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John O'Loughlin
Empowerment of women is the only way to ensure safer motherhood
MJA 1997; 167: 622-625
Introduction - Maternal mortality in Australia - Maternal mortality in developing countries - Maternal injury - Consequences of maternal death - Causes of unsafe motherhood - The solution - References - Authors' details - Pictures
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©MJA1997
Introduction |
In Australia and other developed countries, women embark on
pregnancy with little or no fear for their own safety. Along with the
other great strides that medical science has taken in this century,
there have been huge reductions in maternal and perinatal mortality
rates. In developed countries, maternal mortality rates are no
longer used as measures of the quality of obstetric services. The
emphasis has long since shifted to perinatal mortality and
morbidity.
But how safe is motherhood today in the developing countries of the world or among disadvantaged minority groups? |
Maternal mortality in Australia |
The World Health Organization (WHO) defines maternal death as "the
death of a woman while pregnant, or within 42 days of the completion of
the pregnancy, irrespective of the duration and the site of the
pregnancy, from any cause related to or aggravated by the pregnancy or
its management".1 In
Australia each year there are about 260 000 confinements,2 and in 1990 there were 25 maternal
deaths3 (i.e., nine per 100
000 live births). This is comparable with the lowest rates reported
globally.
However, these figures hide an unpalatable fact. Births to women of Australian Aboriginal or Torres Strait Islander descent represent about 3% of the total number of births per year, but account for about 30% of the overall maternal mortality.4 Accordingly, in 1990, the maternal mortality rate among Aboriginals and Torres Strait Islanders was about 40 per 100 000 live births, as opposed to 2-3 per 100 000 live births in non-Aboriginal women. Governments continue to spend very large amounts of money in an attempt to remove this discrepancy, but clearly have not been successful. Money alone cannot improve the socioeconomic status of this disadvantaged group. |
Maternal mortality in developing countries | The difficulties experienced by Aboriginal women in Australia are reflected to a far greater degree among the peoples of the developing world. UNICEF and WHO estimates, based on a new approach to data collection, show that in 1990, 585 000 women died from causes related to pregnancy and childbirth.3 This is in excess of one death per minute. Over 140 000 died from haemorrhage; about 75 000 died from attempting to abort themselves; another 75 000 died from the brain and kidney damage of eclampsia; 100 000 died of sepsis; and about 40 000 died from obstructed labour.5 Eighty-seven per cent of births occur in developing nations, and these births account for 99% of maternal deaths (Box 1). |
Maternal injury |
For every woman who dies from a pregnancy-related condition, about 30
more (i.e., over 15 million women per year) sustain a severe and
permanent injury, such as chronic pelvic inflammatory disease,
vaginal, rectal and perineal tearing leading to urinary and faecal
incontinence, or Sheehan's syndrome (excessive blood loss causing
pituitary gland necrosis and thus ovarian, adrenal and thyroid
insufficiency).5
"Obstetric fistula" is a vesicovaginal fistula resulting from pressure necrosis from the fetal head on vagina and bladder tissues during prolonged and obstructed labour. As a consequence, there is a constant and uncontrollable flow of urine from the vagina. The woman and her clothing smell, her vulva becomes excoriated and painful, and she is often banished from her home to live with the domestic animals. She must walk everywhere as she cannot use any form of transport; she loses her family, her friends and often in despair surrenders her own life. Approximately 80 000 women develop obstetric fistula each year.5 Female genital mutilation -- the cutting away of the external genitalia, often including the clitoris -- is performed on girls aged 4-12 years. Approximately two million girls are so mutilated every year, mainly in Egypt, Ethiopia, Kenya, Nigeria, Somalia and Sudan.5 It is designed to preserve virginity and ensure marriageability. Giving birth is extremely painful -- the scarred vaginal opening cannot stretch to allow passage of the fetal head -- and results in injury and extensive tearing, often causing permanent damage.5 In developing countries women not uncommonly have up to 10 pregnancies during their lifetime. Based on the probability that some will suffer more than one obstetric injury during their lifetime, the total number of women affected can be conservatively estimated at some 300 million, more than a quarter of the adult women now alive in the developing world.5 |
Consequences of maternal death |
The 585 000 women in the world who die in pregnancy each year leave
behind them at least one million motherless children. The death of a
mother is almost twice as dangerous for her surviving children as the
death of a father, and her daughters are almost twice as likely to die as
her sons. 6
Women in developing nations are the major producers of food. They are responsible for 60%-80% of all food production in Africa, and 40% in Latin America. 7 Furthermore, unpaid household labour by women is worth about four trillion (10 12 ) US dollars per year, or about a third of world economic production (1993 global figures). 8 Clearly, addressing maternal health in developing nations is also sound economics. |
Causes of unsafe motherhood |
To find solutions we need to know and understand the causes of maternal
mortality and morbidity:
All of these are interlinked; a positive change in one is likely to lead to positive changes in all of the others. 1. Poverty There has been no significant decline in poverty rates throughout most of the developing world over the past decade.9 In developing countries the individual family is likely to be impoverished, with no resources for emergencies. When daily survival of the family is at risk, mothers will use fewer resources for their own health. Moreover, most developing countries spend less on health and welfare than they do on servicing their debts.7 However, poverty does not necessarily mean poor maternal health. India, although a nation making economic progress, is still beset by the problems of the developing world -- a dense population and widespread poverty and illiteracy. Kerala State, in south-west India, however, has achieved a maternal mortality rate a third of the rate in the rest of India (Box 2). 2. Access to maternal health services In general, most women in the developing world, particularly in rural areas, have no access to adequate maternal health services. Only low cost strategies unlikely to make a major impact on overall maternal health have been introduced to combat this problem. These are:
Essential obstetric care: Essential obstetric care incorporates the provision of properly trained and skilled birth attendants able to recognise abnormality in labour, able to deal with unpredictable complications as they arise, and able to arrange transfer to a facility which can cope with obstetric emergencies. In India, about three-quarters of the 150 000 women who die each year in childbirth live within a few kilometres of a health unit or district hospital, but those in attendance often fail to recognise complications early enough or arrange for transport to a health facility. Such facilities, even if acces sible, are often inadequately staffed or equipped. Even in the United Kingdom, despite good standards of nutrition, health and hygiene, maternal mortality rates did not fall until the advent of skilled obstetric care, surgery and anaesthesia for the treatment of haemorrhage, obstructed labour and sepsis. Cultural barriers: Often cultural barriers exist that militate against the use of whatever obstetric services are in existence. Many women expect to deliver at home and many refuse to see a male doctor. Many husbands refuse to provide money for medical treatment, or won't allow their wives to be removed from the family compound. Ignorance of potential complications of labour is widespread: obstructed labour can be regarded as a consequence of a wife's infidelity.5 3. Pregnancies too early, too late, too many, too close Frequent pregnancies interspersed with long lactation periods deplete maternal energy, iron, and calcium stores. Women in Bangladesh and Pakistan spend more than half of their time between the ages of 15 and 45 either pregnant or breastfeeding.5 The greater the number of pregnancies, the greater the risk of complications. Teenage pregnancy and pregnancy in the 40s likewise increase maternal risk. Cultural determinants and inequality of the sexes mean that many women have no reproductive choice. If all women who did not want any more children were able to stop becoming pregnant, the birth rate would drop by 57% in Latin America, 23% in Africa and 43% in Asia.14 Of all maternal deaths, 58% could be prevented by a combined approach of general fertility reduction, abortion services, and family planning targeted at high risk groups.15 Almost 50% of couples in the developing world have little or no access to family planning;6 less than 2% of all government health spending and less than 2% of international aid goes to family planning.5 Contraceptive technology is well advanced, and research into distribution methods shows that even poor societies can afford good family planning programs.16 Furthermore, it is possible to supply contraception in ways that are acceptable to all countries and cultures.5 The most important ingredient is the will of governments (rather than resources) to provide these services (Box 3, below).
4. Poor nutrition and health Most women in developing countries suffer from malnutrition during pregnancy and lactation. Custom and tradition have ensured that women have a clearly defined provider role. They are the labourers in the field, and their toil provides the family with food, but men and boys are fed before women and girls.17 About a third of women in Sub-Saharan Africa have an inadequate daily calorie intake,18 while 60%-70% of pregnant women in developing countries are anaemic19,20 and therefore more likely to die from postpartum haemorrhage.21 Protein, mineral and vitamin deficiencies are also widespread, but these can be easily rectified by health authorities with relatively cheap intervention programs. R educing protein-energy malnutrition is more complex.7 5. The low socioeconomic status of women In developing countries, on average, women earn 50%-70% of the income earned by men for similar work, and in Asia the wage gap reaches 50%.22 Women often do the tasks which require considerable physical exertion, regularly working 15 hours a day.23,24 Strenuous physical activity contributes to poor pregnancy outcomes, but women's health is seen by women and by others as a low priority. This acceptance comes from a lack of knowledge and education. Knowledge is power, and they have little knowledge. Illiteracy rates may be almost 50% higher for women than for men,25 and women without formal education have a greater risk of maternal mortality than educated women.26,27 Although education and social welfare are not aimed at improving maternal health, increased spending in these areas leads to sustained reduction in maternal mortality and morbidity.10 |
The solution -- empowerment of women |
At the Safe Motherhood conference in Nairobi, Kenya, in 1987, the
world set itself the target of reducing maternal morbidity by half by
the year 2000. It was considered that almost all conditions that lead
directly to maternal morbidity are either preventable or treatable,
and that with access to better medical facilities a reduction of
unnecessary loss of life of this order was achievable. In many areas of
the developing world various initiatives and programs have been
implemented and it is to be hoped that some progress will be made.
However, with the publication of the 1990 maternal mortality
estimates,3 derived by new
and improved methods, it became apparent that the magnitude of the
problem was even greater than previously realised, and that major
intervention would be necessary if these targets were to be realised.
Better access to family planning services, widespread provision of essential obstetric care and programs to deal with malnutrition in women can be provided by making a relatively small increase in the overall health budget or by changing health care priorities. Authorities such as the World Health Organization and the World Bank 7 have clearly demonstrated that increased expenditure in these areas will produce handsome economic returns. Why, then, is women's health not given greater priority? The reason is the male-dominated culture of much of the developing world. Control can only be exercised by power and this power resides in the hands of men. This describes the lot of women in much of the Third World. Without knowledge they are powerless, and will remain so. Just as we have found with Australian Aboriginal women, women in the developing world will never achieve satisfactory health outcomes until they themselves, through the acquisition of knowledge and learning, are able to compete, at all levels of society, for their fair and equitable share of power and influence. For these women, empowerment is the ultimate key, the way forward to safe motherhood. |
References |
This is an abridged version of the 57th Edward Stirling Memorial Lecture, given at the University of Adelaide on 21 August 1996. |
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