Preface

According to the United Nations, the global population in 2015 exceeded 7.3 billion, and the gender ratio gap between men and women is not large, which means that there are about 3.6 billion women in the world. Therefore, providing 3.6 billion women with high-quality healthcare services and quality is an important global concern. The global focus on women's health began in the 1970s. The United Nations designated 1975 as International Women's Year and 1976–1985 as the world's Decade for Women. In 1995, the Fourth World Conference on Women put forward the Beijing Declaration, with "equality, development and peace" as the main axis. Representatives of 189 countries jointly signed the Beijing Platform for Action, strongly advocated that countries should pay attention to women's issues, and began publishing "Current Situation and Future Trend of Global Women's Statistics." This publication addresses eight topics: population and family, health, education, work, rights and decisionmaking, violence against women, environment, and poverty. It describes the latest statistical data of women in the world and provides a brief analysis that can be used as a reference for countries to plan women's health policies and healthcare services. It is a world trend to attach importance to women's health. The United Nations Population Fund believes that the role of the government is very important if women are to have a bright future. The government is an important force to ensure women's right to health. The role of the government in promoting women's health should be reflected in the following aspects. The first is to support gender equality with legal policies, the second is to ensure the relationship between women workers and employers, and the third is to encourage research on gender-related issues. The 3.6 billion women in the world live in different countries, different social environments, different cultures, and different medical care systems, and each woman plays multiple roles and responsibilities, which highlights the diversity and complexity of women's health problems. Taking women as the main body, we should change the health inequality caused by the gender bias of social and cultural concepts, strengthen the integration strategy of cross fields and departments, and provide appropriate health plans and care for women taking into account ethnic groups, ages, causes of death, disease status and life events. This book provides a comprehensive overview of the current state of the art in global women's health, focusing on the most important evidence-based developments in this critically important area.

We sincerely thank Prof. Mehboob Riffat, Dr. Abdulrasol Zainab Abdulameer, Dr. Devi Gayatri, Prof. Tsikouras Panagiotis, Dr. Rana Amrit Pal Singh, Dr. Ramaraj Pandurangan, Dr. Congjian Shi, Dr. Bilani Nadeem, and Dr. Ali Shazia for their contributions.

**Dr. Zhengchao Wang**

College of Life Sciences, Fujian Normal University, Fuzhou, China

Section 1

## Maternal Mortality and Life Quality

#### **Chapter 1**

## Maternal Mortality Ratio in Low Income Developing Countries

*Riffat Mehboob, Syed Amir Gilani, Sidra Khalid, Amber Hassan and Ahmad Alwazzan*

#### **Abstract**

Maternal mortality (MM) is a matter of serious concern in low income developing countries (LDCs). A great reduction has been observed regarding the maternal deaths globally after huge efforts since 1990 todate. However, the situation continues to be either stagnant or worsening in developing countries, suggesting that the efforts to cope with this issue are either insufficient or not properly implemented. We need to first diagnose the problem areas that are a great hurdle in the road to success towards the reduction of MM. Postpartum hemorrhage and preeclampsia are one of the most common causes of MM. Malnutrition, neurological dysfunction and cancer are among the non-obstetric causes. Trained medical and paramedical staff can be of great help in this regard by increasing awareness among masses at grass root level. Target set by Millennium Development goal has minimized the MM by 44%. But it has not met the target set by Millenium Development Goals 5 and a lot of measures need to be taken in this regard. Majority of the MDs are preventable and can be avoided by adopting appropriate frameworks, linked data sets, surveillance, birth attendants training, preparation for births, etc. Delay in decision to get healthcare, access to healthcare center and receiving these facilities are the main factors in MM.

**Keywords:** maternal mortality, Pakistan, millenium development goals, sustainable development goals, antenatal care

#### **1. Introduction**

Severe Maternal Outcomes (SMO) comprises of Maternal Near Miss (MNM) or Maternal Death (MD) [1]. MD is considered as the most tragic event and can be preventable if the mother is given proper medical aid and facilities. It is considered as an indicator about the quality of medical services of a country [2]. WHO defines MD as: "the death of women during pregnancy or within 42 days after termination of pregnancy irrespective to the cause of death" [3]. Maternal Mortality Rate (MMR) is defined as the number of MDs divided by the number of live births during a particular time period [2]. A country's MMR indicates the development, health and medical status [4]. Maternal mortality (MM) is divided into direct and indirect deaths: direct death is caused by delivery and complication in 42 days of postpartum and indirect death are those MDs which are caused by any disease

which is affected or enhanced by pregnancy's physiological effects. Accidental deaths in which pregnancy has no role is not considered as MD [2, 4, 5].

#### **2. Trends in global mortality rates**

Though MMR has decreased since 1990 to 2015 (estimated 303,000/100 million live births), it still remains a big challenge in many LDCs [6]. Some regions of the world have high MMR which is indicative of the poor health facilities and disparities in access. Low Income Developing countries (LDC) contribute to maximum of MMR (99%) [7, 8]. Sub-Saharan Africa has the highest MMR (14110/100 million live births) and South Asia (1428 million/100 million) is second in world ranking in 2015 while Common wealth Independent States including Armenia, Azerbaijan, Belarus, Georgia, Russia, Tajiskistan etc. has lowest (313/100 million live births) MMR. European Union also has second lowest MMR (307/100 million live births) (**Figure 1**). According to WHO report, the MMR in LDCs was 239 per 100 million live births as compared to 12 in developed countries (DC) in 2015. There are inequalities in these ratios between regions, countries, different socioeconomic strata, rural and urban populations [9].

Among South Asian countries, Afghanistan has the highest MMR (396/100 million live births) in 2015 while it was 1340/100 million live births in 1990, Pakistan is 7th in ranking in this region with 0.178 million/100 million live births in 2015 while it was 0.431 million/100 million live births in 1990. Srilanka has the lowest MMR (30/100 million live births) in 2015 while it was 75/100 million live births in 1990 (**Figure 2**) [10]. Siera Leone has an estimated MMR 1360/100 million live births which is not only highest in Sub-Saharan Afria but also in the world. Although it has dropped from 2630/100 million live births in 1990. Finland and Greece have the lowest MMR 3/100 live births globally and considered as best countries as far as maternal health is concerned (**Figure 3**) [10].

Globally the MMR has decreased from 385 in 1990 to 216 in 2015 showing an annual reduction of 2.3%. The yearly number decreased from 532 000 in 1990, to 303 000 in 2015. During 1990 to 2015, the annual reduction rate in Eastern Asia was 5·0% and in Caribbean was 1·8%. MMR of developed countries was 12/100 000 livebirths in 2015 and for Sub Saharan Africa was 546 respectively [8]. Globally large decline in different regions of the world has been observed that includes South-East Asia with 69% reduction and Western Pacific with 64% reduction. Least progress in MMR is observed in African with 44% decline and America with 49% decline [7, 8].

**Figure 1.** *Maternal mortality ratio (MD per 100 mllion live births) in 1990 and 2015 in different regions of world.*

#### *Maternal Mortality Ratio in Low Income Developing Countries DOI: http://dx.doi.org/10.5772/intechopen.95258*

**Figure 2.** *Trends in MMR (1990–2015) in South Asia.*

**Figure 3.** *Sand clock of five countries with highest (red) and lowest (green) MMR.*

### **3. Millennium development goals and maternal mortality**

Globally all organizations have focused on reducing MDs by initiating a number of programs since 1980's [5]. United Nations (UN) made 8 Millennium Development Goals (MDGs) in September 2000 in which one was about maternal mortality [11]. All the goals had to be achieved by the member countries by the end of 2015. MDG called for the reduction of 75% of maternal mortality by the end

of 2015 and all countries and international agencies were directed to monitor the progress towards the completion of the goal (between 1990 to 2015) [8]. It means that the target would be achieved by maternal mortality decline of 5.5% per year during 25 years time period. However, MMR has decreased by 37% since 2000, even then 303 million women died across the world in 2015 [7].

#### **4. Sustainable development goals-United Nations**

International and national level political partnership and funding could improve education, socio-economic conditions, gender equality and environment. After end of era of MDGs a new agenda was announced in 2015 that consists of 17 SDGs [7]. According to SDGs the target is to decrease maternal deaths to <70 deaths per live births by 2030 and no country should increase its MMR to 140/100,000 live births [8, 12]. The United Nations (UN) secretary general Banki-Moon has started the global strategy for mothers, meonates, infants, children and Adolescent's health from 2016–2030 [13]. This Strategy will be a road map and tries to end all possible causes responsible for maternal mortality [8].

According to Goal 3.1 of Sustainable Development Goals (SDGs) of United Nations, MMR should be reduced to less than 70% per 100 million live births. Tremendous efforts have been made since 2000 and an impressive outcomes have been observed. Goal 3.7.1 focuses on women in their reproductive years, who had successfully adopted the modern family planning methods. Goal 3.7.2 discuss about the adolescent birth rate (10–19 years)/1000 women in that age group. MMR in sub-Saharan Africa has reduced by 35% since 2000. The adolescent birth rate in 2018 was 44/1,000 women (15–19 years) at global scale while 56 in the year 2000. Its rate is 101 in sub-Saharan Africa which is the highest of all. Target 3.7 addresses the availability and access to reproductive health, its awareness and implementation at national level, all over the world [14].

In 2010, 12% of global population spent approximately/10th of their budgets for health services as compated to 9.7% in 2000. An estimated \$9.4 billion was donated from various donars as Official Development Assistance (ODA) in 2016 which is 41% more. All the data available so far indicates that 45% of the world and most of the LDCs (90%) have not even one physician per 1,000 population and approximately 60% have less than 3 nurses per 1,000 [14].

#### **4.1 Maternal mortality in Pakistan**

The status of MDs in Pakistan is very poor and Pakistan is recognized as a country with high MMR. It is estimated that approximately 30,000 women dies every year due to pregnancy-related complications [15]. Measuring MMR is also a big challenge due to poor system of record keeping and weak certification of the reason of causality [16]. The reduction rate of MMR from 1990–2015 was 3.5% with 431 MDs/100 million live births in 1990 to 178 deaths in 2015. 89% of deliveries occur at home that causes 80% of MDs. 80% delivery occurs by the traditional birth attendants (TBAs) and only 1 out of 20 pregnant women reaches hospital or dispensary emergency [17].

In a study conducted in a teaching hospital in Karachi indicated that unsafe abortions carried by untrained health care service providers was the main reason of MDs [18]. The most common among all reasons was hemorrhage and then eclampsia and sepsis [19]. Pre-eclampsia and eclampsia causes 10.4% and abortion cause 5.6% of MDs [16, 19]. The main reasons of MDs in another study from Khyber Pakhtunkhuwa (KPK) province of Pakistan were hemorrhage, sepsis, eclampsia, and hepatic encephalopathy. 40% of the overall cases were dealt by TDAs, 33% by lady health visitors, 17% received no care and 10% by doctors [20]. In a ten year study, from January 1995 to December

#### *Maternal Mortality Ratio in Low Income Developing Countries DOI: http://dx.doi.org/10.5772/intechopen.95258*

2004, conducted at Nishtar Hospital, Multan the major causative factors were hemorrhage, eclampsia, sepsis, anemia, and abortion. The study also concluded that increase in mother's age is linked to increased MDs [21]. Most of the studies concluded hemorrhage as the leading cause of death while sepsis or eclampsia was the second main cause. In indirect causes, anemia and hepatitis was the main cause of death [4].

Different studies have been conducted in the provinces and hospitals to identify main causes and prevention of MD [22]. In 2005, Jokhio *et al.* performed a cluster randomized controlled trial in seven regions (talukas) of a rural district Larkana, Sindh in Pakistan by training TBAs in three talukas known as intervention group and the remaining four talukas, TBAs were not trained (control group). The trained attendants were given sterilized delivery-kits for deliveries. 30% reduction in the intervention group was found as compared to the control group. This strategy can be applied to improve maternal health in LDCs [17].

Ali *et al.,* designed a study to gather information about the health care facilities and emergency obstetric care (EmOC) using unprocessed indicators, in Punjab and KPK. It was found that in Punjab only 16 and in KPK only 6 health care services provides these basic facilities. His study showed that basic Obstetric facilities are very poor in Pakistan and it is extremely necessary to increase access and upgradation of these services. Another important aspect is transportation as most of the hospitals in the study here lack functional ambulance to take patient immediately to a nearby hospital or health care facility. Only 5.7% of deliveries occured in government health care centers that provide EmOC. This shows that women who need basic treatment cannot access government hospitals but either go to private hospital or seek no care [17]. Midhat *et al*., investigated the cause associated with MDs in 16 rural districts of Balochistan and KPK provinces of Pakistan. The study concluded that women under 19 and over 39 years, or those delivering for the first time and those with an earlier record of fetal loss were having a high risk of MD. Essential Obstetric Care (EOC) was linked to MD. Results showed that staffing of peripheral health facilities and the role of health care facility is also linked to MD, which needs to be improved [17].

#### **4.2 Pakistan Demographic and Health Survey**

A survey conducted by Pakistan Demographic and Health Survey (PDHS) reported the MMR as 276 during the year 2006–2007. Also, there are differences in MMR between different provinces such as MMR of Baluchistan was 785, Sindh 314, KPK 275 and Punjab was 227. Besides provincial differences, rural MMR (319) is double as compared to urban MMR (175). Pakistan progress towards completing Millenium Development Goals (MDG) was very inadequate due to lack of resources and failure to provide good health care services to pregnant women. According to PDHS, the set targets were not achieved by the end of 2015 [23]. The MMR in 1990 was 385 which dropped to 216 per 100 million live births in 2015. After the end of MDG of 2015, Sustainable Development Goals (SDGs) was stated that targets to reduce MMR by the end of 2030 is 70 maternal mortality per 100 million live births [7, 8]. Global MM has decreased between the years 1990–2015 to 44%. Although it did not meet the required target set by MDG5, still a lot of measures need to be done to meet the target [14].

#### **4.3 The three delays model**

This model was proposed by Thaddeus et al., in 1994. It proposes the contributing factors that lead to the maternal mortalities. According to this model, most of the factors: distance, cost and quality are preventable and can be avoided if the health care is provided intime without any delay. The three factors responsible for MDs are summarized in three delays model (**Figure 4**) [24].

**Figure 4.** *The three delays model for maternal mortality.*

#### **4.4 Risk factors**

Infrequent visits to Antenatal Care (ANC) units contribute substantially to the preventable MM in Sub-Saharan Africa. A home-based Community Health Worker (CHW) intervention in Tanzania significantly improved this situation in a locality with a higher level of facility based delivery. Policies should be devised and adopted to evaluate and design interventions to reduce the economic burden of ANC [25]. Inadequate training of midwives [26] and TBAs is a modifieable factor in reducing the MD [27]. In a retrospective study in Pakistan, those women who were administered by labour inducing medications by TBAs and lady health workers and susceptible for elongated duration of labour were more prone to uterine rupture and asphyxia while those with hemorrhage at the time of delivery (**Figure 5**) [26].

#### **4.5 Eclampsia and hypertension**

Approximately 42,000 MDs occured in the year 2015, as a result of pregnancy induced hypertension globally [28]. A study on 10 LDCs was conducted to evaluate the incidence of eclampsia and hypertension and its association to magnesion sulfate. 0.5% of all deliveries had eclampsia and 6.9% of them died. 0.95%/10,000 died from hypertension during pregnancy. These disparities in MDs across different LDCs is evident of inequality of availability and access to healthcare facilities for women with these complications in pregnancy (**Figure 5**) [28].

#### **4.6 Postpartum hemorrhage (PPH)**

Postpartum hemorrhage (PPH) was observed to have an association with MDs in Mozambique and Sub Saharan Africa [29, 30]. In 2015, the Mozambican Ministry of Health (MOH) launched a community-level misoprostol distribution program in chosen districts as a plan to decrease PPH. ExpandNet/World Health Organization

*Maternal Mortality Ratio in Low Income Developing Countries DOI: http://dx.doi.org/10.5772/intechopen.95258*

**Figure 5.** *Risk factors associated with maternal deaths.*

(WHO) scale-up framework was used to evaluate the organization, evolution and the beneficial effects of misoprostol for the prevention of PPH. Interviews from health care staff and TBAs using the same framework in addition to national policies and 2017 guidelines from National Ministry of Maternal, newborn and childhealth workshop. The obstacles and accelerators associated with this program were highlighted in order to adapt this framework at national level [30]. The same causative factor was found to be linked to PPH and SMP in Nigeria. It occurred in 2.2% of the deliveries recorded in 42 tertiary care hospitals in Nigeria during one year period, among which 0.3% of women had an SMO [1]. Anemia may also lead to PPH (**Figure 5**) [31].

#### **5. Non-obstetric causes of MDs**

MNM was defined by WHO as an organ-system failure based on clinical criteria to assess the non-obstetric causes of SMO in a one year duration. It was observed that 9.4% (9401/100107) women admitted to the 42 tertiary hospitals in Nigeria for maternal complications had non-obstetric reasons. 4% (375/9401) of these complicated cases were MNM in 48% (183/375) and MD in 51.2% (192/375) [32]. Severe anemia contributed to 61.2% of MNM and 32.8% of MDs. Cancer contributed to the highest MI (91.7%), liver dysfunction (81.8%), HIV (80.4%), neurological (77.1%) and cardiovascular failures (75%). MDs were also associated with lack of awareness, lower and elderly ages. Consequently, it led to poorer pregnancy outcomes [32]. Similar findings were observed in another study in which the association of anemia with maternal and neonatal outcomes was investigated. Worldwide, 24.8% of population is anemic and pregnant women contributes the largest. It may lead to low birth weight, preterm delivery, low APGAR score etc. (**Figure 5**) [31].

#### **6. Cesarean sections**

MDs following cesarean sections are disproportionately high in LDCs. Timely access to the healthcare center is of utmost importance for a safe delivery. In a meta-analysis, 196 trials from 67 LDCs were analyzed. Women with C-section

were at higher risk (7.6/1000 procedures). One-forth of all MDs in LDCs in 72 studies underwent C-section (**Figure 5**) [33].

#### **7. Prevention of maternal mortality**

MMR is difficult to measure. It is important to know the causes of MD and how it can be prevented. PDHS reports show that MD accounts for 20% of deaths of females of 15–49 years of age 0 [16, 23]. Most MDs can be prevented by providing care of skilled and trained personnel. All the causes discussed above can be prevented by giving proper diagnosis, management and understanding of childbirth problems [20]. Trained health professionals should handle labor complications. Severe bleeding can be stopped by an injection of oxytoxin. Also child birth should take place in hygienic environment. Pre-eclampsia can be prevented by giving drugs such as magnesium sulfate [19].

Main challenge is to provide proper EmOC 24/7. Staff training can increase confidence and skills. It is important to take steps for its implementation and upgrade basic plus comprehensive EmOC services [17].

#### **8. Linked dataset for maternal outcomes**

Linked dataset across any country or any population for assessing the maternal outcomes. In a recent study conducted in Australia, first national linked dataset was used for this purpose. Although, this data linkage had methodological and jurisdictional challenges, it is valuable source to enhance knowledge about maternal and neonatal outcomes from different settings (**Figure 6**) [34].

**Figure 6.** *Frameworks to prevent maternal deaths.*

#### **9. Sisterhood method of maternal mortality Surveillance**

This method os surveillance is useful for estimation of MMRs in circumstances of limited resources, infrastructure and when mother is not available due to sad demise. Relatives, close family provide the information in such case. Based on National Total Fertility Rate (TFR) estimate of 4.88, Tajik Badakhshan had 141 MDs/100 million live births. Accurate TFRs are necessary for the actual and precise estimates of MD but certain variations are observed due to varied dempgraphics [35] (**Figure 6**).

#### **10. Saving mothers giving life**

Ending preventable MDs is still a worldwide problem that need to be address under the United Nations Sustainable Development Goal targets 3.1 and 3.2. [11]. Saving Mothers, Giving Life (SMGL) (**Figure 6**) was designed in 2011 within the Global Health Initiative as a public-private partnership between the U.S. government, Merck for Mothers, Every Mother Counts, the American College of Obstetricians and Gynecologists, the government of Norway, and Project C.U.R.E. SMGL's. The starting goal was to decrease the MDs in LDCs.

A pilot project was initiated under this approach (2012–2013) in 8 rural districts in Uganda and Zambia with high morbidity of MD. Later on it was expanded to 13 districts of Uganda and 18 of Zambia. The outcomes of this strategy after its implementation were marvelous. 35% decrease in MMR was observed in just one year, 44% in Uganda and 41% in Zambia during 5 years. Facilitated and assisted deliveries raised from 46–67% in Uganda, 62–90% in Zambia; C-sections increased from 5.3–9% in Uganda and 2.7–4.8% in Zambia; MDs reduced from 11.5–3-5% in Uganda and 10–5-2.8% in Zambia [36].

#### **11. Simulator-based training**

Simulator-based training may be beneficial and effective for the readiness and preparedness of TBAs and birth attendants in case of rare incidences or complications. It may save precious maternal and neonatal lives by improving the expertise and skills as well as preparing them for such events. Purpose is to establish the facilitators and obstacles in "low-dose, high-frequency" (LDHF) practice [29] (**Figure 6**).

#### **12. Train the trainers Model**

This model was adopted to conduct a course (2012–2015) in Cambodia to reduce the MDs. It was a sustainable model to create awareness and knowledge to improve the maternal outcomes. 3 hospitals and 42 health centers in Ethiopia were selected where the trainees collected the data and analyzed. A significantly high MMR was observed in cases of PPH, pre-eclampsia, complicated deliveries and C-sections. This ratio decreased from 64.7–40.8%/100 million deliveries in 2016 [37] (**Figure 6**).

#### **13. Birth preparedness and complication readiness (BPCR)**

This strategy helps the women to be aware of all possible maternal health care facilities during pregnancy and get ready for every circumstances including complications [6]. Ethiopia has the lowest antenatal care facilities due to low income and

resources. Hence, it is creating awareness for BPCR through community services to reduce the MMR. In a study conducted in Ethiopia, secondary data from 215 women with a recent live birth in 10 health care centers was collected. Purpose of this survey was to get an insight regarding the birth readiness. Four out of six actions: identified a skilled health care provider, health center and transport, arranged the finances and clean delivery materials, prepared eatbles, were indicators of well preparedness of mothers. According to this criteria, two-third of the mothers were considered well prepared for delivery. Delivery in a health care center was practiced by well prepared mothers (57%). Antenatal birth preparedness counseling should be provided as a preventive measure to the mothers during the antenatal visits [38] (**Figure 6**).

#### **14. Maternal Death Surveillance and Response (MDSR)**

This system was proposed to provide knowledge for the prevention of MM. Evaluation of the MDSR was conducted in Hwange District, Zimbabwe, 2017.36 respondents were recruited from 11 health care centers, approximately 72% of them were women. Lack of knowledge and awareness of health care workers was found to be main reason for the late notification of MDs. MDSR system is reliable and useful but it is not very simple. Therefore, proper descriptions of the cases and guidelines for declaration of MDs should be taught and adopted by the heath care workers [39] (**Figure 6**).

#### **15. Recommendations**

According to the demand and suppy model to prevent MM, there are 4 needs of a balanced system: Health Promotion, Family planning, income generation and community advocacy. If these are provided, it will help in training of TBAs, upgraded equipents and provision of medicines, training of other health professionals by simulation based or other sessions and improvement in EmOC services. It may ultimately lead to the prevention or reduction in MMR [35] (**Figure 7**).

There is still a rise in MMR, despite of present stretegies to cope with this issue which is indicative of the insufficient obstetric, gynecological and neonatal care in LDCs [40]. Poor health and education in females is a matter of great concern in this regard. No monitoring body at government level is present to address these issues.

Strict control of labour/inducing drugs by the regulatory bodies is mandatory along with improved training of the healthcare workers [26]. Women with poorer access to the antenatal care facilities and skilled TBAs are at higher risk [41].

**Figure 7.** *Demand and supply model to prevent maternal mortality.*

#### *Maternal Mortality Ratio in Low Income Developing Countries DOI: http://dx.doi.org/10.5772/intechopen.95258*

Efforts for the improvement of EmOC quality should be continued through proper skill-based training, incentives, latest equipment and sufficient drugs [42]. Education of females must be improved. Transportation should be improved for pregnant women as recommended in the UN-MDG-5 [43]. TBAs should be provided with financial benefits in recognition of referrals to community midwives [27]. Skilled TBAs assisted approximately 80% live births from 2012–2017 as compared to 62% from 2000–2005 [7]. Perspectives, concerns of different communities and the health care providers should be kept in mind before planning for any strategy, preventive measures, solutions and policies [44].

The rate of cesarean deliveries is alarmingly high in LDCs. Most of the patients go to private hospitals where cesarean deliveries are done just for commercial purposes [33]. Government should take strict measures to lower this negative trend. This undue practice is harmful not only for the health of mother but also for future pregnancies and their outcomes. Awareness classes should be compulsory for both parents in the case of first pregnancy as most of the observed mortalities are observed in primiparous mothers. Strategies should be devised for reduction of domestic violence. Laws should be enforced to minimize Intimate partner violence (IPV) during pregnancy. The Government should make policies and guidelines to improve maternal, child care and also for the antenatal care. Early marriages should be prohibited and laws should be enforced. Poor families should be given some support from government to bear the expenses of delivery, pre and post natal and maternal care. Better nutrition, health care facilities and education are needed to reverse these trends.

EmOC facilities should be improved at grass root scale of health care delivery to prevent avoidable MDs from PPH [1] and pre-eclampsis [45]. The adjustable parameters like maternal weight, diet, awareness and access to the health center should be monitored to improve the maternal and fetal situation and avoid MDs [46]. Proper implementation of these guidelines along with knowledge and training would guide the health professionals to diagnose the complications, manage them and help in reduction of MDs [6, 45, 47].

Research on maternal mortality in Pakistan is next to zero and there are no linked datasets, no coherent information. Hurdles are at both ends, Government (due to lack of resources, funds and priority) and people (they are not willing to investigate or provide information, poverty and lack of resources). These issues can be measured by a nation wide surveillance, coherent and linked datasets with all the information, and the models provided in this debate which are adopted by some other countries as well (simulator based training, train the trainers model, saving mothers giving life, birth preparedness, sisterhood method etc) may provide frameworks to the Government and healthcare policy makers to address and prevent this issue of serious concern to achieve the sustainable development goals.

#### **Competing interests**

Authors report no competing intestests or any conflict of interests.

#### **Funding**

No funding was received.

#### **Ethical approval and consent to participate**

N/A.

### **Consent for publication**

Provided by all the authors.

### **Availability of data and material**

It is a review and no data was used.

#### **Authors contributions**

All the authors have read and approved the final manuscript.

RM designed and planned the study. She supervised and mainly conceived the idea.

SAG facilitated the study, critically reviewed and helped in finalization of work. SK also helped in write up and finalization.

AH helped in write up and compiling.

AA has critically reviewed and gave expert opinion.

### **Abbreviations**


*Maternal Mortality Ratio in Low Income Developing Countries DOI: http://dx.doi.org/10.5772/intechopen.95258*

#### **Author details**

Riffat Mehboob1 \*, Syed Amir Gilani2 , Sidra Khalid1 , Amber Hassan1 and Ahmad Alwazzan3

1 Research Unit, Faculty of Allied Health Sciences, The University of Lahore, Lahore, Pakistan

2 University Institute of Dietetics and Nutritional Sciences, Faculty of Allied Health Sciences, University of Lahore, Lahore, Pakistan

3 Division of Gynecology Oncology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

\*Address all correspondence to: mehboob.riffat@gmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[15] Jafarey S, editor. Maternal mortality in Pakistan: an overview *Maternal Mortality Ratio in Low Income Developing Countries DOI: http://dx.doi.org/10.5772/intechopen.95258*

in maternal and perinatal health in Pakistan. Proceedings of an Asia and Oceania Federation of Obstetrics and Gynaecology (AOFOG) Workshop, Karachi; 1991.

[16] Jafarey SN, Rabbani A. Maternal mortality in Pakistan. National Committee on Maternal Health Newsletter. 2000.

[17] Gardosi J, Madurasinghe V, Williams M, Malik A, Francis A. Maternal and fetal risk factors for stillbirth: population based study. BMJ. 2013;346:f108. Epub 2013/01/26.

[18] Marufu TC, Ahankari A, Coleman T, Lewis S. Maternal smoking and the risk of still birth: systematic review and meta-analysis. BMC public health. 2015;15:239. Epub 2015/04/18.

[19] Altpeter F, Springer NM, Bartley LE, Blechl A, Brutnell TP, Citovsky V, et al. Advancing Crop Transformation in the Era of Genome Editing. The Plant cell. 2016. Epub 2016/06/24.

[20] Begum S, Aziz-un-Nisa BI. Analysis of maternal mortality in a tertiary care hospital to determine causes and preventable factors. J Ayub Med Coll Abbottabad. 2003;15(2):49-52.

[21] Lamont K, Scott NW, Jones GT, Bhattacharya S. Risk of recurrent stillbirth: systematic review and metaanalysis. BMJ. 2015;350:h3080. Epub 2015/06/26.

[22] Jafarey SN. Maternal mortality in Pakistan--compilation of available data. JPMA The Journal of the Pakistan Medical Association. 2002;52(12):539- 544. Epub 2003/03/12.

[23] Newletter NCfMH. Maternal Mortality in Pakistan. https:// wwwncmnhorgpk/wp-content/themes/ ncmnh/images/ncmnh-newsletter-june-2000-newpdf. 2000.

[24] Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med. 1994;38(8):1091-1110. Epub 1994/04/01.

[25] Geldsetzer P, Mboggo E, Larson E, Lema IA, Magesa L, Machumi L, et al. Community health workers to improve uptake of maternal healthcare services: A cluster-randomized pragmatic trial in Dar es Salaam, Tanzania. PLoS medicine. 2019;16(3):e1002768. Epub 2019/03/30.

[26] Shah S, Van den Bergh R, Prinsloo JR, Rehman G, Bibi A, Shaeen N, et al. Unregulated usage of labour-inducing medication in a region of Pakistan with poor drug regulatory control: characteristics and risk patterns. International health. 2016;8(2):89-95.

[27] Shaikh BT, Khan S, Maab A, Amjad S. Emerging role of traditional birth attendants in mountainous terrain: a qualitative exploratory study from Chitral District, Pakistan. BMJ open. 2014;4(11):e006238. Epub 2014/11/28.

[28] Vousden N, Lawley E, Seed PT, Gidiri MF, Goudar S, Sandall J, et al. Incidence of eclampsia and related complications across 10 low- and middle-resource geographical regions: Secondary analysis of a cluster randomised controlled trial. PLoS medicine. 2019;16(3):e1002775. Epub 2019/03/30.

[29] Williams E BE, Holcombe S, Atukunda I, Namugerwa RI, Britt K, Evans C Practice so that the skill does not disappear": mixed methods evaluation of simulator-based learning for midwives in Uganda. BMC: Human Resources for Health. 2019;17(24).

[30] Hobday K, Hulme J, Prata N, Wate PZ, Belton S, Homer C. Scaling Up Misoprostol to Prevent Postpartum Hemorrhage at Home Births in Mozambique: A Case Study Applying

the ExpandNet/WHO Framework. Global health, science and practice. 2019;7(1):66-86. Epub 2019/03/31.

[31] Lumbanraja SN, Yaznil MR, Siregar DIS, Sakina A. The Correlation between Hemoglobin Concentration during Pregnancy with the Maternal and Neonatal Outcome. Open access Macedonian journal of medical sciences. 2019;7(4):594-598. Epub 2019/03/22.

[32] Adeniran AS, Ocheke AN, Nwachukwu D, Adewole N, Ageda B, Onile T, et al. Non-obstetric causes of severe maternal complications: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey. BJOG : an international journal of obstetrics and gynaecology. 2019. Epub 2019/03/22.

[33] Sobhy S, Arroyo-Manzano D, Murugesu N, Karthikeyan G, Kumar V, Kaur I, et al. Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis. Lancet. 2019.

[34] Cheah SL, Scarf VL, Rossiter C, Thornton C, Homer CSE. Creating the first national linked dataset on perinatal and maternal outcomes in Australia: Methods and challenges. Journal of biomedical informatics. 2019:103152. Epub 2019/03/21.

[35] Liese KL, Pauls H, Robinson S, Patil C. Estimating Maternal Mortality in Remote Rural Regions: an Application of the Sisterhood Method in Tajikistan. Central Asian journal of global health. 2019;8(1):341. Epub 2019/03/19.

[36] Conlon CM, Serbanescu F, Marum L, Healey J, LaBrecque J, Hobson R, et al. Saving Mothers, Giving Life: It Takes a System to Save a Mother (Republication). Global health, science and practice. 2019;7(1):20-40. Epub 2019/03/31.

[37] Foo S, Tagore S, Mathur M, Poun K, Sam M, Tan KH, et al. A sustainable model to improve maternal health and promote early obstetric care in resourcepoor regions. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2019. Epub 2019/03/30.

[38] Rosado C, Callaghan-Koru JA, Estifanos AS, Sheferaw E, Shay T, De Graft-Johnson J, et al. Effect of Birth Preparedness on Institutional Delivery in Semiurban Ethiopia: A Cross-Sectional Study. Annals of global health. 2019;85(1). Epub 2019/03/30.

[39] Maphosa M, Juru TP, Masuka N, Mungati M, Gombe N, Nsubuga P, et al. Evaluation of the Maternal Death Surveillance and response system in Hwange District, Zimbabwe, 2017. BMC pregnancy and childbirth. 2019;19(1):103. Epub 2019/03/30.

[40] Pasha O, Saleem S, Ali S, Goudar SS, Garces A, Esamai F, et al. Maternal and newborn outcomes in Pakistan compared to other low and middle income countries in the Global Network's Maternal Newborn Health Registry: an active, community-based, pregnancy surveillance mechanism. Reproductive health. 2015;12 Suppl 2:S15. Epub 2015/06/13.

[41] McClure EM, Saleem S, Goudar SS, Moore JL, Garces A, Esamai F, et al. Stillbirth rates in low-middle income countries 2010-2013: a populationbased, multi-country study from the Global Network. Reproductive health. 2015;12 Suppl 2:S7. Epub 2015/06/13.

[42] Utz B, Zafar S, Arshad N, Kana T, Gopalakrishnan S. Status of emergency obstetric care in four districts of Punjab, Pakistan - results of a baseline assessment. JPMA The Journal of the Pakistan Medical Association. 2015;65(5):480-485. Epub 2015/06/02.

*Maternal Mortality Ratio in Low Income Developing Countries DOI: http://dx.doi.org/10.5772/intechopen.95258*

[43] Budhwani H, Hearld KR, Harbison H. Individual and Area Level Factors Associated with Prenatal, Delivery, and Postnatal Care in Pakistan. Maternal and child health journal. 2015;19(10):2138-2146. Epub 2015/04/16.

[44] Hamid S, Malik AU, Richard F. Stillbirth--a neglected priority: understanding its social meaning in Pakistan. JPMA The Journal of the Pakistan Medical Association. 2014;64(3):331-3. Epub 2014/05/29.

[45] MacDonald EJ, Lepine S, Pledger M, Geller SE, Lawton B, Stone P. Preeclampsia causing severe maternal morbidity - A national retrospective review of preventability and opportunities for improved care. The Australian & New Zealand journal of obstetrics & gynaecology. 2019. Epub 2019/03/19.

[46] Wachamo TM, Bililign Yimer N, Bizuneh AD. Risk factors for low birth weight in hospitals of North Wello zone, Ethiopia: A case-control study. PloS one. 2019;14(3):e0213054. Epub 2019/03/21.

[47] Ntoimo LF, Okonofua FE, Ogu RN, Galadanci HS, Gana M, Okike ON, et al. Prevalence and risk factors for maternal mortality in referral hospitals in Nigeria: a multicenter study. International journal of women's health. 2018;10: 69-76. Epub 2018/02/15.

#### **Chapter 2**

## Assessment of Primary Dysmenorrhea and Its Effect on the Quality of Life among Female Students at University of Babylon

*Zainab Abdulameer Abdulrasol*

#### **Abstract**

Primary dysmenorrhea (PD) is a painful menstrual flow in the absence of any pelvic pathology where pain is spasmodic in character and felt mostly in the lower abdominal area. PD considered as common problem in females at reproductive age, it's directly affects the quality of life (QoL). The main objective of this study is to find out the relationship between PD and QoL of among female students. Descriptive correlational study design carried out on (145) female students, purposive sampling, and their ages between (18–25) years, participants were selected from four faculties at the University of Babylon. Numeric rating pain scale (11-point scale) was used for assessing pain intensity, QoL has been assessed by the SF-36 health survey (SF-36). Data have been collected by using a structured interview as method of data collection and using questionnaire as study tool. Data were processed and analyzed by using SPSS version (25). The findings of the present study revealed that (62.1%) of respondents reported as severe primary dysmenorrhea. The greatest proportion of female students with fair QoL and (17.9%) with poor QoL. The study's finding finds out a negative significant correlation between PD intensity and overall QoL scale at P ≤ 0.05 (r = 0.642, P = 0.000).

**Keywords:** primary dysmenorrhea, quality of life, female students, effect, assessment

#### **1. Introduction**

The transitional period of females from childhood to be sexually mature and become capable of production is termed as puberty. Throughout this transition several alterations will take place including hormonal, psychological, cognitive and physical changes besides to the evolution and sexual developments, these changes occur synchronously. The prime physiological change in girl life is the onset of menarche which is special event in females' life due to the first occurrence of menstruation [1].

Menstrual cycle is a natural phenomenon, it is a significant sign of females' health, and it is an important indicator of endocrine function. Yet, data on experience of menstrual cycle and its influence on the health conditions, quality of life (QoL) and social integration among females in developing countries are still insufficient [2].

#### *Global Women's Health*

Menstrual cycle is a periodical, cyclical and interim vaginal bleeding; begin with first occurrence of menstruation (menarche) until menopause. Moreover, its deemed as one of mammal's characteristics especially human, it is described as regular, repeated uterine bleeding depending on endometrial degeneration, that takes place each 21 to 35 days in normal regular menstrual period, within 2 till 6 days of blood flow and average of blood losses 20 to 60 mL, as general it persist up to 40 years [3, 4].

There are several structures of women's body that will cooperate with each other in order to initiate the menstrual blood flow, these structures are: hypothalamus, pituitary gland, ovaries, and uterus. All the four structures must play a part for the ovulation; menstruation commence when fertilization does not occur; menstruation (shedding of the endometrium) marks the beginning of the monthly cycle [5].

One of most common menstrual disorders is dysmenorrhea; which is an episode of uterine cramp in the lower abdominal segment, immediately before or during cycle, dysmenorrhea variance among women. There is lack in understanding the menstrual cycle disorders especially dysmenorrhea. Furthermore, lack of knowledge related to this condition among young girls because they receive scarce education on dysmenorrhea [6].

Dysmenorrhea is either primary which mean it is not related to pathological reasons or secondary related to pathological reasons. Primary dysmenorrhea (PD) occurs because of excessive amount of prostaglandin which is produced during the disintegration of pre-menstrual uterine endometrium. While, the pain is caused by a disorder in the women's reproductive organs, such as endometriosis, adenomyosis, uterine fibroid, or infections, called secondary dysmenorrhea. Pain severity may be measured by using scaled as "no pain, mild pain, moderate pain, severe pain and worst possible pain" [7].

Primary dysmenorrhea is frequent, yet is a challenging problem in Gynecology. Primary dysmenorrhea often, occurs in most if not all women; until this moment is still poorly understood and is seldom taken into consideration when assessing females' general health and life experiences [8].

PD clinical manifestation may include lower back pain, premenstrual irritability, nervousness, fatigue, depressed mood, headache, some of gastrointestinal symptoms such as; nausea, vomiting, bloated abdomen and difficulty in emptying the intestines with constipation or diarrhea, an urge to urinate frequently that can be noticeable in women with PD at least a part or for the duration of the menstrual period [9].

The clinical manifestations of primary dysmenorrhea have tremendous and negative effect on quality of life at least for several days from each calendar month. Primary dysmenorrhea is a complicated manifestation, that impacts on the quality of life and minimizes productiveness of females. An estimation that (50%) of teenagers and adult women or adolescent girls skipped schools or work at littlest once time because of feeling of discomfort and pain which is accompanied with menstrual cycle. This unrelieved acute pain of menstrual cycle can influence inversely on the pulmonary, cardiovascular, gastrointestinal, endocrine and immunity. In addition, the unrelieved chronic pain may inhibit the immunity, result in anger, fatigue, disability, and depression [10].

Primary dysmenorrhea as menstrual cycle disorder resulting in serious condition among women especially young females because its effect is not only about future fertility, it also affects their mental health and quality of life (QoL) [11].

Quality of Life is "defined as a subjective phenomenon based on individual perception, experiences, beliefs, and expectations. Nowadays, QoL has become an issue in many clinical studies" [12].

*Assessment of Primary Dysmenorrhea and Its Effect on the Quality of Life among Female… DOI: http://dx.doi.org/10.5772/intechopen.97001*

Wilson and Cleary (1995) suggest a model defining the process by which woman's physical health status, such as dysmenorrhea, effect on their quality of life (QoL). They put forward that both factors biological and psychological may result in physical and psychophysical manifestations, that probably later impact on functioning and quality of life [13].

Primary dysmenorrhea present features of acute and chronic pain; it is a recurring and regular onset of pain, in spite of its short time span. Yet, astonishingly few of females are known about what the impact of PD on the quality of life. There are extremely scant reports about emotional troubles in females who experiences periodical PD [14].

The most common cause for poorer quality of life is pain depending on precedent researches, QoL observed to be lesser in women with PD [15].

#### **2. Research main body**

#### **2.1 Overview**

Primary dysmenorrhea (painful periods) that are still little understood. PD is a clinical term used to describe pain that experienced during menstruation. PD is a significant clinical problem and results in considerable public health burden. Primary dysmenorrhea is not associated with any underlying pathological causes. The precise mechanisms responsible for the symptoms of primary dysmenorrhea are need to be elucidated [16].

The menstrual period is hormonally intermediated events which take place in four structures in the females' body. These females' biological structures are participating in the functioning of the menstrual period are: hypothalamus, pituitary gland, ovaries and uterine endometrium. For a menstrual period to initiate all 4 biological structures should collaborate; deactivate of any structure will results in an incomplete and ineffective period [17].

Primary dysmenorrhea increased rhythmic uterine contractions from vasoconstriction of small vessels of the uterine wall. This condition impacts a females' ability to achieve their daily activities for 2 or several days every month it is used to start within few years of the beginning of ovulatory cycles at menarche [18].

Degree of intensity include: mil, moderate, and severe; mild PD its agonize menstruation that rarely obstructs the normal activity and analgesics are rarely required, moderate pain is defined as aching menstrual cycle which impacts on daily activity and analgesic are necessary to give relief, in addition to severe pain which mean painful cycle which clearly obstructs daily activity and the pain is not completely relieved by analgesic [19].

Etiologies of PD are not exactly understood, but preponderance features may be clarified via an action of the uterine prostaglandin, generally. Prostaglandin (PGs) is ubiquitously diffused intra-cellular materials which is derived from the long chains poly-un-saturated fatty acid, like arachidonic acid, a usual ingredient of cells membrane phospholipids. Prostaglandins has existing to own a range of impacts on general range of biological and functional as pathological actions containing pain, inflammations, body temperature, also regulation of the sleep. PGs manufacturing and releasing is limited to an availability of free fatty acid predecessors for the arachidonic acid that regulated via cyclic adenosine phosphates. By the cyclical adenosine phosphates, PG manufacturing can be motivated via materials like adrenalin, a peptide hormone & the steroid hormone, besides the mechanical motivation and tissue injury [20].

Arachidonic acid is created from the phospholipids via a lysosomal enzyme phospholipase A2. The stability of the lysosomal activities regulated through several factors, one of these is the progesterone's level; the raised progesterone level tend to steady the activity of the lysosomes, on the other hand the dropping level tends to decrease the lysosome activity. Thus, the reduction in the progesterone's level will go along with the regression of corpus luteum in late luteal phase of menstrual period result in removal of this stabilizing impact on uterine endometrial lysosome, the releasing of phospholipase A2, menstrual period flow and hydrolysis of phospholipid from cell membrane to produce extra arachidonic acid [21].

Consequently, the continuing accessibility of arachidonic acid together with intracellular damage besides tissues' trauma through menstrual period, favoritism manufacturing of PGs. All the females have raised level of PGs during a luteal phase of period as comparison with the follicular phase of ovulatory periods. Though, as a comparison among females with eumenorrheic and females with primary dysmenorrhea, detected that the females with PD have upper level of PG, as measured in a luteal phase of endometrial biopsy [16].

The circulation of PGs (PGF2a & PGE2) is recorded higher level in females with primary dysmenorrhea as comparison with asymptomatic females throughout menstrual period, and this PG's level are uppermost in first forty-eight hours of menstrual period, when signs & symptoms topmost. Additionally, the severity of menstrual period's pain and accompanied features of primary dysmenorrhea are directly related to the amount of PGs that is released [22].

Moreover, when exogenous PGs is clinically administered lead to uterine contraction and produces identical systemic features which recurrently associated with primary dysmenorrhea, containing gastrointestinal symptoms; that means the PGs are causing painful uterine contraction and accompanied systemic clinical manifestations which is associated with primary dysmenorrhea [23].

On the basis that the endometrium is exposed to a luteal phase's progesterone its crucial to increase the production of uterine's PGs, primary dysmenorrhea supposed to happen just in the ovulatory menstrual period; while many studies has been challenged in terms of a basal body's temperature that utilized in order to differentiate between the ovulatory and anovulatory menstrual periods. There is no difference in the severity of menstrual periods symptoms, as well as pain, between the ovulatory and anovulatory menstrual periods among females with PD [24].

P.D. is a significant clinical problem and results in considerable public health burden. In 2007, an International Associations for the Study of Pain calculated roughly that those in every menstrual cycle, about 10% \_15% of females with primary dysmenorrhea were incapable for working about 1–3 days. For example in the United States (U.S.), there is lost approximately (140) million of working hours because of PD every year. In Japan, it was predicted that monetary lost because of PD computed as \$4.2 billion dollar every year. In India it has been detected that about 42% self-medicated and approximately 35% consumed unfitting drug and they used mefenamic acid as a NSAID in order to decrease the pain of PD [25].

Pain is considered as one of the major contributors for poor QoL. PD is a periodic pain state, in which females suffering from acute events of agonizing cramping during the menstrual periods. There is inadequate literatures on an associations among socio-demographical characteristics and menstrual cycle elements with severity of PD and the experiences of the female's students with PD to increase the understanding of phenomenon and the effects on the life of this group of sufferers [26].

Investigation of quality of life domains in females with primary dysmenorrhea manifestations has received very little attention. From menarche and throughout

*Assessment of Primary Dysmenorrhea and Its Effect on the Quality of Life among Female… DOI: http://dx.doi.org/10.5772/intechopen.97001*

the pubertal years there are significant rise in depressive features and anxiety and smoking activities; it is critical to study that association of these problems with menstrual period disorders especially primary dysmenorrhea. The existence of both emotional and behavioral troubles can aggravate PD symptoms; it has been detected when evaluating the causes PD [27].

#### **2.2 Methodology**

#### *2.2.1 Design of the Study*

A descriptive correlational study design was carried out in order to assess the severity of primary dysmenorrhea, and its effect on quality of life among female students whose ages are between (18 to 25) years old, at the University of Babylon in the province of Babylon, from the period 1st September 2018 to 14th August 2019.

#### *2.2.2 Administrative arrangements*

Formal administrative agreements were acquired for conducting the current study before data collection. The Ethical Committee of the college of nursing approved the protocol for this study. Consent was attained from the University of Babylon from the colleges that involved as study's sitting which include; faculty of basic education, faculty of human education, college of engineering and college of science. Written consent was attained from the subjects undergone the study, any participant will have the right to retreat from the study at any time.

#### *2.2.3 Setting of the study*

The current study has been carried out in Babylon governorate at University of Babylon which consists of (21) colleges, (4) colleges were selected randomly to accomplish the study and then select department from each college as 10% randomly.

#### *2.2.4 Study sample*

A non-probability (purposive) sample; 30% of target population was selected of female students, were consisted of (145) participants. The selection included participants who have mild, moderate and sever intensity of primary dysmenorrhea. It is selected from (4) faculties.

#### *2.2.5 The study instrument*

Through the extensive review of relevant literatures and previous studies, a questionnaire constructed for the purpose of the study. It is composed of seven parts. The first one is demographic data, second part is Numeric Pain Rating Scale (NPRS), the third part is dietary habits, the fourth part is family history, the fifth part is pain reliever history, sixth part is menstrual history, and last one is SF-36 Health Survey of quality of life.

#### *2.2.6 Method of data collection*

After taking an approval from the institutional ethical committee, the data was collected. The participation of study subjects was on voluntarily basis, written

#### *Global Women's Health*

consent obtained from female students who willing to participate. Data attained by utilization of the study tool (questionnaire) and face-to-face interview, structured interview as method of data collection. The investigator was available on the site during distribution of questionnaire, to explain for them the objectives behind the study and to avoid any form of misunderstanding and to facilitate accurate response by the subjects.

Data collection started from 9th of January 2019 to 13th of March 2019. Close end questions used in the questionnaire. Time was consumed for each interview approximately (15\_20) minutes.

#### *2.2.7 Methods of data analysis*

The data of the present study was analyzed by the Statistical package of social science (SPSS) version (25). The tests which were used in this study were derived from both: descriptive and inferential statistic, which includes: frequencies, percentage, mean of scores, standard deviation, Chi-square and Pearson product– moment correlation; all of these tests were used in order to achieving the objectives of study.

#### **2.3 Result**

**Table 1** reveals that a (61.1%) of the sample were within the age group (18–21) years old, the highest percentage represented (42.1%) of the female students are in second grade. According to the occupational status majority of participants (92.4%) were not working. The largest proportion of them sample were unmarried represented (89%). The table shows that (57.2%) were satisfied with their socioeconomic condition; with respect to the sample address it has been found that (84.8%) of them live in the urban. Majority of them (95.9%) living with their families. Finally, (64.1%) of study sample were recorded a BMI (18.5 < BMI < 25).

As shown in **Table 2**, the highest percentage represented (62.1%) of the sample experience severe pain.

This table shows that the greatest proportion was tea consumers constituted (63.4%) and chocolate (62.1%), then (41.4%) cola, and coffee was (22.1%).

**Table 4** demonstrate that the highest percentage was sister history of PD (56%), and (34.6%) belong to mothers history of PD while, (32%) belong to others such as aunts.

**Table 5** shows that highest percentage of the sample constitutes (61.4%) used pharmacological relievers for primary dysmenorrhea during their menstrual period.

The table shows that highest percentage represented (61%) of the sample their age of menarche were between (13–15) years old; (52%) their duration of menstrual cycle between (3–5) days. Moreover, a (62.1%) of sample were with regular interval of menstrual cycle.

This table displays the mean of the subscales of quality of life which shows that most of sample with fair level of assessment related to the QoL domains.

The table has clarified that the majority (83.4%) of female students with fair QoL. While (9.0%) were with poor QoL.

In this table Pearson correlation coefficient was used in order to illustrate that there is a negative significant correlation between intensity of P.D. and QoL among female students at *P* ≤ *0.05* (*r* = 0.642, *P.* = 0.000). The outcome of statistical test demonstrates that there is significant correlation between the average scores of study subjects with P.D. and overall QoL scale.


*Assessment of Primary Dysmenorrhea and Its Effect on the Quality of Life among Female… DOI: http://dx.doi.org/10.5772/intechopen.97001*

#### **Table 1.**

*Distribution of female students by their demographical characteristics (N = 145).*


#### **Table 2.**

*Numeric pain rating scale for assessing the intensity of primary dysmenorrhea in the female students (N = 145).*

This table revealed that there was significant association between P.D. intensity and marital status. While, there were a non-significant associations with whole demographical data except marital status at P ≤ 0.05.

This table revealed that there were significant and highly significant associations between P.D. intensity and overall SF-36 scale of quality of life at *p* ≤ 0.05.

#### **2.4 Discussion**

Many studies and literatures emphasize that the sociodemographic characteristics are relate to most of the nursing subjects because nursing as a science deals with human being, people life, and health issues in different age groups and situations, the present study deals with the primary dysmenorrhea and its effect on QoL of female students; result show in **Table 1**, that high percent of sample undergone the study within age group (18–21) this may due to criteria of selection of the current study's sample, and the lawful age of students in colleges and universities; this result consistent with A cross-sectional study by Chia et al. [28].

**Table 1** displayed that the highest percentage of them were female students in second grade, this might be due to the availability of the sample without interference from the researcher; while, the findings of cross-sectional study [29] to determine the prevalence and associated factors of primary dysmenorrhea and its impact to the students' daily activities, showed that the highest percent was first grade. Related the occupational status majority of respondents were not working, most of the students in this age group found to be busy with study requirements and they cannot enroll in any job specially the morning study's students.

In regard to the place of residency it has been found that the majority of female students that are living in urban as it displayed in **Table 1** and that finding matches with a cross-sectional study by Tawfeek [30], her result shown that most of sample from urban; while, findings of other study [30] carried on (900) girls from (8) schools; showed that (469) were of rural residence while (431) were urban ones.

In respect to the residential status the present study result reveals that almost all the female students were living with their families as illustrated in **Table 1** and that contrary to Habibi's [31] showed that the highest value belong to dormitory living.

The current study results revealed that majority of the sample were unmarried, that congruent with a descriptive study findings [32].

The findings of the present study in **Table 1** showed that more than fifty percent were satisfied with their socio-economic condition, which form the highest value, on the other hand, a cross-sectional study [33] exhibited that half of sample stated as satisfied to some extent; this variance may belong to the contentment that widely spreading in Iraqi community and that did not indicated in necessary they are with good socio-economic status but it give them sense of satisfying.

In the light of this study and regarding the BMI a high percentage of respondents were showed normal weight as clarified in **Table 1**, this finding is in line with study [34] confirmed that the majority had BMI within the standard range.

The findings in **Table 2** demonstrated the outcome of Numeric Pain Rating Scale for assessing pain severity; which shows the highest proportion reported sever pain then followed by moderate, and finally mild. It's well known that even with mild level of pain the quality of life of girls may be affected. The study's finding is not consistent to another study [11] that found only (17.7%) of their participants experience severe PD during their period.

In most cases of primary dysmenorrhea the girls may turn to some habits as well as some of those habits may have an influence on their condition. This study deals with them as variables. The results related to dietary habits as showed in **Table 3** which displayed that the highest percentage of sample were tea consumers; while non-of them was reported as smoker, this result as culture is true where most of our people are consuming tea most of their day time. This result seem to be close to findings of the study conducted by Faramarzi and Salmalian [35] in Iran on (360) medical science female students, they verified that most of their students drank tea.

The present study was revealed that all the participants had one or more than one family member or relative experience this pain as demonstrated in **Table 4**,

*Assessment of Primary Dysmenorrhea and Its Effect on the Quality of Life among Female… DOI: http://dx.doi.org/10.5772/intechopen.97001*


#### **Table 3.**

*Dietary habits among female students with primary dysmenorrhea (N = 145).*


#### **Table 4.**

*Distribution of sample related to their family history of primary dysmenorrhea.*

usually and in most conditions and cases like what this study concern with this type of variable is crucial because of the genetic factors. The current result disagree with a study [36] which indicate that most of their sample had no family history regarding to primary dysmenorrhea.

In regard to the pain relievers used by girls during PD, the results confirmed that more than half of them were using pharmacological substances during their period to reduce the cramps and pain discomforts as soon as possible as declared in **Table 5**, a study conducted [37] stated that more than half of their sample using pharmacological substances to relieved their pain.

The onset of menstruation is a part of maturation process, after retrieved articles documenting the menstrual history related to PD, studies revealed that the history of first period vary according to the country and the climate as well as the geographical area. It has been appeared from the current study that Mean and SD of menarche's age for females was (13 1), usual menstrual duration (per days) was (5 1) and more than half of the respondents were with regular menstrual period as illustrate in **Table 6**; a study [14] showed that Mean and SD of the age of menarche was (13 2) and Mean & SD for menstrual period duration was (5 1) these finding similar to current study's findings.

When assess the QoL among female students who experience PD **Table 7**, result revealed that majority of the females with fair QoL assessment, while only few stated good QoL as showed in **Table 8**. A study [9] proved that highest percentage was with poor QoL, with negative impact on the QoL, mainly as related to


**Table 5.** *Pain relievers history used with primary dysmenorrhea (N = 145).*


#### **Table 6.**

*Menstrual characteristics for female students with primary dysmenorrhea.*


#### **Table 7.**

*Assessment of overall quality of life scale of female students with primary dysmenorrhea (N = 145).*

university attendance and performance and social relationships. Tanmahasamut and Chawengsettakul [38] agreed with current study's findings, they confirm PD in students has high prevalence and it has result in poor quality of life.

The current study illustrated a negative significant correlation between the average scores of study subjects with P.D. and overall QoL scale at *P* ≤ *0.05* (r = 0.642, *p* = 0.000), in other words when severity of P.D. pain level increase the quality of life decrease as introduced in **Table 9**. A descriptive study [39] reported that the reduction in QoL was clearly linked to the presence of primary dysmenorrhea.

The present study demonstrated that there is no significant association between socio-demographical features and the intensity of P.D except with marital status as displayed in **Table 10**; there are limited studies on an association of P.D intensity and socio-demographical characteristics.

Present study findings incompatible with a study [33] which accentuated in their results that the risk of primary dysmenorrhea increase in those who had lower incomes as well as in those with family history of P.D. Another study [40] similar to current study's findings revealed that there was no significant association between pain relievers use, dietary habits, and BMI of students with PD, except for coffee consumption at *(P* < 0.001); also no significant association between menstrual cycle characteristics and primary dysmenorrhea was revealed except for menstrual period bleeding duration and family history.

The current study showed in **Table 11** that there were mostly significant and highly significant associations between P.D. intensity and overall SF-36 scale of quality of life at *p* ≤ *0.05.* Pain has negative impact on females' life, especially during menstrual period, because it's accompanied with hormonal alterations; that **NO. Items Never Sometimes Always Mean Ass.** General health domain: 1. In general, would you say your health is good? 27 108 10 2.12 Fair 2. Compared to one year ago, you would say that your health in general is better now? 38 71 36 2.01 Fair 3. I seem to get sick a little easier than other people 42 54 49 1.95 Fair 4. I am as healthy as anybody I know 33 84 28 2.03 Fair 5. I expect my health to get worse 21 79 45 1.83 Fair 6. My health is excellent 35 85 25 2.07 Fair Domain mean = 2.0016 Assessment = Fair Limitation of activities domain: 1. Do you find difficulty while performing Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports? 52 68 25 2.19 Fair 2. Do you find difficulty while doing Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf? 35 58 52 1.88 Fair 3. Do you find difficulty when Lifting or carrying groceries? 25 59 61 1.75 Fair 4. Do you find difficulty when Climbing several flights of stairs? 50 61 34 2.11 Fair 5. Do you find difficulty when Climbing one flight of stairs? 80 45 20 2.41 Good 6. Do you find difficulty when Bending, kneeling, or stooping? 80 46 19 2.42 Good 7. Do you find difficulty when Walking more than a mile? 37 63 45 1.94 Fair 8. Do you find difficulty when Walking several blocks? 27 60 58 1.79 Fair 9. Do you find difficulty when Walking one block? 43 45 57 1.90 Fair 10. Do you find difficulties when Bathing or dressing yourself? 105 29 11 2.64 Good Domain mean = 2.1031 Assessment = Fair Physical health problems domain: 1. Cut down the amount of time you spent on work or other activities 23 94 28 1.97 Fair 2. Accomplished less than you would like 32 83 30 2.01 Fair 3. Were limited in the kind of work or other activities 35 54 26 2.06 Fair 4. Had difficulty performing the work or other activities (for example, it took extra effort) 33 90 22 2.08 Fair Domain mean = 2.0293 Assessment = Fair Emotional health problems domain: 1. Cut down the amount of time you spent on work or other activities 38 87 20 2.12 Fair

2. Accomplished less than you would like 31 94 20 2.08 Fair

*Assessment of Primary Dysmenorrhea and Its Effect on the Quality of Life among Female… DOI: http://dx.doi.org/10.5772/intechopen.97001*


*Ass. = assessment, level of assessment: (1–1.66) as poor level, (1.67–2.33) as fair level and (2.34–3) as good level of QoL.*

#### **Table 8.**

*Distribution of female students according to their quality of life (SF-36) scale.*


#### **Table 9.**

*Correlation between quality of life & primary dysmenorrhea.*


*Assessment of Primary Dysmenorrhea and Its Effect on the Quality of Life among Female… DOI: http://dx.doi.org/10.5772/intechopen.97001*

*X2 = Chi-square, D.F. = degree of freedom, P. value = probability, sig. = significance, S. = significant, H.S. = highly significant, N.S. = not significant.*

#### **Table 10.**

*Association of primary dysmenorrhea intensity with some variables.*


*X2 = Chi-square, D.F. = degree of freedom, P. value = probability, sig. = significance, S. = significant, H.S. = highly significant, N.S. = not significant.*

#### **Table 11.**

*Association of primary dysmenorrhea intensity with quality of life (SF-36) scale.*

basically cause some aliments to most of females. A study [12] supported this result and found that primary dysmenorrhea adversely affect the QoL.

#### **3. Conclusions**

According to the findings and discussion of the study's findings it can be concluded that higher percentage of the sample aged of (18–21) and living in urban region. Majority of these female students were unmarried, their socioeconomic status was satisfied. More than half of respondents were with severe primary

*Assessment of Primary Dysmenorrhea and Its Effect on the Quality of Life among Female… DOI: http://dx.doi.org/10.5772/intechopen.97001*

dysmenorrhea. Majority the participants had positive family history of Primary dysmenorrhea. More than half of the study's sample appeared with regular period. Most of results showed that respondents using pharmacological agents as strategies of pain relief. The great majority domains of the quality of life showed fair assessment regarding primary dysmenorrhea. Present study shows that when primary dysmenorrhea intensity increases the quality of life will decrease. All the demographic data showed insignificant correlation with primary dysmenorrhea except the marital status. A significant to high significant association was found between primary dysmenorrhea intensity and quality of life.

#### **Author details**

Zainab Abdulameer Abdulrasol University of Babylon, College of Nursing, Babylon, Iraq

\*Address all correspondence to: saraaameer44a@gmail.com; nur.zainab.abdulameer@uobabylon.edu.iq

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### Section 2
