-Saharan Africa where there has been a particularly small drop over the past two decades.
He said a "huge and urgent" emphasis was needed to improve pregnancy and delivery care in the developing world.
Unsafe abortion
In a separate study, also published in the Lancet, Dr Iqbal Shah from the World Health Organization, found rates of abortion fell globally by 17% between 1995 and 2003.
However, the number of abortions taking place in "unsafe" conditions remained the same - about half of all abortions carried out.
The vast majority of unsafe abortions are done in developing countries, the figures show.
Abortion rates were lowest in Western Europe at 12 pregnancy terminations per 1,000 women but highest in Eastern Europe at 44 abortions per 1,000 women.
In Africa and Asia, the abortion rate was 29 per 1,000 women.

MATERNAL MORTALITY
The number of women dying in childbirth varies dramatically worldwide from one in eight in Afghanistan and Sierra Leone to one in 47,000 in Ireland
Maternal health is strongly linked to access to safe abortion, contraception and emergency obstetric care
If a mother is ill or dies, the baby is less likely to survive and her other children less likely to be healthy and educated

Dr Shah said rates of abortion did not differ according to whether access was good or highly restricted by law, and reducing the number of unsafe abortions was "imperative".
In Bangladesh, a massive decrease in maternal deaths has occurred because women now have access to safe abortion services and emergency obstetric care, another study by Dr Carine Ronsmans from the London School of Hygiene and Tropical Medicine showed.
Experts said the experience of Bangladesh - where abortion mortality fell by 74% over the past 30 years - shows the Millennium Development Goal are achievable.
Ann Starrs, executive vice president of Family Care International, said maternal health had a massive impact on the survival and health of children and on society.
"The general message is we still have the situation we had 20 years ago - that half a million women die every year from the complications of childbirth and 10-20 million women suffer disability."
To meet the Millennium Development Goal ￡3 billion ($6.1 billion) was needed by 2015, she said.
Money needs to be spent on safe abortion and family planning services and midwives who can help women access emergency care where necessary.
A spokesperson for Marie Stopes International said lack of access to modern family planning resulted in nearly 80 million unintended pregnancies every year in the developing world.
"Unsafe abortion is one of the most neglected public health issues of our time.
"The poor health of a mother, or her premature death from unsafe abortion, can have particularly detrimental effects on the health and survival chances of infants."
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The Lancet 2007; 370:1283
DOI:10.1016/S0140-6736(07)61546-3
Editorial
Women: more than mothers
20 years ago, the Safe Motherhood Initiative was launched by WHO and others to help reduce the severe global burden of pregnancy-related illness and death. Sadly, today, most of that burden remains unchanged. Over 300 million women in the developing world suffer from illness brought about by pregnancy and childbirth; nearly 536 000 die each year. Additionally, newborn babies whose mothers die in childbirth are three to ten times more likely to die within 2 years than those whose mothers survive. It is disappointing that little progress has been made to halt these largely preventable deaths. On Oct 18–20, 2007, to mark the initiative's 20th anniversary, the Women Deliver conference in London, UK, aims to reflect on the immense challenges faced by women and their families. This week's issue of The Lancet includes research and policy articles that should inform discussion and action that flows from the conference.

New estimates of maternal mortality for 2005, and regional mortality trends since 1990, are described by Ken Hill and colleagues, who show that most deaths occur in sub-Saharan Africa and Asia, with very little improvement in sub-Saharan Africa in the past 15 years. At a global rate of decline of only 2·5%, and no significant decline in sub-Saharan Africa, it is unlikely that Millennium Development Goal 5―to reduce maternal mortality by three quarters by 2015―will be met. Hill stresses the difficulties in accurately measuring maternal mortality and calls for a greater investment in development and validation of the newer methods, as well as improving countries' civil registration systems. Later this year, The Lancet will be launching its own report on this crucial issue at the Global Forum for Health Research in Beijing, China (Oct 29–Nov 2, 2007).

Among the interventions that have a significant effect on maternal mortality is access to safe abortion. Gilda Sedgh and colleagues present new findings on global rates and trends of all abortions. They found that despite the worldwide abortion rate slowly declining between 1995 and 2003, the unsafe abortion rate was essentially unchanged. The authors make a clear and compelling case for better access to contraception as well as safe and legal abortion services as a core tenet of improving the health of women worldwide. Indeed, as Carine Ronsmans and colleagues show, access to safe abortions is among the factors that have led to a substantial decrease in maternal mortality in Bangladesh during the past 30 years.

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2005年に、母体死亡は535,900人あり、母体死亡率は10万出生当たり 402(216--654)推定される。ほとんどはサハラ以南(270,500, 50%)とアジア(240,600, 45%)である。1990と2005の間ですべての国で年率2.5%の死亡率の低下があるが、サハラ以南地域では減少したという証拠がない。2015年Millennium Development Goal(MDG5)目標を達成するには発展途上国の妊娠出産ケアの改善が急務である。危険な流産が母胎死亡の大きな原因であり、意図しない妊娠と危険な流産を減らし、安全な流産へのアクセスを増大させることに取り組む必要がある。1995年には4600万だったが、2003年には4200万流産が推計される。15-44才の人口1000人当たりの人工流産の頻度は1995年に35であったが2003年には29に減少した。西欧が最も低く12、北欧が17、南欧が18、北米が21であった。流産のうち48%が危険なもので、危険な流産の97%は発展途上国で起きている。100出生に対し31流産あり、東欧が100出生に対し105流産と最も高い。全体の流産率は世界で差は少ないが、危険な流産は発展途上国に集中している。避妊と安全な流産の保証が母体死亡を減らし母体の健康を保つことになる。

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Women: more than mothers
20 years ago, the Safe Motherhood Initiative was launched by WHO and others to help reduce the severe global burden of pregnancy-related illness and death. Over 300 million women in the developing world suffer from illness brought about by pregnancy and childbirth; nearly 536 000 die each year. Additionally, newborn babies whose mothers die in childbirth are three to ten times more likely to die within 2 years than those whose mothers survive. It is disappointing that little progress has been made to halt these largely preventable deaths, comments an editorial..

Estimating maternal mortality
New estimates of maternal mortality for 2005, and regional mortality trends since 1990, are described by Ken Hill and colleagues,who show that most deaths occur in sub-Saharan Africa and Asia, with very little improvement in sub-Saharan Africa in the past 15 years. At a global rate of decline of only 2?5%, and no significant decline in sub-Saharan Africa, it is unlikely that Millennium Development Goal 5―to reduce maternal mortality by three quarters by 2015―will be met. .....

Access to safe abortions a key intervention to improving maternal health
Among the interventions that have a significant effect on maternal mortality is access to safe abortion. Gilda Sedgh and colleagues present new findings on global rates and trends of all abortions.They found that despite the worldwide abortion rate slowly declining between 1995 and 2003, the unsafe abortion rate was essentially unchanged. The authors make a clear and compelling case for better access to contraception as well as safe and legal abortion services as a core tenet of improving the health of women worldwide. .....



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The Lancet 2007; 370:1311-1319
DOI:10.1016/S0140-6736(07)61572-4

Articles

Estimates of maternal mortality worldwide between 1990 and 2005: an assessment of available data

Prof Kenneth Hill PhD email address a Corresponding Author Information, Prof Kevin Thomas PhD b, Carla AbouZahr MSc c, Neff Walker PhD d e, Lale Say MD f, Mie Inoue MA g and Emi Suzuki PhD h, on behalf of the Maternal Mortality Working Group
Summary
Background

Maternal mortality, as a largely avoidable cause of death, is an important focus of international development efforts, and a target for Millennium Development Goal (MDG) 5. However, data weaknesses have made monitoring progress problematic. In 2006, a new maternal mortality working group was established to develop improved estimation methods and make new estimates of maternal mortality for 2005, and to analyse trends in maternal mortality since 1990.
Methods

We developed and used a range of methods, depending on the type of data available, to produce comparable country, regional, and global estimates of maternal mortality ratios for 2005 and to assess trends between 1990 and 2005.
Findings

We estimate that there were 535900 maternal deaths in 2005, corresponding to a maternal mortality ratio of 402 (uncertainty bounds 216--654) deaths per 100000 livebirths. Most maternal deaths in 2005 were concentrated in sub-Saharan Africa (270500, 50%) and Asia (240600, 45%). For all countries with data, there was a decrease of 2?5% per year in the maternal mortality ratio between 1990 and 2005 (p<0?0001); however, there was no evidence of a significant reduction in maternal mortality ratios in sub-Saharan Africa in the same period.
Interpretation

Although some regions have shown some progress since 1990 in reducing maternal deaths, maternal mortality ratios in sub-Saharan Africa have remained very high, with little evidence of improvement in the past 15 years. To achieve MDG5 targets by 2015 will require sustained and urgent emphasis on improved pregnancy and delivery care throughout the developing world.

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The Lancet 2007; 370:1338-1345
DOI:10.1016/S0140-6736(07)61575-X

Articles

Induced abortion: estimated rates and trends worldwide

Dr Gilda Sedgh ScD email address a Corresponding Author Information, Stanley Henshaw PhD a, Susheela Singh PhD a, Elisabeth A*hman MA b and Iqbal H Shah PhD b
Summary
Background

Information on incidence of induced abortion is crucial for identifying policy and programmatic needs aimed at reducing unintended pregnancy. Because unsafe abortion is a cause of maternal morbidity and mortality, measures of its incidence are also important for monitoring progress towards Millennium Development Goal 5. We present new worldwide estimates of abortion rates and trends and discuss their implications for policies and programmes to reduce unintended pregnancy and unsafe abortion and to increase access to safe abortion.
Methods

The worldwide and regional incidences of safe abortions in 2003 were calculated by use of reports from official national reporting systems, nationally representative surveys, and published studies. Unsafe abortion rates in 2003 were estimated from hospital data, surveys, and other published studies. Demographic techniques were applied to estimate numbers of abortions and to calculate rates and ratios for 2003. UN estimates of female populations and livebirths were the source for denominators for rates and ratios, respectively. Regions are defined according to UN classifications. Trends in abortion rates and incidences between 1995 and 2003 are presented.
Findings

An estimated 42 million abortions were induced in 2003, compared with 46 million in 1995. The induced abortion rate in 2003 was 29 per 1000 women aged 15--44 years, down from 35 in 1995. Abortion rates were lowest in western Europe (12 per 1000 women). Rates were 17 per 1000 women in northern Europe, 18 per 1000 women in southern Europe, and 21 per 1000 women in northern America (USA and Canada). In 2003, 48% of all abortions worldwide were unsafe, and more than 97% of all unsafe abortions were in developing countries. There were 31 abortions for every 100 livebirths worldwide in 2003, and this ratio was highest in eastern Europe (105 for every 100 livebirths).
Interpretation

Overall abortion rates are similar in the developing and developed world, but unsafe abortion is concentrated in developing countries. Ensuring that the need for contraception is met and that all abortions are safe will reduce maternal mortality substantially and protect maternal health.
For 20 years, maternal and child survival have struggled for attention on political agendas. The perceptions and constraints that have plagued the Safe Motherhood Initiative are discussed by Jeremy Shiffman and Stephanie Smith as well as by Ann Starrs. Much can be learned from the HIV/AIDS world. The strong wave of AIDS activism in the 1980s and 1990s, and well-organised groups of civil society demanding access to life-saving services has given justified prominence to HIV/AIDS. Activism around maternal and child health has not gained anywhere near the same traction―a sad reflection of the low status accorded to women's issues in political circles.

Those working on HIV/AIDS developed a clear strategy for success, which was to take the issue beyond medical and public-health spheres so that it became recognised as a socioeconomic issue. Here, it is encouraging to see that the maternal health community has also shifted its thinking. That women are not only mothers but highly valuable contributors to society is the theme of the conference. The links between maternal health, women's status, and broader development are reviewed by Rohini Pande and colleagues. They support the notion that investing in women and their health pays off for governments as well as families.

The idea of the continuum of care (the continuity of care throughout the life cycle) is still relatively new and The Partnership for Maternal, Newborn and Child Health, launched as a larger, broader successor to the Safe Motherhood inter-agency group, is yet to find its comparative advantage among the plethora of global organisations. However, a flurry of new initiatives together with huge sums of money, suggest that a momentum is building to tackle maternal and child health.

This is a crucial moment to redress an appalling historical neglect. It is time for a new wave of 21st century activism to throw a bright light on the low status of women. The need is known as is the knowledge to fix it. More money exists than ever, and a range of existing global initiatives has yielded useful experiences and lessons. There can be no more excuses and no further delay. Women's rights are worth fighting for; their lives can and must be saved.