Maternal health is a pro-life issue
Posted by Fiorella Nash on 22 December 2015
I am ashamed to admit that I did not entirely appreciate how dangerous childbirth can be for both women and their babies until I became a mother myself.
My eldest son, who is now five years old, would not be alive today if it were not for a skilled obstetrics team who delivered him by emergency caesarean, following a lengthy obstructed labour.
My youngest child would not be alive today if it were not for skilled midwives and paediatricians who resuscitated him when he stopped breathing, and detected and treated his chest infection in a well-equipped Special Care Baby Unit, manned 24 hours a day by dedicated nurses.
And I am aware that I would not be alive today to raise my children if I had not had access to excellent hospital facilities, nurses, midwives and doctors who were able to save my life when I developed complications during two out of three labours. I told somebody after my first baby was born that when, after nearly twenty-four hours of the worst agony I had ever experienced, an obstetrician entered the labour room, I felt as though I were being rescued from a torture chamber.
Contrary to the opinions of some of my more acerbic critics, this was not my "fondness for hyperbole" at work: I was in fact demonstrating the great British art of understatement. The obstetrics team at the Rosie Maternity Hospital were not rescuing me from torture; they were rescuing me and my baby from death sentences.
Victorian horror stories
Here in the West I think we can all be in danger of complacency when it comes to maternal health. Very few people reading this, mercifully, will know a woman who has died in childbirth and maternal mortality can feel rather like the stuff of Victorian horror stories.
I remember us giggling during A-level English Literature classes over the number of nineteenth century novelists who introduced their heroines with the words "her mother died in childbirth and left her an orphan and a beggar" or over the typical emotional outcry "save the child!" from the mouths of other worthy heroines.
But even these Victorian melodramas should be stark reminders that not so long ago in our own history, everyone would have known some woman who had died in childbirth and the tragedy of maternal mortality - of women dying young, of children growing up orphans - remains the reality in many countries of the world.
"International disgrace"
However, whereas in early nineteenth century Britain, there was little that could be done to save a woman facing complications such as sepsis or obstructed labour, there is no reason in 2015 why any woman should die during or as a result of giving birth.
That is the real tragedy. There is no inevitability here. Dr Robert Walley, director of the Canadian-based group of Catholic obstetricians and gynaecologists MaterCare International describes maternal mortality rather more accurately as 'an international disgrace'.
Numbers
How many women around the world are dying in childbirth every year? Accurate numbers are very difficult to calculate for a number of reasons.
The first is poor reporting in some countries, or indeed, no reporting of maternal death at all. It is notable that developing countries tend to have poor or nonexistent mechanisms for recording maternal death - and these are the countries which have the biggest problem with maternal mortality.
However, there are also differences in methods of reporting. For example, one country may define a maternal death as a death which occurs up to seven days after birth whereas another may define it as a death up to 42 days after birth. The generally accepted definition of maternal death is, in fact, death 42 days after birth.
Some countries will include only direct causes - sepsis, haemorrhage, obstruction - whereas others will include indirect causes; that is, a condition exacerbated by pregnancy or childbirth such as malaria or anaemia.
Maternal mortality rates
So we need to be aware that we are looking at estimates and these estimates vary from between 350,000 and 600,000 maternal deaths a year, 99% of which are believed to occur in developing countries.
I think it was Disraeli who said: "Lies, damned lies and statistics!" but I would stress that no matter how uncertain we may be about the actual raw data, we should not allow ourselves to become distracted from the tragedy of maternal mortality. Not one woman should be dying in childbirth anywhere when the means are available to prevent it.
To give a slightly clearer picture of the way different countries fare (again these are in some cases estimates but when you talk in comparative terms, it can sometimes give a more accurate perception of what is going on):
In Britain, the maternal mortality rate is 9 per 100,000 live births - and incidentally, Britain does not have the lowest maternal mortality rate by any means. Ireland and Poland, both historically pro-life countries, have a rather better record.
In Sierra Leone the maternal mortality rate is 1,360 per 100,000.
Causes
The two biggest causes of maternal death (as is very well established) are:
Haemorrhage is the single biggest cause of maternal death anywhere in the world. It accounts for around one quarter of all cases and around a third of cases in sub-Saharan Africa, followed by sepsis at around 10%.
A less common but particularly horrific cause of death is obstructed labour, where the baby becomes stuck in the birth canal and the mother may be maimed for life or killed having spent days in appalling pain trying to deliver a baby who may also die in the process. This is common among very young or malnourished mothers whose pelvises are too small for them to deliver naturally.
What is particularly dangerous about haemorrhage is that there is very little time to treat it. If a woman starts bleeding during labour, she has around 12 hours, but if she has a postpartum bleed, she has more like two hours before she bleeds to death.
Other factors
So, if a woman is giving birth in a remote area, miles away from the nearest hospital, without easy access to affordable or suitable transport, she is highly unlikely to receive help in time, or if the hospital has just one doctor on duty or no blood bank and relatives have to be rounded up as donors, it will be very touch and go.
Beyond the clinical causes of death, there are a whole raft of reasons why women die in childbirth, all of which need to be addressed. These include, of course, lack of accessible antenatal care where certain health problems could be picked up in good time, lack of good obstetric care and trained birth attendants and facilities such as equipped operating theatres and cheap antibiotics, but also broader issues such as poor infrastructure. A study published in the Journal of Sustainable Development in Africa in 2010 found:
"Despite the recognition of the role of transport to development and the livelihoods of poor people, rural transport networks, in most developing countries, are underdeveloped and of poor quality. It is estimated that about 900 million rural dwellers in developing countries do not have reliable, all season access to main road networks and about 300 million do not have motorised access at all."
I watched an interview with an obstetrician in, I think it was Sierra Leone, a couple of years ago and she was saying that there is a river near her hospital but no bridge, so people will carry women in labour across that stretch of water to bring them safely to the hospital, but if it is the rainy season, the river will be very swollen and fast-flowing and it is not possible to enter the water without being swept away. Hospital staff have watched women die, stranded on the other side of that river - in full view of the hospital - for want of a footbridge.
Cultural attitudes
Then, perhaps most significantly of all, there is the poor status of women in many cultures which renders it difficult for women to access medical care in time even if it is readily available. I have come across stories of women living opposite maternity hospitals whose families would not allow them to access help until it was too late. Neglect can also be seen as a form of violence against women. As MaterCare International states:
"Violence to women may be done by commission, for example, by abortion, genital mutilation, and sexual assault, especially during times of war, or by trafficking, or domestic abuse, all of which have received considerable attention by civil societies. Violence, however, may also be perpetrated by omission as in the case of neglect during pregnancy and childbirth."
If the lives of women are not valued, they will not receive the care they need. And what we must always remain acutely aware of as campaigners, when we look at figures and statistics, is that these numbers and categories alone cannot convey the full horror of young women dying unattended, in terrible fear and agony, leaving behind devastated families and other children whose own survival may well be jeopardised by the loss of a mother. In many cultures around the world, the mother is the lynchpin of the family and if she goes, the entire family is shattered. We need always to be aware of the human face of this tragedy.
This is the first in a 4-part series Fiorella is writing for us on maternal health - you can now read Part 2, Part 3, and Part 4.