Givers of Life Condemned to Death

by Barbara Crossette

In vast, struggling stretches of the world, there lurks a killer of women and girls that no vaccine can prevent. This is the often agonizing, sudden death in pregnancy or childbirth, and it takes the lives, needlessly in most cases, of more than half a million women a year.

An unknown number of other women who survive complications of pregnancy and delivery are left maimed or weakened for life, their lives forever diminished or possibly cut short. For the world’s poorest women, this is a medical crisis, a tragedy compounded by the fact that these deaths and disabilities can be avoided.

About 210 million women worldwide become pregnant every year, and almost 60 million of these pregnancies end with the death of the mother or the baby, or as abortions, according to experts writing in Disease Control Priorities in Developing Countries.¹  The World Health Organization and the Guttmacher Institute announced on October 12, 2007, that there were about 42 million induced abortions in 2003 worldwide, down from 46 million in 1995. A majority of induced abortion are in developing countries, where procedures are often illegal and unsafe. As many as 5 million women in the developing world were hospitalized in 2005 as a result of unsafe induced abortions, WHO reports, though the number may be far higher because of girls and women who do not seek or cannot get medical care. Additionally, spontaneous abortions or miscarriages may result in infections, loss of blood or other debilitating or life-threatening problems.

 

Given that modern health care providers know how to prevent such a high toll in lives and well-being, the sorry statistics surrounding childbirth become indicators of both the state of entire health systems and mindsets that accept women dying to give life. How a mother lives and dies involves almost every aspect of how a society and culture works for women, or fails them.²

Astronomical sums of money may not be the solution for this epidemic, though some spending will be needed to train skilled birth attendants and to improve many thousands of small rudimentary health centers on which the poor depend. These health centers must offer services that are free as well as effective for pregnant women. Maternal mortality has to be fought not in the medical laboratories of the rich countries but in the smallest villages, in the poorest places, by local people who need targeted kinds of support from neighbors, local health officials, and their national governments. They need access to the advice of obstetric experts committed to expanding knowledge everywhere of what can go wrong, how to diagnose a life-threatening problem, and what every community should have on hand to act quickly and effectively when disaster strikes.

 

When the nations of the world adopted the Millennium Development Goals at the turn of the century, a target was set to reduce maternal mortality by 75 percent between 2000 and 2015. Maternal mortality is defined as the death of a woman in pregnancy or childbirth, or within 42 days of the end of a pregnancy, however it ends. The 2015 goal line is fast approaching, but there are many countries that will not reach their targets. At the same time, a growing body of research on how to improve care for women promises that where there are basic resources and the will to change, success is still possible.

Meeting the goal is possible for many countries, say the authors of a comprehensive and illuminating series of articles published in 2006 in the British medical journal The Lancet.³  The team of authors pointed to the successes of Thailand, Malaysia, Sri Lanka and Bangladesh in reducing their maternal mortality ratios (deaths per 100,000 live births) by 50 percent or more in the last four decades of the 20th century. Honduras and Egypt were able to halve their maternal mortality ratios in less than seven years. In such cases, the team writing in The Lancet credited a combination of factors including “long-term investment in midwifery training and referral hospitals; free care and a supporting system with regulation, control, and supervision of the medical and midwifery professions; and information to confirm progress.”⁴  

 

The importance of information—collected accurately and consistently and shared widely—runs through The Lancet series and other research on combating maternal mortality, since the poorest countries where women are often in the greatest danger also have the poorest data. It is an issue being taken up by a number of aid donors, especially foundations with long-term ideas on how to correct underlying institutional weaknesses that prevent progress on many fronts in developing countries. If governments in developing nations are to take charge of setting their own priorities, they need better data with which to frame policies and public health responses. Development assistance experts in a range of fields would like, for example, to see the 2010 round of national censuses produce more and better data than has been the norm.

In an earlier 2004 article in The Lancet, Wendy Graham of the University of Aberdeen, a leader in campaigns to reduce maternal mortality, and the principal investigator of the Immpact⁵  research project for developing nations, wrote with a colleague, Julia Hussein, about the persistent unreliability of statistics. They argued the case for “the women who are not even statistics—for their right to count.”⁶ 

 

Where Death Lurks
 
Maternal mortality remains highest in many parts of sub-Saharan Africa and in South Asia (a region where India’s population dominates). The United Nations Population Fund (UNFPA) says that one in every 16 women in sub-Saharan Africa has a chance of dying in pregnancy or childbirth, compared with one in 2,800 in a developed country. Of the half a million known maternal deaths annually, 95 percent are in Africa and South Asia.

 

In the poorest countries in these regions, the successes of the East/Southeast Asia-Pacific region as well as Latin America, the Caribbean, the Middle East and North Africa will be very hard to match because health systems are inadequate or often stretched beyond capacity by diseases such as AIDS and malaria, fertility levels are high, and family planning services are often scarce. Many women go into a new pregnancy still weakened from earlier births. Not only does women’s reproductive health not get high priority, but there are cultural factors that keep the status of women low and render them powerless to demand better care or the right to control their own fertility safely. Obstetric hemorrhage is the main cause of death in many poor nations, but unsafe abortions also figure high among killers of women. Abortions often speak of desperation, as married or unmarried girls and women without access to contraception turn to often illegal practitioners using unsafe and unsterile methods.

More and better family planning and reproductive health services should be an essential goal in development thinking, experts in both intergovernmental and private agencies insist, even more so in the face of spreading HIV/AIDS epidemics in poor countries. UNFPA, the International Planned Parenthood Federation, and other organizations find very high levels of unmet need for family planning; that is, services or contraceptives are not available to women and men who say they want them. UNFPA said in 2007 that almost one-fifth of married women in developing countries have such unmet needs.  Adolescent girls, married or not, were the least well served. In all, UNFPA said, a lack of access to contraception leads to 70 million to 80 million unintended pregnancies a year in the developing world.

When women cannot find or use or sometimes even learn about contraception or be allowed to seek it, and male use of condoms may be as low as five percent, pregnancies can be dangerously closely spaced.  There is still conflicting evidence regarding pregnancy intervals and its potential effect on maternal mortality and morbidity.  However, it is worth noting that a 2000 study by Agustin Conde-Agudelo and José M. Belizán suggested that “women with interpregnancy intervals shorter than 6 months are at increased risk of maternal death, third trimester bleeding, premature rupture of membrane, puerperal endometritis, and anemia” though recognizing that further studies are warranted.⁷

 

It Starts With Conception

 

The factors that come together to make pregnancy a potentially life-threatening condition are many and differ from place to place. Poor or nonexistent prenatal care is often in the background. Sometimes geography makes access to health centers prohibitively difficult. In the mountainous Himalayan kingdom of Bhutan, where there are very few roads, more than a fifth of the country’s 700,000 people live in remote hamlets from four hours’ to seven days’ walk from even the most basic clinics. Because of this unique challenge, Bhutan bucked international advice favoring home births attended by skilled midwives and adopted a goal of 100 percent institutional deliveries. Health spending has been focused on basic health units, regional clinics and district hospitals rather than on specialty care at the national level. With trained attendants scattered around the country offering good prenatal care and safe deliveries in clean if not sterile settings, maternal mortality has been slashed from 770 per 100,000 live births in 1984 to under 200 per 100,000 live births now, the government says.⁸  Its goal is to get to 100 per 100,000 live births or below in the coming year.

The importance of well-trained birth attendants is emphasized by the Immpact team experts writing in Disease Control Priorities in Developing Countries. The principle, “first, do no harm,” is particularly significant in this area, “because many preventive practices related to pregnancy and childbirth can readily become harmful in unskilled hands—for example, inappropriately early induction of labor and poor forceps technique,”⁹  they say. They also warn that severe problems in pregnancy and delivery can escalate rapidly to a life-threatening situation requiring surgical intervention. Such a situation more often than not carries a death sentence if essential skilled medical help is too far away, or if there is no way to transport a woman to a better equipped hospital.

 

In rural Laos, a very conscientious staff in a small regional clinic looked at me strangely when I asked if there were any kind of ambulance or other transportation available in emergencies. The family of the woman in trouble would just have to find some way to take her to a bigger hospital, they said. There was no money for that kind of luxury. In Ghana, I saw inexpensive Indian-manufactured tractors connected to small trailers carrying emergency supplies that could serve as ambulances where even trucks could not navigate rutted rural tracts.  The Bhutanese have met the problem of moving a woman from her reluctant family before a possible crisis by offering food and accommodation to family members who take her to a regional health center. 

The Disease Control Priorities in Developing Countries authors on maternal and perinatal health (the Immpact team) put together a “kit” of components of a safe motherhood strategy.¹⁰  Here are the basics:

 

• Community education programs;
• Evidence-based prenatal care and counseling, including nutritional advice and dispensing iron and multivitamins and micronutrient supplements;
• Iodization of edible oils and salt and vitamin A in areas of deficiency;
• Blood pressure screening;
• Screening for and treatment of syphilis, HIV testing and antiretrovirals if needed;
• Breastfeeding advice;
• Tetanus immunization;
• Treatment of urinary tract infections;
• Skilled assistance at delivery;
• Postpartum care;
• Safe abortion and post-abortion services; and
• Reproductive health education for adolescents.

 

Involving men in understanding the process and importance of safe motherhood is increasingly recognized as crucial to backing up—and certainly not blocking—a woman’s right to a range of reproductive health services. The World Health Organization’s Making Pregnancy Safer Initiative stresses the value of educating not only fathers but also whole families and communities about caring for girls and women.

 

Morbidity: The Silent Factor

 

If data on maternal deaths are still considered incomplete by those who work hard for safer motherhood, then reliable figures on the incidence and type of maternal morbidity are even less accessible.  Morbidity, in particular severe acute maternal morbidity, has been defined by a team of experts as “a very ill pregnant or recently delivered woman who would have died had it not been that luck and good care was on her side.”¹¹  In recent years, the devastation caused when something goes horribly wrong in a pregnancy or birth, such as excessive blood loss, heart failure, obstetric fistulae,¹²  and infection, is often associated with motherhood in the developing world, where health services in general and delivery options especially may be dangerously substandard. But increasingly, experts are arguing that a closer study of morbidity in the richer nations can be an important and often overlooked guide to reproductive health services where maternal mortality may be low but not much is known about the “near misses.”

In 2005, the Canadian Medical Association Journal published a report on severe maternal morbidity based on information gleaned from across Canada¹³  that looked at a range of 13 health problems and 11 pre-existing conditions (such as diabetes) that threaten the lives of pregnant women and mothers. Pre-existing conditions, the study pointed out, increased the risk of death six-fold. Overall, the Canadian study sought to demonstrate how important better knowledge of morbidity can be in understanding and dealing with maternal mortality.

 

Severe maternal morbidity was found in one in every 250 deliveries in Canada, with increasing cases of venous thromboembolism, uterine ruptures, respiratory distress, pulmonary edema, myocardial infarction and hemorrhaging requiring hysterectomies. An interesting aspect of the findings—given widespread assumptions that older mothers and those with repeated caesarian sections are more at risk—was that adjustments in the data for maternal age, multiple fetuses and previous caesarian deliveries did not change the overall results.

 

Young Lives Cut Short
 
The story of the youngest sexually active girls is especially tragic when maternal mortality and morbidity are at issue, according to the UNFPA. In South Asia, dominated by India (soon to be the world’s most populous country), and in sub-Saharan Africa, many girls who have not yet reached puberty are often forced into child marriages, depriving them not only of good reproductive health but also of education and a life of choices. Teen marriages, or the use of teenage girls as sex objects or casual partners who may accept the arrangement for as little as a meal or a school fee, are common.

 

In its State of the World Population 2005,¹⁴  UNFPA reported that in South Asia, 48 percent of girls—amounting to 10 million of them—were married before age 18. The figure for Africa was 42 percent. In the US, the percentage was about 11 percent, UNFPA says, so the situation needs more study there also. In New York, Women’s eNews recently reported that while teen pregnancies were on the decline nationally, they were declining only half as fast among Hispanic girls, a growing sector of the population.¹⁵ 

 

The mortality and morbidity risks to girls forced into too early sexual activity are enormous. Girls between the ages of 10 and 14 are five times more likely to die in pregnancy or childbirth than women aged 20 to 24. Girls between 15 and 19 are twice as likely to die as young women in their early 20s.  As examples of even worse cases, UNFPA found that in Cameroon, Ethiopia, and Nigeria, maternal mortality among adolescents under 16 was six times higher than in women 20-24. In some places, pregnancy is the leading cause of death among teenage girls.

The occurrence of obstetric fistulae, causing lifelong damage, is also high because their immature bodies cannot sustain a pregnancy or delivery. Girls forced into early marriage are not protected from HIV/AIDS infection, as some parents have been led to believe, UNFPA says. It  cites studies in Kenya and Zambia that show teenage brides are being infected at a faster rate than sexually active single girls.

“Every minute, another woman dies in childbirth,” says UNFPA. “Every minute the loss of a mother shatters a family and threatens the well-being of surviving children. For every woman who dies, 20 or more experience serious complications….Working for the survival of mothers is a human rights imperative. It also has enormous socio-economic ramifications—and is a crucial international development priority.”

 

     Barbara Crossette is a freelance writer based in Pennsylvania.   

 

References

 

¹ Graham, Wendy J,, John Cairns, Sohinee Battacharaya, Colin H.W. Bulloough, Zahidul Quayyum, AND Khama Rogo. 2006. “Maternal and Perinatal Condition” In Disease Control Priorities in Developing Countries, 2nd ed. (DCP2), ed. D.T. Jamison, A.R. Measham, J.B. Breman et al., chapter 26, page 499. New York: Oxford University Press.
² These complex maternal health issues will be discussed at the Women Deliver Conference 18-20 October 2007 in London.     
³ The Lancet Maternal Survival series. 2006  volume 368, accessed online at www.thelancet.com, August 2007.
⁴  Ronsmans, C. Graham, W.J. et al.  “Maternal Mortality: Who, When, Where and Why.” First in The Lancet Maternal Survival series, 2006; 368:  pp 1189-1200. 
⁵ For more information about Immpact, visit www.immpact-international.org.
⁶ Graham, W. and J. Hussein. “The Right to Count.” The Lancet. 2004;  363: pp 67-68.
⁷ United Nations Population Fund (UNFPA), State of the World Population 2007. Accessed online at www.unfpa.org/swp, August 2007.
⁸ Crossette, B. “Bhutan: When Environment Drives Public Health Policies.” Accessed online at  www.dcp2.org/features/45.
⁹ DCP2, 500.
¹⁰  DCP2, 509. 
¹¹ Mantel G.D., E. Buchmann, H. Rees, R.C. Pattinson. “Severe Acute Maternal Morbidity: A Pilot Study of a Definition for a Near Miss.” British Journal of Obstetrics and Gynecology, September 1998. Published for the Royal College of Obstetricians and Gynaecologists by Blackwell Publishing. www.blackwellpublishing.com
¹² A tear between the vagina or cervix and the bladder or rectum most often caused by obstructed labor.
¹³Wen S.S. et al. “Severe Morbidity in Canada 1991-2201.” CMAJ.  2005.

¹⁴ UNFPA, State of the World Population 2005. Accessed online at www.unfpa.org/swp/2005, August 2007.
¹⁵ Bowen, Alison. “Latina teen pregnancies spur push for family talks.”  Accessed online at www.womensenews.org, on Aug. 21, 2007.