Healthy women bearing healthy children build healthy communities
— Lynn Freedman, Director, Averting Maternal Death and Disability Program, Mailman School of Public Health, Columbia University
By Donna Shaver
All over the developing world, the frequency with which women have died in, or as the direct result of, childbirth, has cast a dark shadow over families and communities. The fifth UN Millennium Development Goal set the bar high: To reduce by three quarters the maternal mortality ratio between 1990 and 2015, and to achieve, by 2015, universal access to reproductive health. The vast majority of these deaths are, as you might expect, in the developing world.
For many years, the accepted wisdom was that a woman died in childbirth somewhere in the world roughly every minute of every day, 365 days a year—for a total of 543,000 per year. The vast majority of those deaths occurred in sub-Saharan Africa and Southern Asia. Most were in rural areas, and among poor populations. In 2008, a study published in The Lancet reported that the number had dropped to 342,000. In May 2012, the World Health Organization (WHO), The United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), and the World Bank released a new study, showing that the number of maternal deaths had been cut in half, dropping from 543,000 to 287,000 from 1990 – 2010.
This is wonderful and heartening news, but it still means that every two minutes, a woman dies of pregnancy related complications. There are four common causes: Severe bleeding after childbirth, infections, high blood pressure during pregnancy (pre-eclampsia), and unsafe abortion. Most important to note is that 99% of maternal deaths occur in developing countries, and most could have been prevented with appropriate interventions. So for most of the developing world’s women, little has changed.
Our Dining for Women recipient this month is the Pachamama Alliance’s Jungle Mamas project, which is working with the indigenous Achuar people in the rainforest in southeast Ecuador. Jungle Mamas is bringing childbirth education and skilled birth attendant education to the Achuar, as well as educating the communities on good health practices, including improved sanitation.
UN Millennium Development Goals
Goal 4: Reduce child mortality
Target: Reduce by two thirds, between 1990 and 2015, the under-five mortality rate.
Under-five mortality rates in Latin American have fallen by more than half between 1990 and 2010. However, most of those gains are in urban areas. There continues to be a substantial lag in progress in rural areas. Latin America is an area in which this is most pronounced. In Ecuador, the rainforest is especially remote, which makes progress even more difficult.
In the developing regions as a whole, children from the poorest 20% of households have more than twice the risk of dying before their fifth birthday as children in the richest 20% of households. But in Latin America, the risk is nearly three times as high (2011 MDG report). This is borne out in the Achuar region. The Pachamama Alliance reports that the average Achuar woman has six children and has experienced the death of at least one infant.
In all regions, the risk of a child dying is strongly correlated with the mother’s level of education. The more education she has, the lower the risk.
Goal 5: Improve maternal health
Target 5.A: Reduce by three quarters the maternal mortality index
While maternal deaths have decreased in Latin America as a whole, Ecuador has one of the highest rates in Latin America. For the Achuar and other isolated groups with limited or no access to maternal care or skilled birth attendants, the figures are definitely higher. The vast majority of maternal deaths are avoidable. The presence of a trained health-care worker during delivery is crucial in reducing maternal deaths. The lack of medical facilities with the skills and equipment to handle emergencies is also a factor. Other factors in maternal mortality are women who have many children, are poorly educated, or are very young or old.
Target 5.B: Achieve universal access to reproductive health
- Increase the proportion of women (15-49 years old) attended at least once by skilled health personnel during pregnancy: Health care during pregnancy is vitally important in detecting and managing conditions that may complicate pregnancy and childbirth. Basic antenatal care provides women with a package of preventive interventions, including nutritional advice. Again, the statistics for Latin America are very promising, but in rural areas—and in particularly inaccessible places like the rainforest—little progress has been made.
- Reduce the number of births per 1,000 women aged 15-19: Worldwide, fewer teens are bearing children, but progress has slowed. As noted above, this figure may be dropping with the Achuar, as more girls are staying in school and postponing marriage.
- Increase proportion of women who are using any method of contraception among women aged 15-49, married or in a union: Millions of women throughout the world are still lacking access to contraception, and aid for contraception is declining.
Maternal Health Overview
On the whole, South America is making great progress in controlling maternal mortality, with most countries coming in at 20-99 deaths for every 100,000 live births. But four countries are lagging behind:
Ecuador (110), Surinam (130), Bolivia (190), and Guyana (280). To put this in perspective, the number of deaths per 100,000 live births worldwide ranges from two in Estonia to 1,100 in Chad. All of the countries with more than 500 deaths are in Africa. (The United States ranks 48th with 21 deaths.)
Causes of Maternal Mortality
- Child Marriage: Marriage before age 20 is a critical factor. Every day, more than 25,000 girls below age 18, almost 10 million a year, will be married and most are forced marriages. A girl’s or young woman’s body is not prepared for childbirth. In developing countries, many girls are malnourished and underweight for their age, making them all the more likely to die in childbirth or suffer a serious childbirth injury. Girls younger than 15 are five times more likely to die in childbirth than women in their twenties. Pregnancy is the leading cause of death worldwide for women ages 15 to 19. Within the Achuar, the tradition has been for adolescent girls to marry boys in their same age bracket. But the best news is that an increasing number of girls are staying in school, raising the age of marriage and therefore raising the age at which they begin bearing children.
- Female Genital Mutilation (also known as female genital cutting or female circumcision): This is practiced in at least 26 of 43 African countries, and by ethnic groups in Oman, the United Arab Emirates, and Yemen, as well as in parts of India, Indonesia, and Malaysia. There are varying levels of excision of genital tissue, the most extreme (FGM III) causing the most severe problems. Scar tissue can make birth difficult. A study done by the World Health Organization shows “evidence that deliveries among women who have been subject to FGM are significantly more likely to be complicated and dangerous.” The danger is to both mothers and babies. Mothers are more likely to hemorrhage. Babies are in substantial danger during birth, as they are far more likely to have to be resuscitated, having been deprived of oxygen during the difficult delivery. The death rate for babies was much higher for women who had undergone the procedure, with the danger increasing according to the level of FGM. (Note: No form of FGM is practiced in Latin America. It is, however, becoming a problem in the West in immigrant populations from the regions where it is practiced.)
- Multiple Pregnancies: With each additional pregnancy, the odds of maternal mortality increase. The mother’s health may be compromised from hard work and poor nutrition. Many women would like to space their children, but lack access to contraception. In addition, women are responsible for a great deal of the physical labor—from carrying water to gathering firewood to building and maintaining the family’s shelter to farming. Pregnancy does not excuse a woman from her chores, as there is may be no one else to do them.
- Lack of Access to Contraception: Many women and families would prefer to be able to control both family size and the spacing of pregnancies, but are unable to do so because they have no means of contraception. If such spacing could occur, it would have the benefit not only of helping to ensure the health of the mother, but keep the size of the family from outstripping its access to resources—food, medical care, housing, and education. Women in developing countries often have little control over their own reproductive systems, so without contraception, there is little they can do to control family size.
- Lack of Prenatal Care: Appropriate prenatal care will help ensure that women get the appropriate nutrition, are monitored and treated for elevated blood pressure, educated on how to take care of themselves and understand what will be happening to them in the birthing process.
- Lack of Skilled Birth Attendants: Millions of women give birth either alone or attended by unskilled family, friends, and neighbors who are unprepared for anything that might go wrong. Countries across the world are scrambling to train and deploy midwives to rural and remote villages. The traditional Achuar process is for the mother to go alone into to the forest to give birth. To quote Robin Fink from The Pachamama Alliance: “Sometimes mothers will explain to their daughters what birth is like, but it is rare. There is no help or assistance in the birth process traditionally because birth is seen as 1) very sacred, so sacred that no one but the mother should see or touch or go through the birth process. 2) It is shameful for anyone to see the mother in pain or screaming. It is a sign of weakness.” Jungle Mamas is working to bring modern maternity practices to the Achuar.
- Lack of Access to Medical Facilities in an Emergency: Millions of people live in areas without roads, or any access to rapid transportation in an emergency. In places like the rainforest, as we find in the Achuar region in Ecuador, there are few if any roads. Transportation is often by boat, canoe, or on foot. Some areas may have an airstrip, but air evacuation is extremely expensive and out of the reach of most of the population.
Women who do not die in a difficult delivery may experience the devastating injury of obstetric fistula. When a mother’s pelvis is too small to accommodate the birth (especially frequent with underage girls), the baby may become lodged in the birth canal, cutting off the blood supply to organs such as the bladder and/or rectum. The labor may go on for an extended period of time, during which the baby usually succumbs. For the mother, tissue dies in the affected organ(s), and a hole develops. Fistula can often be surgically repaired, but for women and girls without access to medical care, the condition is lifelong.
According to the World Health Organization: “Each year between 50,000 and 100,000 women worldwide are affected by obstetric fistula, a hole in the birth canal….Women who experience obstetric fistula suffer constant incontinence, shame, social segregation and health problems. It is estimated that more than 2 million young women live with untreated obstetric fistula in Asia and sub-Saharan Africa.”
Fortunately, there is significant and growing attention worldwide to maternal health. Especially exciting is the emphasis being placed on eliminating child marriage. But there is a long way to go in providing every woman with appropriate maternal care, and access to medical facilities and trained personnel in a crisis. According to Averting Maternal Death & Disability, a program of the Mailman School of Public Health at Columbia University, “The majority of life threatening complications during pregnancy and childbirth cannot be predicted or prevented, but nearly all can be treated successfully with good, timely EmOC (emergency obstetric care). That’s virtually 270,000 women’s lives saved each year.”
- “Emergency obstetric care” (Factsheet). Averting Maternal Disability & Death, Mailman School of Public Health, Columbia University. http://www.amddprogram.org/d/sites/default/files/EmOC_factsheet-Dec2010.pdf
- “Female genital mutilation”. Wikipedia. http://en.wikipedia.org/wiki/Female_genital_mutilation
- “Maternal Deaths Halved in 20 Years, but Faster Progress Needed. UNFPA Press Release, 16 May 2012. http://www.unfpa.org/public/home/news/pid/10730
- “Maternal mortality ratio (per 100,000 live births) 2010”, Interactive Map. World Health Organization. http://gamapserver.who.int/gho/interactive_charts/mdg5_mm/atlas.html
- The Millennium Development Goals Report 2012. United Nations.
- “New study shows female genital mutilation exposes women and babies to significant risk at childbirth.” World Health Organization, 2006. http://www.who.int/mediacentre/news/releases/2006/pr30/en/index.html
- “10 facts on obstetric fistula” World Health Organization, March 2010. http://www.who.int/features/factfiles/obstetric_fistula/en/