Pregnancy Should Be a Cause for Cheer, Not a Reason to Fear for Your Life
Maternal mortality is the most dramatic health inequality on the planet - that it is relatively easy to curb shames us all
Fourteen years ago this week, I discovered I was pregnant with my first child. I was nervous -- it was my second pregnancy and I couldn't be sure I wouldn't lose this one -- and I worried what a child might mean for my life. But at least I did not have to worry about losing my life. The lottery of childbirth -- whether a mother would live to see her baby -- ended in my family two generations ago when maternal mortality in the UK dramatically improved in the 1930s. The legacy of that great breakthrough is that pregnancy is now usually a cause for celebration, not an occasion to write a will.
What prompted the recollection of an anniversary I've not noticed before was the realisation that what I relied on, as a matter of course, is regarded as a luxury in most of the developing world: skilled midwives, an obstetrician and operating theatre if needed, and the antibiotics and drugs that ensured that, 14 years and another two births later, I'm still around to bring up my children. Basic, everyday stuff in the developed world.
But not so in sub-Saharan Africa, where one in every 16 women dies in childbirth. (Since you started reading this article, a woman somewhere in the world has died giving birth.) In the UK, the comparable ratio is one dead woman in every 8,200. Maternal mortality is the most dramatic health inequality on the planet -- more stark even than child mortality.
There is plenty of evidence for how, with the right combination of political will and policy, the maternal mortality rate can be dramatically reduced. Thailand cut it by 75% in 18 years; the Matlab region of Bangladesh cut it by two-thirds in 21 years. Yet in 20 years, the rate in sub-Saharan Africa has barely budged. The lamentable lack of progress on millennium development goal five -- a 75% cut in the maternal mortality rate by 2015, to which 186 countries have committed themselves -- has become an acute embarrassment to the world. It is the incontrovertible evidence of how little women's lives are valued or their voices heard in many parts of the world.
That is the message Sarah Brown will be taking to Japan next week in the latest stage of her quietly effective campaigning for the White Ribbon Alliance, the Bill Gates-funded international coalition. Its aim is to drum up commitments of $10bn a year in aid for health systems, rising to $20bn a year by 2015 and an extra 4 million healthcare workers. This is the scale of what is needed if the UN summit on the millennium development goals at the end of September is not to look a farce.
Maternal mortality is the MDG that has fallen furthest adrift of its target. It is the scandal of the MDG that either gets forgotten or provokes too much controversy to mobilise the effort required. First, the forgetting: maternal mortality is easy to ignore in many developing countries. The highest rates are among the poorest women in remote rural areas, and they are not the kind to storm barricades and demand their rights. No, they die in a dark mud hut with a terrified relative or on the back of a bicycle or a pick-up truck being rushed over bumpy roads to a hospital where there are neither the doctors nor drugs to treat them. After the bungled chaos of a dead mother, no one wants to shout about it. The data on maternal mortality in sub-Saharan Africa is hopelessly inaccurate: no one really knows who is dying, where or even why. (Another woman has just died in childbirth.)
But the forgetting is also here in the developed west. I took for granted the services on which my life depended through four pregnancies. We forget that millions of women have no such luck. What the campaign on maternal mortality wants to do is mobilise mothers here to campaign on the part of mothers everywhere. Ann Pettifor, the veteran campaigner who got debt on to the mainstream agenda through Jubilee 2000, wants women to play the role that the HIV/Aids activists in the US played in getting massive US funding into treating HIV/Aids in Africa. Can women find some degree of internationalist solidarity with other women on this issue?
Second, this is a subject that has been dogged by controversies that have blunted the impact of advocacy. It has run into obvious rows over abortion -- deaths from terminations are the third-biggest cause of maternal mortality -- and contraception, but the whole subject has been riven by a deeper divide over what is the best approach.
In remote rural areas in Africa, most childbirths are attended by a traditional birthing attendant. Their levels of skill and knowledge vary hugely. To some organisations -- particularly those dominated by doctors and obstetricians -- they are a danger to women. To others, they represent the best hope of improving the care of the most vulnerable. So there's a split between those who advocate investing in hospitals, clinics, obstetricians and midwives, and those who say those kinds of health systems take generations to build up and that they don't reach the poorest. Yet another group of experts argue, sensibly, that you need both, invest in both traditional birthing attendants and obstetricians. Plus there are some very simple, very easy ideas. Sarah Boseley, the Guardian's health editor, who has followed this issue closely, believes one effective intervention would be to give community health workers bicycle ambulances to transport women in labour to a clinic.
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While the discussions go on about the most cost-effective way to stop half a million women dying, Pettifor has found an option that she passionately believes must be implemented quickly. It was devised by Professor Anthony Costello, a paediatrician, who has stumbled into the field of maternal mortality. Over the past decade of working in poor countries such as Malawi, he has come to the conclusion that there is a very easy, relatively cheap way to dramatically reduce the number of women dying in childbirth. He believes traditional birthing attendants and community health volunteers need a maternity kit with two critical drugs: antibiotics to treat infection and misoprostol to treat postpartum haemorrhage. These are the two big killers of women in childbirth. If these cheap drugs were widely enough distributed, lives would be saved immediately.
It was antibiotics -- they began to be used in 1931 -- that made childbirth safe for my grandmother's generation. It could well be the availability of antibiotics which accounts for Bangladesh's dramatic reductions in maternal mortality without any increase in skilled care. But the aid foundations and medical community are reluctant to back the kits. The old arguments that were used about the distribution of anti-retrovirals to treat HIV/Aids are being used again: uneducated Africans don't know how to use drugs. Even more controversially, misoprostol, a common treatment in the US for gastric ulcers, has been discovered to work as an abortion agent. The anti-abortion lobby seems ready to sacrifice women's lives rather than take the risk of such a use in Africa. While the arguments about power and responsibility over reproduction rumble on, women bleed to death.
Another woman has just died. If you were interrupted reading this column -- maybe by your own children who are lucky enough not to have cost their mother her life -- as many as 20 women may have died. They leave behind them up to 100 children without the mothers who are their best guarantee of health and education. How can any of us live with that?
© 2008 Guardian/UK