Unsafe motherhood

Print edition : August 13, 2004

As the country with the highest number of maternal deaths, India needs to improve on a priority basis healthcare, transport and infrastructure facilities, particularly in the rural areas.

AS Sompi Chinnappa was collecting gooseberries from her farm in Karakavalasa, a tribal hamlet in Andhra Pradesh's Visakhapatnam district, a woman came running breathlessly towards her and shouted: "The pain has started, hurry up and come."

A destitute mother and her child in Kozhikode, Kerala. The graffiti lists the seven steps to safe motherhood - medical check-ups during pregnancy, delivery in a hospital, adequate gaps between pregnancies, good food and rest, iron tablets... .-S. RAMESH KURUP

Sompi, the 50-year-old village dai or midwife, dropped her bag of berries and ran towards the Rallagaravu hamlet a kilometre away, where a 17-year-old woman was writhing in pain. Sompi entered the hut and asked for hot oil. Soon she was massaging the pregnant woman. After about two hours, Sompi pulled out a baby girl with her bare hands. She cut the umbilical cord with a razor blade and wrapped the newborn in a rag. A safe delivery as far as the midwife was concerned. But what about the total disregard for infections? No gloves, not even clean sheets.

But the young mother is happy, for not every woman in Karakavalasa and its adjoining hamlets has problem-free childbirth. Moreover, complications are not easy to handle in remote areas like these. Two months ago, Sompi had tried in vain for hours to help a severely anaemic 19-year-old, Vimalamma, deliver her second baby. The woman was then taken down the hill to a primary health centre (PHC), 10 km away. She died on the way, in the handcart she was being taken on.

In the absence of an accessible and affordable health-care facility, village midwives, mostly illiterate and untrained, are often the only help available for pregnant women in rural and remote areas. But if there is a complication, these midwives are helpless.

Not that the midwives are unaware of the complications that arise during childbirth. By the time they realise that normal delivery is not possible, it is most often too late. The nearest PHC is in most cases some distance away. Reaching the PHC in time is a near impossibility thanks to the rudimentary roads and poor transport facilities. The PHCs are rarely equipped to deal with emergencies. Generally, there is no anaesthetist or blood bank, and medicines are severely in short supply. In most cases it is either too late or too expensive to go to a private facility. With primary medicare being in such a sorry state, the only hope is that complications do not happen.

According to statistics, every minute in the world, 380 women become pregnant; 190 face unplanned or unwanted pregnancy; 110 experience a pregnancy-related complication; 40 have an unsafe abortion; and one woman dies from a pregnancy-related cause. Social and cultural practices, which themselves are responsible for the poor health conditions of most women, are also among the important causes of maternal mortality. Early marriage and pregnancy, when the reproductive organs are not yet properly developed; high fertility rate leading to recurrent pregnancies; and unwanted pregnancies, when the foetus is aborted crudely most often at home, all leave most women vulnerable. Only one out of six women between the ages of 17 and 35 receives prenatal care while more than half of them are anaemic. Hardly 20 per cent of mothers receive all the required components of prenatal care.

In India, over two-thirds of women give birth at home - close to 85 per cent in the rural areas, and 95 per cent in the remote areas. Every five minutes a woman dies from complications related to pregnancy and childbirth, adding up to around 136,000 fatalities a year, one of the highest numbers of maternal mortality cases in the world; globally, some 550,000 pregnancy-related deaths occur every year and 90 per cent of these deaths occur in the developing countries. Maternal mortality is the main factor that substantially lowers the life expectancy of women.

Maternal mortality, according to the World Health Organisation (WHO), is the death of a woman while "pregnant or within 42 days of termination (by delivery, miscarriage or abortion) of pregnancy, irrespective of the duration of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes."

The country with the highest number of maternal deaths is India, followed by Nigeria (37,000), Pakistan (26,000) and the Democratic Republic of Congo and Ethiopia (24,000 each). Thirteen countries account for 67 per cent of all maternal deaths worldwide.

Of the world's population of some 6.2 billion, there are 1.5 billion women of reproductive age who give birth to 133 million babies each year, or 247 births every minute, or four every second. Less than half of these births are attended by qualified health workers. Fifteen million of these births (12 per cent) are to adolescent mothers, whose mortality rate is higher than that of adult women (five times higher for girls under 15, and two times higher for those in the 15-19 age group).

"I do not believe for one minute that if men were dying in their prime in these numbers, so little would be done," observed James Wolfensohn, World Bank President, speaking on safe motherhood and maternal mortality on World Health Day, April 7 in 1998.

Of all the social indicators, maternal mortality accounts for the largest gap between rich and poor nations. Over 90 per cent of maternal deaths occur in Asia and sub-Saharan Africa, with the latter accounting for 50 per cent of the fatalities.

The number of maternal deaths is a product of the total number of births and the obstetric risk per birth, described as maternal mortality rate (the number of deaths per 100,000 women between the ages of 15 and 49 in a given period). On a risk per birth basis, the list looks different. With the exception of Afghanistan, the countries with the highest mortality rates are all in Africa.

The maternal mortality ratio or MMR (the number of deaths per 100,000 live births) is a measure of the risk of death once a woman becomes pregnant. While the global MMR is 400, in some Asian countries MMR is as high as 850. For instance, it is 830 in Nepal, 650 in Laos PDR, 600 in Bangladesh, 590 in Cambodia, 470 in Indonesia and 440 in India. But it is as low as 95 in Vietnam, 60 in China and Sri Lanka, 44 in Thailand, 35 in North Korea, 20 in Fiji and in South Korea, 15 in New Zealand, 12 in Japan, nine in Singapore and six in Australia.

A more dramatic assessment of risk that takes into account both the probability of becoming pregnant and the probability of death as a result of that pregnancy cumulated across a woman's reproductive years. The more times a woman becomes pregnant, the greater the risk of pregnancy-related death.

The lifetime risk of maternal death is one in 16 in Africa (one in 12 in sub-Saharan Africa), one in 65 in Asia, one in 130 in Latin America, as against one in 400 in northern Europe. Even more worrisome is the fact that for every woman who dies, at least 30 suffer injuries and often permanent disability. It is estimated that one in four women in the developing world suffers from acute or chronic conditions owing to pregnancy.

For every woman who dies in the developed world, 99 die in the developing world. Moreover, a woman's lifetime risk of dying from pregnancy-related complications in developing countries is 40 times higher than that of her developed country counterpart.

Maternal mortality and morbidity are more likely in nations and cultures that give little priority to the needs, status and situation of girls; where girls and women are routinely discriminated against; where girls are married off immediately after attaining puberty; where education levels are low; and where the only roles of women are as wives and mothers. In many of these cultures, maternal illness and suffering are viewed as natural, inevitable, and part of what it means to be a woman.

Hence an understanding of the social and cultural environment is necessary to save women's lives.

Girls routinely face discrimination in many cultures. In many communities, a baby girl is less welcome than a boy; her birth is not celebrated with the same enthusiasm as her brother's; her needs for nutrition and healthcare are likely to be neglected, resulting in poor physical development that will have consequences during childbirth; and a girl child is less likely to go to school and, if she does, will stay there for a shorter period. Indeed, girls comprise two-thirds of the young people not in school; women comprise two-thirds of the world's adult illiterate population. Lack of education, among other handicaps, prevents women from learning about pregnancy and health issues. Girls are married off early and begin child-bearing before they are physically ready. One-third of all pregnancies are unwanted or unintended, and even today about 350 million women worldwide do not have the choice of safe, effective contraceptive methods. Unsafe abortions are estimated to claim 70,000 lives globally each year.

More than 80 per cent of maternal deaths worldwide have five direct causes: haemorrhage (34 per cent), unsafe abortion (18 per cent), obstructed labour (11 per cent), hypertensive disorders (16 per cent) and infections (21 per cent). Indirect deaths are caused by conditions that, in association with pregnancy, precipitate the fatal outcome - for instance, malaria, hepatitis and, increasingly, Acquired Immune Deficiency Syndrome (AIDS). Most life-threatening complications occur around the time of childbirth and require recognition and prompt treatment.

Twenty-five per cent of maternal deaths occur during pregnancy; 50 per cent within 24 hours of childbirth; 20 per cent within seven days of delivery; and 5 per cent from two to six weeks of childbirth.

It is, however, difficult to predict which woman will develop a life-threatening complication during pregnancy. But three important ways by which maternal deaths can be controlled are: (a) by promoting family planning - that is, every pregnancy should be a wanted one; (b) skilled attendance at birth - all pregnant women must have access to skilled medical care; and essential obstetric care - all pregnant women must be able to reach a manned and equipped healthcare facility if complications arise.

If antenatal investigations are done for all pregnant women, it will dramatically lower pregnancy-related risks. They help in detecting and treating existing problems and complications and providing counselling thereafter; help the women prepare for birth; and advise women where to seek care if complications arise. It was found that in the three years preceding India's National Family Health Survey 1998-99 (NFHS-2), 35 per cent of pregnant women received no antenatal care.

A 2001 Population Council study in India's most populous State of Uttar Pradesh showed that less than half the pregnant women had sought some form of care. In the rural areas of the State it was particularly bad - more than three-fourths of the women in Sitapur district and three-fifths of the women in Agra district received no antenatal care. Most women tended to see a healthcare professional in the second trimester only to confirm pregnancy.

The reasons given by the survey respondents for not seeking care include: they did not think that check-ups were necessary (60 per cent) or customary (4 per cent); inability to meet the costs of visiting a healthcare facility (15 per cent); and not being allowed by their families to have these check-ups (9 per cent). Lack of knowledge of antenatal care and poor access to health centres were the other reasons cited.

According to C. Jagdish Bhatia ("Levels and Causes of Maternal Mortality in Southern India", Studies in Family Planning; pages 310-318), more than three-fourths (77.8 per cent) of the maternal deaths in Andhra Pradesh's Kurnool district could have been prevented if there were early antenatal care, treatment of existing health conditions, and timely availability of medical care and hospitalisation.

The importance of transport facilities is evident from the fact that of the 140 women who were taken to hospital in a serious condition, 96 (68.5 per cent) were transported by bus, 27 (19.2 per cent) by bullock-cart, five (3.5 per cent) by rickshaw, and only 12 (8.6 per cent) by a motor-driven vehicle or ambulance. Consequently, 24 women died en route to and 54 when they reached hospital.

The Population Council study also found that most deliveries happened in situations in which it was difficult to identify or respond to obstetric complications. Close to 90 per cent of the deliveries happened at home, and in nearly half these cases family members or kin delivered the babies.

"Even these figures are an underestimation," says Jagdish Bhatia. According to him, estimating maternal mortality is very difficult given that most deliveries happen at home and over half of the deaths among women of reproductive age and two-thirds of maternal deaths are not recorded.

Not that the government is not aware of all this. In fact, the latest National Population Policy of India focusses on the government's commitment to safe motherhood. Among the goals identified for 2010 are: reducing MMR to below 100; achieving 80 per cent deliveries within health institutions; addressing the unmet needs for basic reproductive and child health services, supplies, and infrastructure; and the presence of trained personnel in the community at all births.

In a drive to make childbirth safer, the Health Ministry last year decided to pay midwives to bring pregnant women to hospitals for check-ups and delivery, and the latter for having their babies there. The idea, according to an official in the Health Ministry, is to raise the number of women delivering in medical institutions from 33 per cent to 80 per cent.

A happy situation for midwives? Apparently not. People like Sompi, who delivers about a dozen babies a month in remote villages where girls are usually married off at the age of 14 and have five to seven children, feel cheated by the government's policy turnabout. She says: "I learnt this work by watching my mother for years." Sompi is illiterate but is proud of the fact that she can tell the position of a baby in the womb just by touching. But now, she feels the government has not taken her skills into consideration while persuading her to take women to hospital.

Sompi was given a three-day training on hygiene last year. But can she tackle any of the common causes of maternal deaths - haemorrhage, eclampsia, obstructed labour or sepsis? No, say health officials. Only a hospital can deal with such emergencies.

Yet, for the pregnant women who are caught between a poor and inadequate government health system and an unaffordable private one, midwives, though most often from a lower caste, are godsend. Says Sompi: "The government should concentrate on raising the age for marriage (the average age at marriage in rural India is 15), reducing unwanted pregnancies, improving infrastructural facilities such as roads and public transport, and enhancing facilities at PHCs."

According to a WHO study, a safe motherhood programme using existing resources would cost developing countries less than $3 per person a year. The study concludes: "Ultimately, the critical need may be one of generating sufficient political and social will at international and national levels to overcome this avoidable tragedy." Can the government deliver on this?

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