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Women's Health in Developing Countries--The Role of the United Nations

A talk by Charlotte Houde-Quimby to the League of Women Voters, November 19, 2002
Page one: an Overview
Page two: Contraception
Page three:  Safe Motherhood
Page four:   HIV/AIDS
3. Safe Motherhood

The World Health Organization now estimates that over 600,000 women die each year from pregnancy-related causes. This is the equivalent of five jumbo jets filled with 250 pregnant women crashing into the ground every single day, 365 days a year, with no survivors. Ninety-nine percent of the deaths occur in the developing world. Maternal mortality rates in developing countries are as much as 100 times higher than those seen in industrialized countries and over ninety percent of the causes are known to be preventable. Maternal mortality is one of the greatest neglected problems in the world's health care.

Childbirth is a biological event. Yet, understandings of what is considered appropriate care vary within and across cultures. Differences in perceptions surrounding childbirth emergencies often lead to delays in taking appropriate action, and can provoke dangerous actions, or may result in no action at all. Taking appropriate action is not simply a matter of having correct knowledge and skills to manage emergencies, however. There are often barriers preventing appropriate action; some are more obvious than others. The physical environment may be so problematic that transport becomes difficult or impossible. A family may be, or believe themselves to be, too poor to obtain medical care immediately. A family member present at birth may be well aware of the gravity of a particular situation, but not in a position to recommend or take action because of lack of power or seniority. A woman may refuse referral because she is of a different ethnic and language group than staff at the health facility, or she may believe that hospitals are where you go to die. A TBA may not refer a woman needing referral for fear of being viewed by the family as "failing on the job". She may lose face in the eyes of the community, or believe that she will do so, if she transfers too many of her patients. Cultural factors, which influence decision-making, interact profoundly with existing or newly acquired knowledge and skills.

It is estimated that some 60% - 80% of births in developing countries occur in the home. Untrained persons such as mothers, mothers-in-law, sisters, and husbands, attend the majority of these births; some women labor and deliver totally alone. Traditional Birth Attendants (TBAs), women who are accessible to and chosen by women to assist at their births, are often poorly trained and equipped. This is especially true in the rural regions of developing countries where most people live, and where only an estimated 45-55 % of the population has access to trained health personnel and emergency medical supplies. 'Access' here is commonly defined as within one hour's walk. How do you talk a woman who has been in difficult labor for over 12 or 18 hours into getting up and walking to a health facility? If she is fortunate, her husband may own a bicycle he can use to transport her. If he must find other transportation for her, he will need to kill two goats as payment, goats that supply milk for his other children. Once at the hospital, there may be no supplies available to treat her. During the year I worked in Uganda, young mothers died because of a lack of anesthesia to perform necessary caesarean sections, or from toxemia when drugs were not available to control the blood pressure and the seizures, or because no one recognized how much bleeding was too much. Women who survived were often left physically damaged by birth injuries that went untreated. Talking a family into moving a laboring woman becomes understandably difficult.

USAID began funding a major program to reduce the mortality rate among mothers in several developing countries in 1988. Known as MOTHERCARE, the project promotes health behaviors and practices among mothers by understanding the particular problems in each community. In Bangladesh, e.g., the maternal mortality rate has been reduced by nearly two-thirds in sections of the country where MOTHERCARE carried out programs of prenatal care and folic acid tablet distribution. In Uganda, midwives trained in an ACNM Life Saving Skills course for emergency childbirth techniques have new skills in managing hemorrhage during delivery, recognizing medical complications requiring acute care, and in the resuscitation of newborns. In one area of Indonesia, birthing huts with two-way radios and access to an ambulance were established in 10 villages; in Matlab, Bangladesh, the midwife is now called by a messenger who travels on foot; she also now has access to a boat and boatmen to transport her to the woman's home.

Another USAID-funded Project, PRIME, working with ACNM and UNC, has developed an innovative strategy entitled "Obstetric First Aid in the Community: Partners in Safe Motherhood ."5 It is being field-tested in India, Vietnam, and Ethiopia. This is a broad community sponsored effort that includes a safe motherhood campaign focusing on key issues and information, helping women understand the nature of the risks and the importance of planning for emergency transportation. Stakeholders, such as local authorities, women's groups, teachers/educators, other providers of maternal and neonatal health, and those who may influence health behavior are the primary targets. The goal of this project is to get obstetric first aid to the women at the most peripheral level, i.e., within their home. This can only be achieved by addressing the most common direct causes and critical time periods of death. Sixty three percent of maternal deaths occur in the immediate and early postpartum period as a result of postpartum hemorrhage, which is largely unpredictable6. Neonatal deaths also occur in the immediate and early postpartum period. Many of these deaths are preventable. With this project, the women, their families, friends and communities are being helped to recognize problems and are given the information necessary to respond with appropriate obstetric first aid,, such as putting the baby to breast to reduce bleeding, stimulating and feeding a "too quiet baby."

A key action message to emerge from the 1997 Global Technical Consultation on Safe Motherhood: "The single most critical intervention for safe motherhood is to ensure that a health care worker with midwifery skills is present at every birth, and transportation is available in case of an emergency. [To this end] A sufficient number of health workers must be trained and provided with essential supplies and equipment, especially in poor and rural communities,"7

This IS a major "take home" message. However, the reality of what it will take to achieve this goal boggles the mind. Development projects the world over are vulnerable to certain realities:

From the countries' perspective:

Some 13,000,000 children under five years of age die annually, 4 million within the first four weeks of life.8 Another 4 million are stillborn. If a mother dies in childbirth, the chance of death for her newborn and children under five rises to 50%. Reducing such unconscionable loss involves a four-step process:
  1. Recognizing a life-threatening complication
  2. Deciding to seek care (usually the family member)
  3. Reaching services in time (Overcoming barriers such as distance, cost, lack of transportation, perceived poor quality of health care providers)
  4. Once at a health care facility, they must be able to obtain adequate care for complications.

But, introducing these health care changes means understanding the culture and needs of the people receiving the care. That's true whether it's in New Hampshire or in a developing country. In one clinic I attended in Uganda, the midwives did no pelvic examinations of pregnant women. They had no rubber gloves, and no resources to do anything with information they might gain from the examination. Women traveled up to five miles on foot under the African sun to attend the clinic, sat in a large, crowded waiting room until they were called, and had no access to food or water unless they brought some from home. The extent of their examination was a weight check and blood pressure check. Blood tests were available until noon. If a woman did not arrive in time, no provisions would be made to test her blood. Only two or three of the women I questioned on any given morning had anything more than tea to eat before making the journey to the clinic. How could we teach women to assess a headache when, as a woman, her daily tasks included carrying j jerry cans holding 4 to 5 gallons of water on her head, firewood on her back and a toddler on her hip, sustained only by a little tea?

The challenges to reducing MM are enormous.

5 Sibley L. & Armbruster, D. 1997, 'Obstetric first aid in the community: Partners in Safe Motherhood', Journal of Nurse-Midwifery, vol. 42, no. 2, pp. 117-120.

6 Li,X.F., Fortney,, J.A., Kotelchuck, M. & Glover, L.H. 1996, 'The postpartum period: the key to maternal mortality. International Journal of Gynecology and Obstetrics, vol. 54, pp. I - 10.

7Starrs, A. 1998, The Safe Motherhood Action Agenda: Priorities for the Next Decade. Report of the Safe Motherhood Technical Consultation, 18-23 0ctober, 1977,Colombo, Sri Lanka, Family Care International and the Inter-Agency Group for Safe Motherhood, New York

8 AbouZahr C. 1998, 'Maternal mortality overview', in Health dimensions of sex and reproduction: Global burden of disease and injury, vol. 3, eds C. L. Murray & A.D. Lopez, vol. 31, World Health Organization, Geneva.

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