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• Is having a baby any safer?

Is having a baby any safer?

" Is having a baby any safer now than it was 15 years ago?" asks Brigid McConville.

Anita Daundkar, aged 26, from India died of septicaemic shock after her third abortion. She already had three daughters, but an illegal amniocentesis had shown that this baby was another girl. Amina Amadou, aged 17, from Niger survived three days of labour, but her baby died. However the resulting fistula (hole between vagina and bladder) made her into an incontinent outcast.

These stories and millions more - of death and long term illness from postpartum haemorrhage, ruptured uterus, eclampsia and so on - are all too familiar to those who work in maternal and newborn health in the developing world.

"A jumbo jet crashing every day" was the image used in the early days of the International Safe Motherhood Movement, which set out some 15 years ago to change all this. It seemed a good way to make real the unimaginable figure of half a million women dying every year, and up to 30 times as many being damaged and becoming ill.

That image is fallen out of use, but nothing much else has changed. With a few notable exceptions, it is still no safer for a woman to give birth in the developing world.

Why not? Because 99 per cent of those who die are poor, with no power, no voice. And because maternal health comes under the banner of "reproductive health". To the powerful voices in America the Vatican, and certain Islamist governments, reproductive health spells abortion, contraception and sex education for adolescents. In other words, it is beyond the pale.

It doesn't help that maternal mortality is a highly complex issue, spanning gender, the empowerment and education of women and their communities, human rights, human and financial resources and neglected health systems.

It's not surprising then that the safe motherhood movement has not come up with a magic formula, however, 15 years ago it seemed like a practicable solution to provide pregnant women with traditional birth attendants (TBAs), and to screen pregnant women for life-threatening complications.

According to Adrienne Germain of the International Women's Health Coalition, this first safe motherhood initiative "went down the wrong track". Traditional Birth Assistants aren't trained to deal with obstetric emergencies, while ante-natal screening can't predict which women will get into difficulties.

At the end of the first decade it emerged that what was needed was not TBAs but skilled attendants (professional midwives, plus nurses and doctors with midwifery skills) at birth, plus a referral system to get women to functioning health facilities in time for emergency care.

Decades of neglect, however, have left the public health systems of many countries in ruins. Lynn Freedman of Columbia University's Averting Maternal Death and Disability Program (AMDD) lists some of the current obstacles: "Health facilities are often not functioning, and there is increasing poverty, making it even more difficult for women to access the services that do exist." And of course, HIV/AIDS has had an enormous impact on maternal health too.

So what is the way forward? With funds short almost everywhere and cost-cutting rife, the current bandwagon in health is "health systems reform". It is widely accepted that a health system which functions at every level - from the home to the skilled attendant to the emergency health facility - is vital to maternal health. It is the funding of health systems, and making sure that reproductive health is not squeezed out, which is controversial.

"The people who control the agenda are the economists" says Susannah Mayhew, of the Centre for Population Studies (London School of Hygiene and Tropical Medicine), "They talk about 'burden of disease' and DALYS" (the World Bank and World Health Organisation's notion of Disability Adjusted Life Years, an economic measure of productive days lost through disease).

But 85 per cent of pregnancies lead to normal deliveries, and maternal death figures are small compared to deaths from malaria and HIV/AIDS. Current forms of measurement can make progress in reproductive health invisible (and so overlooked by donors). "Take contraception," explains Susannah Mayhew. "It prevents unwanted and high risk pregnancies, and so prevents maternal deaths. But you can't count pregnancies that haven't happened, and you can't measure the freedom that contraception brings to women. We need better indicators."

Indeed, says Marge Berer, editor of the journal Reproductive Health Matters, "family planning is the only intervention that has successfully reduced maternal mortality. (It does this) by reducing the number of unwanted pregnancies, some of which might have ended in maternal deaths. The prevention of deaths in wanted pregnancies is still the unresolved problem".

Counting maternal deaths then, only deals with the tip of the iceberg. It doesn't include the much broader problem of maternal morbidity. Nor does it show why women died.

Dr Gwyneth Lewis of WHO's Making Pregnancy Safer initiative (and director of the UK Confidential Enquiries into maternal deaths) argues that "maternal mortality rates give us only a rough idea of what's going on. They don't tell us whether women are from rural or urban areas, or from certain ethnic groups, or whether they died at home, or because they had no transport or access to a blood transfusion."

Progress is only possible when we can learn from specific local circumstances, she argues. "Then we can say that 90 per cent of women at a facility died because there was no bicycle ambulance, or because the midwife post had been frozen. Solutions can be as simple, and cheap, as getting the doctor to hand over the keys to the drug cabinet to the local midwife when going off duty."

Susan Murray of King's College, University of London, also advocates taking a local perspective. Solutions, where they exist, are "very setting specific" she argues. But if she "had to choose one thing... it would be national insurance". (Who should pay for health remains one of the hottest issues within the health systems debate.)

If there is a Big Idea in safe motherhood, it is very big: the whole health system. "We need a package," says Susannah Mayhew. "We must have trained skilled attendants. We can't forget family planning; we have to make this more accessible, particularly to adolescents. Emergency obstetric care is essential to reducing maternal mortality - and women have to be able to get there. That means roads and transport. It also means social change to empower women to make decisions about their health, while getting men and mothers-in-law to understand the risk factors and to avoid delays in seeking care."

Marge Berer adds that "the provision of safe, legal abortion is the best way of avoiding deaths from unsafe, clandestine abortions, which constitute one in six maternal deaths. That, a functioning referral system for women with obstetric complications, and national insurance to cover the costs of these services."

To achieve safer motherhood, argues Susannah Mayhew, we need "a holistic, person-based approach which takes gender and reproductive rights into account. Yes, we still have a long way to go, but we can't isolate safe motherhood from the broader reproductive health issues."

Adrienne Germain is clear about what this means. "There's no cheap solution for maternal mortality and morbidity. It will take substantial resources and funding of health systems. We are not going to make birth safe unless there is a full investment in reproductive health - including contraception, control of sexually transmitted diseases and the termination of unwanted pregnancy. We face enormous challenges - especially that girls and adolescents learn about sex, and that boys learn to respect women's rights."

She sees the Millennium Development Goals as an opportunity, because they extend beyond health sector requirements to poverty reduction, investment in water and sanitation, gender equality targets. "These are valuable elements in reducing maternal mortality. For the first time we have a balanced set of goals and can keep track."

She argues that in the political maelstrom of reproductive health, the European governments could be an effective counterbalance to initiatives by the US and what she sees as "other fundamentalists", but "they must stand up to the conservatives in a way they have not yet done." The bottom line is that "finance is crucial, and urgent."

And like Marge Berer, who believes that "we're seeing an acceptance of the importance of sexual and reproductive health care by (the world's) governments", Adrienne Germain is optimistic. "There is an increasingly strong international women's health and rights movement to keep these issues on the agenda," she says. "Over the past 35 years , highly skilled women's organisations and leaders have developed in virtually every country. There has been an enormous amount of networking regionally; we are now extremely skilled in UN negotiations. So far we haven't lost anything . We are holding the line."

Key facts:

• Addressing maternal health also means addressing newborn health. Every year, 4 million babies die during the first month of life. 70% of avoidable newborn deaths could be averted through interventions delivered through maternal health services.
• Most women and babies die within 24 hours of childbirth.
• A woman in the UK has a 1 in 3,800 risk of dying due to a complication of pregnancy, childbirth or the postpartum period, compared to 1 in 6 for a woman in Afghanistan. This represents the greatest disparity of all human development indicators .

 

Article courtesey of The International Development Magazine