By the time the pregnant 17 year old arrives at a hospital in Sierra Leone, it is already too late. Her baby has died—maybe the day before, maybe even longer. She has been left in labor for far too long—approximately 36 hours—waiting for a caesarean section that has been delayed due to an electricity cut. When power resumes, there is no doctor to help her. Now the race is on to save this teenage mother from death as well. Her womb is infected; the tissue falling apart. The doctors try their best to repair it, but her severe infection worsens overnight. The next morning is her last.
“Too much, too late,” writes a Médecins Sans Frontières obstetrics/gynecology registrar, Benjamin Black, on his MSF blog. This girl’s tragedy is shared by thousands more. In 2013, an estimated 289,000 women died during pregnancy or while giving birth. That’s almost 800 women every day. 99 percent of these deaths occur in the developing world.
Nearly all of these deaths and serious injuries are preventable and needless. Very few of them would happen in the west. Reading the statistics, we don’t need the World Health Organization (WHO) to tell us that maternal mortality is “unacceptably high” and that these deaths are a tragedy. The numbers speak for themselves: 800 maternal deaths every day are 800 too many. And yet, despite a 45 percent drop in maternal mortality since 1990, family planning organization Marie Stopes International still reports that the lifetime risk of dying from such complications is one in 22 in sub-Saharan Africa. In some African countries, the rate is as high as one in eight.
The United Nations Population Fund (UNFPA), whose work involves improving reproductive health, states on its website that the world has made “significant strides, but not enough.” While some developing countries have seen maternal deaths fall significantly in recent years, sub-Saharan Africa and southern Asia are still struggling.
A doctor with a baby Maasai patient in Kenya.
In Europe and North America, it is too easy to assume that death during childbirth is a thing of the past. A sensational plot development on an Edwardian costume drama—Downton Abbey, perhaps—or a Victorian tragedy in a Charles Dickens novel. You may be surprised to find that the five main causes of maternal death are, according to Marie Stopes: Hemorrhage, infection, unsafe abortion, eclampsia (a condition where convulsions occur in a pregnant woman with high blood pressure) and obstructed labor. Surprised—and horrified. Preventable, treatable, and avoidable; yet happening here and now in 2015.
It’s worth underlining that there has been a significant and steady drop in numbers over the last 25 years. In addition, during the 2010 Millennium Development Goals Summit at the UN, secretary-general Ban Ki-moon unveiled a ‘global strategy for women’s and children’s health’ that aimed to save 16 million women and children over a four-year period. I asked Luc de Bernis, the UNFPA’s senior maternal health advisor in Geneva, if we are doing enough.
“Certainly not, but this is encouraging,” he said. “The challenge now is to maintain this gain in lives saved, and to accelerate the progress towards the goal and targets for 2030. Women’s health, maternal and adolescent health are not receiving enough attention, even if it has been demonstrated that the major part of the maternal and newborn mortality is preventable, even in poor settings.”
A woman had turned up to a hospital clearly needing a caesarean section. But there was no people to work the generator, no electricity, and no light.
“Unfortunately the answer isn’t simple and it’s not a purely medical answer,” said Black, the oby-gyn whose work with Médecins Sans Frontières has taken him to the Central African Republic and Sierra Leone. When it comes to maternal health, there is no “silver bullet,” as he puts it, to remedy this complex issue. “You’ve got to look at the social, political, economic dimensions to the problem,” he explained.
Benjamin talked about “the three delays”: A trio of barriers that too often prevent women from receiving the timely and effective medical attention they need. Delay one: The delay in recognising that something isn’t right. “If you’re a woman in sub-Saharan Africa who is in labor in your local village with your local birth attendant, they may not realize at first signs that there’s a problem. It may take more than a day,” he explained.
The second delay lies in actually getting to a place where you can even receive care. Benjamin recalled working in Sierra Leone, where it can take patients more than a day to reach a hospital because of poor roads, or because patients have no access to transport nor the money to pay for a taxi. Then there’s the third delay: The delay in receiving care once you’re there. Benjamin recalls the time “a woman had turned up to a hospital clearly needing a caesarean section. But there was no people to work the generator, no electricity, and no light.”
I was ‘a child giving birth to a child’ because I was only 14.
There’s another twist in this narrative: Teenagers are most at risk. Marie Stopes International, which provides sexual and reproductive healthcare to women around the world, reported on the case of 16-year-old Mi Aye, who lives in Myanmar. Married at 13 and pregnant at 14, Mi Aye told the organization: “Nobody told me about how you have children or how I could avoid getting pregnant, so of course, I got pregnant. I was ‘a child giving birth to a child’ because I was only 14. And afterwards I was really frightened about getting pregnant again but I didn’t know what to do to stop it.”
Women aged between 15 and 19 are twice as likely to die during pregnancy or childbirth as women over 20; girls under the age of 15 are five times more likely to perish. Bethan Cobley, senior manager of policy and partnerships at Marie Stopes International explained why teens are most at risk. “Sometimes their bodies are not mature enough for pregnancy and childbirth, but more often it’s because young people are less likely to have access to quality health services, particularly in the developing world.”
Benjamin Black referred to this as an issue of ‘vulnerability.’ “Your vulnerability increases according to the wider socio-economic situation that you’re in,” he said. “For example, if you’re a 15-year-old girl from a poor [and] rural family, your vulnerability to each of those delays is much higher than, for example, a professional woman who’s working in a capital city, even in the same country.”
According to the UNFPA, access to trained midwives could help avert two-thirds of maternal and newborn deaths. According to de Bernis, “midwives can implement more than 85 percent of the recommended essential evidence-based RMNH (Reproductive, Maternal and Newborn Health) interventions”—yet there is so much more than mere medical intervention to tackling these horrifying mortality numbers.
Dr Azhar Abid Raza, a health and immunization specialist with UNICEF in New York, agreed that a holistic approach is “essential” and “is working.” Antenatal care and maternal vaccinations have improved. UNICEF also has programmes targeting child marriage. “In addition, UNICEF, WHO and UNFPA are collaborating to improve the nutritional status of mothers, and in promoting the concept of early initiation and exclusive breastfeeding,” he said.
Access to family planning is equally vital—as is ensuring abortions are a safe option for all women. As it stands, there are 222 million women in the world who would like to use contraception but aren’t able to access it. “An estimated 22 million unsafe abortions are performed each year, resulting in 47,000 deaths and leaving 8 million women with medical complications,” Bethan Cobley of Marie Stopes International told me. “It may sound obvious, but when women have access to contraception, the number of unplanned pregnancies falls dramatically.”
It’s about the choices girls should be able to make—freely and safely—about their own bodies, without feeling stigmatized or judged.
Family planning and termination of pregnancy is still taboo in many developing countries. As a result, abortion becomes a secret and often deadly operation that can involve ingesting poisonous herbs or using sharp instruments. Perhaps unsurprisingly, these methods often lead to medical complications, infertility, and in the worst cases, death.
So what’s the bottom line? It’s about the choices girls should be able to make—freely and safely—about their own bodies, without feeling stigmatized or judged. When the political will, support and funding is there, women’s lives are saved.
“Where governments have made the decision to fund family planning services and remove policy restrictions, we have seen maternal mortality dramatically fall in a relatively short period of time,” Cobley said. “For example, the Ethiopian government has invested in family planning and as a result maternal mortality in the country has more than halved, falling from 990 deaths in 100,000 live births in 2000 to 440 in 2013.”
Pregnancy shouldn’t be an imposed death sentence for any woman, wherever she lives or whatever her financial circumstance. In 2015, it doesn’t have to be.