Reproductive Health

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Module overview (Delete this slide when no longer necessary)• Author note: This file provides a PowerPoint template for your module.

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Module overview (Delete this slide when no longer necessary)

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Module goals (Replace illustrative text with your own text)

On completion of this module you will have a good understanding of the risks of pregnancy and delivery, the causes of maternal morbidity and mortality, and of terms used to describe maternal morbidity and mortality. The module focuses on preventive and therapeutic measures used to reduce risks and morbidity, and concludes with recommendations for improving reproductive health.

Note to authors. This slide describes the overall goal for the module. It is more general than the learning objectives that follow for individual

sections.

List of module sections (Replace template text)

• Section 1, Reproductive health: Historical perspectives• Section 2, Maternal morbidity and mortality• Section 3, Major reproductive risk factors• Section 4, Sexually transmitted diseases• Section 5, Etc.

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Learning objectives: Section 1

On completing this section you will be able to:1. List the principal causes and risk factors affecting

pregnancy-related morbidity and mortality.

2. Describe how the major risk factors affect these rates

3. Etc.

4. Etc.

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Section content

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for this response you can acknowledge that yours is just one answer of many, that every situation is different, and that there is no perfect answer

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Supplementary note

Note to authors : A “note” supplements the information provided on a slide. It allows the author to provide additional text, graphics , case studies, or other resources about a topic without filling the module with content likely to be of interest only to the more advanced or curious learner. This slide and the next several slides are blank pages, without special formatting. To provide a supplementary note scroll through the next several slides to see a demonstration of how to provide a note. You can then select and erase these slides or insert blank slides to provide a note. Do the following:

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Maternal mortality (Demonstration index slide for a note)

• Maternal health refers to the health of women during pregnancy, childbirth and the postpartum period. While motherhood is often a positive and fulfilling experience, for too many women it is associated with suffering, ill-health and even death.

• The major direct causes of maternal morbidity and mortality include hemorrhage, infection, high blood pressure, unsafe abortion, and obstructed labor.

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Note button

A click on the note button takes viewer

to the note

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Supplementary note to the preceding slide

Every day, 1500 women die from pregnancy- or childbirth-related complications. In 2005, there were an estimated 536 000 maternal deaths worldwide. Most of these deaths occurred in developing countries, and most were avoidable. (1) Improving maternal health is one of the eight Millennium Development Goals adopted by the international community at the United Nations Millennium Summit in 2000. In Millennium Development Goal 5 (MDG5), countries have committed to reducing the maternal mortality ratio by three quarters between 1990 and 2015. However, between 1990 and 2005 the maternal mortality ratio declined by only 5%. Achieving Millennium Development Goal 5 requires accelerating progress.

Maternal mortality in 2005: estimates developed by WHO, UNICEF,

UNFPA and the World Bank. Geneva, World Health Organization, 2007 (http://www.

who.int/reproductive-health/publications/maternal_mortality_2005/index.html,

accessed 14 August 2008).

Source: http://www.who.int/making_pregnancy_safer/topics/maternal_mortality/en/index.html

Photo credits

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Supplementary note to the preceding slide

Source: http://www.who.int/making_pregnancy_safer/topics/maternal_mortality/en/index.html

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Supplementary note to a preceding slide

Why do mothers die?Women die from a wide range of complications in pregnancy, childbirth or the postpartum period. Most of these complications develop because of their pregnant status and some because pregnancy aggravated an existing disease. The four major killers are: severe bleeding (mostly bleeding postpartum), infections (also mostly soon after delivery), hypertensive disorders in pregnancy (eclampsia) and obstructed labour. Complications after unsafe abortion cause 13% of maternal deaths. Globally, about 80% of maternal deaths are due to these causes. Among the indirect causes (20%) of maternal death are diseases that complicate pregnancy or are aggravated by pregnancy, such as malaria, anaemia and HIV.(2) Women also die because of poor health at conception and a lack of adequate care needed for the healthy outcome of the pregnancy for themselves and their babies.

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Supplementary note to a preceding slide

Semmelweis's observations conflicted with the established scientific and medical opinions of the time. The theory of diseases was highly influenced by ideas of an imbalance of the basic "four humours" in the body, a theory known as dyscrasia, for which the main treatment was bloodlettings. Medical texts at the time emphasized that each case of disease was unique, the result of a personal imbalance, and the main difficulty of the medical profession was to establish precisely each patient's unique situation, case by case.The findings from autopsies of deceased women also showed a confusing multitude of various physical signs, which emphasised the belief that puerperal fever was not one, but many different, yet unidentified, diseases. Semmelweis's main finding — that all instances of puerperal fever could be traced back to only one single cause: lack of cleanliness — was simply unacceptable. His findings also ran against the conventional wisdom that diseases spread in the form of "bad air", also known as miasmas or vaguely as "unfavourable atmospheric-cosmic-terrestrial influences". Semmelweis's groundbreaking idea was contrary to all established medical understanding.As a result, his ideas were rejected by the medical community. Other more subtle factors may also have played a role. Some doctors, for instance, were offended at the suggestion that they should wash their hands; they felt that their social status as gentlemen was inconsistent with the idea that their hands could be unclean. [6]:9[Note 7]

Specifically, Semmelweis's claims were thought to lack scientific basis, since he could offer no acceptable explanation for his findings. Such a scientific explanation was made possible only some decades later, when the germ theory of disease was developed by Louis Pasteur, Joseph Lister, and others.During 1848, Semmelweis widened the scope of his washing protocol to include all instruments coming in contact with patients in labor, and used mortality-rate time series to document his success in virtually eliminating puerperal fever from the hospital ward.

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During 1848–1849 some 70 000 troops from the Habsburg-ruled Austrian Empire thwarted the Hungarian independence movement, executed or imprisoned its leaders and in the process destroyed parts of Pest. It seems likely that Semmelweis, upon arriving from the Habsburg Vienna in 1850, was not warmly welcomed in Pest.On May 20, 1851 Semmelweis took the relatively insignificant, unpaid, honorary head physician position of the obstetric ward of Pest's small St. Rochus Hospital. He held that position for six years, until June 1857.[4]:107[6]:68 Childbed fever was rampant at the clinic; at a visit in 1850, just after returning to Pest, Semmelweis found one fresh corpse, another patient in severe agony, and four others seriously ill with the disease. After taking over in 1851, Semmelweis virtually eliminated the disease. During 1851–1855 only 8 patients died from childbed fever out of 933 births (0.85%).[4]:106–108

Despite the impressive results, Semmelweis's ideas were not accepted by the other obstetricians in Budapest.[6]:69 The professor of obstetrics at the University of Pest, Ede Flórián Birly, never adopted Semmelweis's methods. He continued to believe that puerperal fever was due to uncleanliness of the bowel.[4]:24* Therefore, extensive purges was the preferred treatment.After Birly died in 1854, Semmelweis applied for the position. So did Carl Braun — Semmelweis's nemesis and successor as Johann Klein's assistant in Vienna — and Braun received more votes from his Hungarian colleagues than Semmelweis did. Semmelweis was eventually appointed in 1855, but only because the Viennese authorities overruled the wishes of the Hungarians, as Braun did not speak Hungarian. As professor of obstetrics, Semmelweis instituted chlorine washings at the University of Pest maternity clinic. Once again, the results were impressive.[6]:69

Semmelweis turned down an offer in 1857 to become professor of obstetrics at the University of Zurich.[4]:56 The same year, Semmelweis married Mária Weidenhoffer (1837–1910), nineteen years his younger and the daughter of a successful merchant in Pest. They had five children: a son who died shortly after birth, a daughter who died at the age of 4 months, another son who committed suicide at age 23 (possibly due to gambling debts), another daughter who would remain unmarried, and a third daughter who would have children of her own.[6]:70

One of the first to respond to Semmelweis's 1848 communications was James Young Simpson who wrote a stinging letter. Simpson surmised that the English obstetrical literature must be totally unknown in Vienna, otherwise Semmelweis would have known that the English have long regarded childbed fever as contagious and would have employed chlorine washings to protect against it.[4]:174

Semmelweis's views were much more favorably received in England than on the continent, but he was more often cited than understood. The English consistently regarded Semmelweis as having supported their theory of contagion. A typical example was W. Tyler Smith, who claimed that Semmelweis "made out very conclusively" that "miasms derived from the dissecting room will excite puerperal disease."[4]:176*[11]

:504

In 1856, Semmelweis's assistant József Fleischer reported the successful results of handwashings at St. Rochus and Pest maternity institutions in the Viennese Medical Weekly (Wiener Medizinische Wochenschrift).[6]:69 The editor remarked sarcastically that it was time people stopped being misled about the theory of chlorine washings.[4]:24[12]:536

In 1858 Semmelweis finally published his own account of his work in an essay entitled, "The Etiology of Childbed Fever".[Note 9] Two years later he published a second essay, "The Difference in Opinion between Myself and the English Physicians regarding Childbed Fever".[Note 10] In 1861, Semmelweis finally published his main work Die Ätiologie, der Begriff und die Prophylaxis des Kindbettfiebers (German for The Etiology, Concept and Prophylaxis of Childbed Fever).In his 1861 book, Semmelweis lamented the slow adoption of his ideas: "Most medical lecture halls continue to resound with lectures on epidemic childbed fever and with discourses against my theories. […] The medical literature for the last twelve years continues to swell with reports of puerperal epidemics, and in 1854 in Vienna, the birthplace of my theory, 400 maternity patients died from childbed fever. In published medical works my teachings are either ignored or attacked. The medical faculty at Würzburg awarded a prize to a monograph written in 1859 in which my teachings were rejected".[4]:169[Note 11]

In Berlin, the professor of obstetrics, Joseph Hermann Schmidt, approved of obstetrical students having ready access to morgues in which they could spend time while waiting for the labor process.[4]:34[14]:501

In a textbook, Carl Braun, Semmelweis's successor as assistant in the first clinic, identified 30 causes of childbed fever; only the 28th of these was cadaverous infection. Other causes included conception and pregnancy, uremia, pressure exerted on adjacent organs by the shrinking uterus, emotional traumata, mistakes in diet, chilling, and atmospheric epidemic influences.[15][Note 12] The impact of Braun's views are clearly visible in the rising mortality rates in the 1850s.Ede Flórián Birly, Semmelweis's predecessor as Professor of Obstetrics at the University of Pest, never accepted Semmelweis's teachings; he continued to believe that puerperal fever was due to uncleanliness of the bowel.[4]:4*

August Breisky, an obstetrician in Prague, rejected Semmelweis's book as "naive" and he referred to it as "the Koran of puerperal theology". Breisky objected that Semmelweis had not proved that puerperal fever and pyemia are identical, and he insisted that other factors beyond decaying organic matter certainly had to be included in the etiology of the disease.[4]:41[16]:1

Carl Edvard Marius Levy, head of the Copenhagen maternity hospital and an outspoken critic of Semmelweis's ideas, had reservations concerning the unspecific nature of cadaverous particles and that the supposed quantities were unreasonably small. "If Dr. Semmelweis had limited his opinion regarding infections from corpses to puerperal corpses, I would have been less disposed to denial than I am. […] And, with due respect for the cleanliness of the Viennese students, it seems improbable that enough infective matter or vapor could be secluded around the fingernails to kill a patient."[4]:180–181[17] In fact, Robert Koch later used precisely this fact to prove that various infecting materials contained living organisms which could reproduce in the human body, i.e. since the poison could be neither chemical nor physical in operation, it must be biological.[4]:183*

At a conference of German physicians and natural scientists, most of the speakers rejected his doctrine, including the celebrated Rudolf Virchow, who was a scientist of the highest authority of his time. Virchow’s great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time.[13]

It has been contended that Semmelweis could have had an even greater impact if he had managed to communicate his findings more effectively and avoid antagonising the medical establishment, even given the opposition from entrenched viewpoints.[18]

Supplementary note -- Example of extensive text

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Special features

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Audio voiceover

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Box 1 Five common shortcomings ofhealth-care delivery

Inverse care. People with the most means – whose needs forhealth care are often less – consume the most care, whereasthose with the least means and greatest health problems consumethe least10. Public spending on health services mostoften benefits the rich more than the poor11 in high- and low incomecountries alike12,13.Impoverishing care. Wherever people lack social protectionand payment for care is largely out-of-pocket at the point ofservice, they can be confronted with catastrophic expenses.Over 100 million people annually fall into poverty because theyhave to pay for health care14.Fragmented and fragmenting care. The excessive specializationof health-care providers and the narrow focus of manydisease control programmes discourage a holistic approachto the individuals and the families they deal with and do notappreciate the need for continuity in care15. Health servicesfor poor and marginalized groups are often highly fragmentedand severely under-resourced16, while development aid oftenadds to the fragmentation17.Unsafe care. Poor system design that is unable to ensure safetyand hygiene standards leads to high rates of hospital-acquiredinfections, along with medication errors and other avoidableadverse effects that are an underestimated cause of deathand ill-health18.Misdirected care. Resource allocation clusters around curativeservices at great cost, neglecting the potential of primaryprevention and health promotion to prevent up to 70% of thedisease burden19,20. At the same time, the health sector lacksthe expertise to mitigate the adverse effects on health fromother sectors and make the

Demonstration voiceover; click on the loud speaker

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Quiz, format options – Author note

The next slides demonstrate six types of question options that you can use as “pop ups” or as section and final quizzes. Please provide your questions on individual slides inserted in the location where you want the questions to appear. For each question indicate the desired option style if not readily apparent. Indicate which answer(s) are correct, and provide short feedback answers that you want to appear when a student’s response is not correct. Do not be concerned with formatting; we will handle that at the time of assembling your module.

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Quiz, format option 1

How many women die each year due to pregnancy-related conditions?

a. abc -- incorrect; correct answer is….b. def -- incorrect; correct answer is….c. ghi -- correctd. jkl -- incorrect; correct answer is….e. mno -- incorrect; correct answer is….

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Quiz, format option 2

Which two of the following answers are major risk factors for pregnancy-related morbidity?

a. abc -- incorrect; correct answers are….b. def -- incorrect; correct answers are….c. ghi -- correctd. jkl -- incorrect; correct answers are….e. mno -- correct

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Quiz, format option 3

Which word or phrase best fills in the blank?

_________ would be the most effective single measure to reduce maternal morbidity due to hemorrhage?

a. abc -- incorrect; correct answer is….b. def -- incorrect; correct answer is….c. ghi -- incorrect; correct answer is….d. jkl -- incorrect; correct answer is….e. mno -- correct

Quiz, format option 4Match each item on the left with the appropriate line on the right

• Abc• Def• Ghi• Jkl• Mno• Pqr

• 123• 456• 789• 987• 654• 321

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Note: Be sure to indicate which items are linked

Quiz option 5 – ranking Rank the below answers starting from most important to least important

• Abc• Def• Ghi• Jkl• Mno• Pqr

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Quiz option 6 – true/falseIndicate whether each answer is true or false. (When response is incorrect a brief explanation as to why it is incorrect should be provided)

• Abc [true]• Def [false]• Ghi [false]• Jkl [true]• Mno [true]• Pqr [false]

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Quiz

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Summary

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Further readings & other resources

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Acknowledgments

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