Maternal Mortality: Numbers and Reality

29 Sep 2010

Giving birth can be deadly for women around the world. While the international community reinvigorated commitment to maternal health last week, the gulf between these international pledges and the harsh realities for mothers on the ground remains wide.

In the face of staggeringly slow global progress toward improving maternal health access, the United Nations created a external pagenew initiative for Maternal and Child Health last week. This comes after much publicity about the slow improvement of maternal health rates, the fifth millennium development goal (MDG), over the last decade.

The external pageeight MDGs outline priorities for the world development agenda, setting benchmarks to be achieved by 2015. While many of the MDGs are lagging, maternal health is the most likely to fail by 2015 at current rates. external pageAdvocates emphasize that without healthy women and mothers, the rest of the development goals and the general well being and fruitfulness of society are threatened. Children whose mothers die are less likely to attend school or even survive childhood.

Quantifying maternal health
The precise numbers around maternal mortality are hard to gauge, and a minor scandal erupted earlier this year when The Lancet released new figures demonstrating a smaller problem in the same week the UN began pushing the initiative, using more elevated figures. The UN and the World Health organization external pagehave been accused of inflating numbers to encourage donors to fund projects.

But whatever the actual yearly figure, be it 342,000 as The Lancet external pageshows, or 500,000 as UNICEF still external pageestimates, maternal mortality remains a significant issue in the world today. In Haiti, maternal and reproductive health is a glaring issue women face throughout their lives. Of course Haiti has the highest maternal mortality rate in the western hemisphere with external page670 deaths per 100,000 live births, unsurprising given the oft repeated, but nonetheless accurate, refrain that Haiti is the poorest country in the western hemisphere.

Maternal mortality is not only linked to poverty; the United States, for example, spends more on health care than any other country, but still has external pageone of the highest maternal mortality rates. Analysts link this to social stratification and the high cost of pre- and post-natal care.

Case study: Rural Haiti
But in Haiti, as in many poor countries, the economic weakness of the country worsens the epidemic. Mirlande Aurelien is a young woman I met in Petit Trou de Nippes, a small city in the south of the country. At 29 years old, she has nine children. She gave birth to her seventh child by herself at her home. “I wasn’t scared”, she said, “I trusted in God.” Why didn’t she call for help? I asked; my translator shot me a look and said, “Please, she doesn’t have a phone.”

Among her nine births, only the first took place in a medical center, the rest were at home. “I didn’t have time or the means to go to the hospital,” Aurelien said, “If I could have, I would have gone.”

Among approximately 30 women I talked to, the vast majority gave birth at home, with the help of matrons, unofficial birth assistants. Many said they could not afford the transportation to the local clinic. Willen Cadet lost so much blood during her home labor that she went into a coma after the birth. “I couldn’t go to the clinic because I didn’t have transportation,” she explained, and specified, “and I couldn’t walk.”

Anna, who did not give her family name, lost her only child due to untreated complications. She managed to see the doctor, but he referred her to St Thérèse hospital in Miragoane, a bigger medical center with more advanced services, including cesarean sections, which are unavailable at the clinic in Petit Trou. But it takes two hours to reach Miragoane, and that is only if the vehicle does not flood while crossing a sizable river that still has no bridge. Anna could not make the trip to Miragoane and lost her baby. Unable to give birth again, she adopted her only child.

Women often send for a matron when giving birth; many times the assistance does not arrive in time. Even when a birth attendant is present, their capacity varies widely. Some midwives have medical training, but the vast majority learn informally. Edline Vilier, a 35-year-old mother of two, who gave birth at the clinic, critiqued the support the matrons bring. “When women talk about stillborn children, they really mean the baby was born and then died. Because, you see, the matrons are not specialists; they use any scissors, and don’t sterilize them. If women have to go to the clinic, they have to ride on a motorcycle. The clinic that we have shouldn’t even be called a clinic. If the doctor goes on vacation, there’s no one else to replace him.”

Anne Danik Francois is an assistant at the medical center in Petit Trou. She acknowledged the problem with maternal health throughout the district, and said the clinic is trying to expand its reach. Currently only women living in the city center, not the rural outskirts give birth at the clinic. The clinic has been working on outreach to matrons, training them in better practices. They also have a mobile clinic offering check-ups, follow-up care and vaccinations. But for the last two months the mobile clinic has not been running because there is no fuel. Francois blames higher-level political wrangling for the lack of funding.

A series of overlapping issues complicate pregnancy and childbirth for these women: inadequate – or even nonexistent – health services; inability to access medical centers and the advanced medical technology they may contain; and lack of awareness about choosing the best birth support.

The way forward
The international community has acknowledged the issue, but as always, following through on their pledges is critical. The disbursal of funds will need to address these layered issues as well, i.e. would building a bridge count as supporting maternal health - or buying women cell phones?

Access to prevention, treatment and care, as external pagespecified in the global strategy is a good start. But empowering women to make choices, improving their economic standing to support these choices, and increased availability of, and access to, services are long-term and complicated processes. It will take much more than lip service to alleviate the dangers women face.
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