Maternal
Mortality
Kyra Payne and Amanda Rohdenburg
 |
| Photo Courtesy of Matt Miller |
Introduction
Of the eight millennium development
goals established and agreed upon by world leaders at the 2000 UN summit, Goal
5 and its targets focus on diminishing the suffering of women by reducing
all-together the inexcusably high rates of global maternal mortality. Goal 5’s targets and indicators, as written in
the Millennium Declaration, signed by 189 countries in September 2000, are as
follows:
5.A Goal: Reduce by
three quarters, between 1990 and 2015, the maternal mortality ratio
·
5.1
Maternal mortality ratio
·
5.2
Proportion of births attended by skilled health personnel
5.B Goal: Achieve, by
2015, universal access to reproductive health
·
5.3
Contraceptive prevalence rate
·
5.4
Adolescent birth rate
·
5.5
Antenatal care coverage (at least one visit and at least four visits)
·
5.6
Unmet need for family planning
History: The Making of Goal 5
The making of Millennium Development
Goal 5 is a compilation of feminist, health and human rights advocacy and a multitude
of women-centric conferences.
Originally, global anxiety regarding overpopulation placed reproductive
health in the limelight of the international agenda but it was not until the
1970’s that the feminist movement began to spearhead the fight for reproductive
rights (Petchesky, 3). Rising social
justice and domestic women’s health movements continued to place importance on
reproductive rights, encouraging the use of health experts, insisting on
meaningful application of informed consent and establishing physical integrity
as a fundamental human right (Morgen, 3-8).
Backed by an increase in demand for
international actors to take up the call for women’s reproductive rights,
conferences began to spring up on the world stage; further pushing the issues
of gender and reproductive health. In
June 1975 The First World Conference on Women held in Mexico City attempted to
promote the incorporation of women in development. While failing to make substantial
contributions to women’s health rights, this conference was when followed by
the 1979 Convention on the Elimination of All Forms of Discrimination Against
Women (CEDAW). Significantly more
encouraging that its predecessor, the CEDAW (unanimously accepted by the United
Nations General Assembly) outlined the individual rights and freedoms of women
to both promote equality and prevent discrimination, and required signatories
to address systemic obstacles to female empowerment. Furthermore the CEDAW delivered a baseline
for women’s case for reproductive rights and “represents a standard to which
advocates of rights-based development can appeal” (Dixon-Mueller 7-9).
These conferences held in the 70s
continued into the 80s, 90s and 2000s with mixed results. Following the First World Conference on Women
and the CEDAW, the Second World Conference on Women was held in Copenhagen,
July of 1980; focusing on the prominence of equal access to healthcare. Five years later the Third World Conference
on Women held in Nairobi, 1985, drew attention to social and legal
participation in congruence with decision-making. Of all of the numerous conferences regarding
women and reproductive health, it was not until the United Nations
International Conference on Population and Development (ICPD) held in Cairo,
November 1994, that reproductive health took a spot in the international
limelight.
The ICPD represents a bag of mixed
results, on the one hand the ICPD marks a huge breakthrough in population and
development (International Planned
Parenthood Federation, 2013).
Focused on more than sexual and reproductive health, the IDPC Programme
of Action sought to recognize the interdependent nature existing “between
population, sustained economic growth, health, education, economic status and
empowerment of women” and was “remarkably…the first time world leaders agreed
to invest in people, not demographic targets” (International Planned Parenthood Federation, 2013). The ICPD Programme of Action, a
comprehensive (and ambitious list of improvements to be made in regards to
universal access to healthcare), recognizes the voluntary choose to marry or
not to marry, the right to establish a family, determine number, timing and
spacing of children, “the right to access the information and means needed to
exercise voluntary choices, the right to the highest attainable standard of
health are human rights . . . rights that women and young women in particular
are unable to access” (Osentimehin, UNFPA)
Principle 4, documented in the Report of the International Conference on Population and Development,
Cairo, 5-13 September 1994 reads:
“Advancing gender equality and equity
and the empowerment of women, and the elimination of all kinds of violence
against women, and ensuring women’s ability to control their own fertility, are
cornerstones of population and development-related programmes. The human rights of women and the girl child
are an inalienable, integral and indivisible part of universal human rights.
The full and equal participation of women in civil, cultural, economic,
political and social life, at the national, regional and international levels,
and the eradication of all forms of discrimination on grounds of sex, are
priority objectives of the international community.”
The recognition of gender inequality,
women’s ability to control their fertility and the call to eliminate “all kinds
of violence against women” is an important movement towards dealing with the
multifaceted challenges of maternal mortality.
However, the ICPD also helped enabled the violence against women by failing
to stand up for the right to abortion.
The ICPD proved to be the ideal stomping ground for the controversial fight
over abortion, resulting in hot debate between member states. The compromising text regarding abortion does
not unequivocally acknowledge a women’s right to abortion, stating instead:
“In no case should abortion be promoted
as a method of family planning. All Governments and relevant intergovernmental
and non-governmental organizations are urged to strengthen their commitment to
women’s health, to deal with the health impact of unsafe abortion as a major
public health concern and to reduce the recourse to abortion through expanded
and improved family planning services.
Prevention of unwanted pregnancies must always be given the highest
priority and all attempts should be made to eliminate the need for
abortion. Women who have unwanted
pregnancies should have ready access to reliable information and compassionate
counselling. Any measures or changes
related to abortion within the health system can only be determined at the
national or local level according to the national legislative process. In circumstances in which abortion is not
against the law, such abortion should be safe.
In all cases women should have access to quality services for the
management of complications arising from abortion. Post-abortion counselling, education and
family planning services should be offered promptly which will also help to
avoid repeat abortions” (8.25 Cairo 1994)
While
essential in bringing to light the importance of women’s rights and the need
for equal access, the ICPD’s failure to defend abortion as a fundamental right
has served to worsen violence against women.
Following the ICIPD was the Fourth
World Conference on Women (FWCW) held in Beijing in 1995, which continued to
draw attention to women’s health.
Pivotal in “broadening the international understanding of reproductive
health services beyond the limited scope of family planning” the FWCW focused on
making medical services affordable and easily accessible. The FWCW focused, as well on gender-based and
poverty-based violence which restricts women’s ability to control fertility (Beijing
Earth Negotiations Bulletin). Further,
the FWCW drew attention to marginalized populations and insisted that maternal
health and empowerment of women are considerations for development initiatives.
A compilation of feminist, human
rights and population control, MDG 5 grew from the international cascade of
women’s reproductive health. The
multitude of Women-centric conferences and continuing efforts to recognize the
importance of gender equality and women’s control over fertility demonstrate
the monumental importance of addressing these issues on a global scale. MDG 5, while not all-encompassing of these
important issues, is a step in the right direction for addressing and promoting
gender and health concerns.
Current Status
Undeniably maternal rates have decreased
globally between 1990 and 2010, with a global reduction in maternal deaths of
roughly 47%, progressing from a median of 400 deaths per 100,000 births in 1990
to 210:100,000 in 2010 (United Nations 2013).
However, the faces of Halima and Sessay still represent thousands of
women in the developing world, their suffering but a mere drop in the bucket. Lacking
access to sufficient healthcare and financial security, pregnancy for women
within developing countries could well be considered a death sentence. Defined in the International Classifications
of Diseases, 10th edition (ICD-10), maternal mortality is “the death
of a woman while pregnant or within 42 days”, every year approximately 529,000
women within developed nations die of complications during pregnancy (Khan, WHO)(Nour
2008).
The disparity between the developed
Global North and the developing Global South (specifically Africa) regarding
maternal mortality rate (1:16 for Africa and 1:2800 for Western nations)
demonstrates the effect of poverty, gender inequality and lack of national
healthcare infrastructure (Nour 2008). The
major causes of maternal death range from severe, uncontrolled bleeding, pre-existing
health issues exacerbated by pregnancy (HIV, malaria, heart disease, ect),
infection and unsafe abortion. As of
2011, 46 million of 135 million live births women delivered alone or without
the assistance of skilled birth attendants, placing 46 million at risk of the
dying from hemorrhage, infection, or botched abortions (United Nations, 2013). Annually, of an estimate 211 million
pregnancies, 46 million end in unsafe abortions, killing roughly 67,000 women
every year (Nour 2008) (Gillespie 2004) Dangers
to maternal health that are of little consequence within the developed North
prove to be life-threatening to women who lack the access or financial power to
receive the care needed; these women in turn become victims of “the three delays”.
“The
3 Delays”
Halima and Sessay are an example of
hundreds of women’s lives throughout the developing world, inhibited by poverty
and distance these women are held captive from receiving timely medical care. The first delay which prevents women from
reaching hospitals in time is the postponement in deciding to receive
care. Women, their families, community
or birth assistants do not always recognize life-threatening complications,
therefore aggravating already serious conditions. Further worsening the time sensitive nature
of medical emergencies is the second delay, suspension in reaching health-care
facilities due to lack of transportation, infrastructure and isolated locations
(Nour 2008). The disparity between rural
and urban women is emphasized as women living within rural villages are
isolated, forced to give birth in their homes due to the inaccessible nature of
hospitals. Time lost between delay one
and delay two serves to magnify birth-related complications, which in turn is
further exacerbated by the third delay; delay in receiving care. Due to lack of health-care infrastructure,
developing countries are severely understaffed, further postponing patient
treatment. Resource-poor countries
often lack the staff, technologies and services required to properly treat
women suffering from hemorrhaging, infection, obstructed labor or fistulas
(Nour 2008).
Halima’s body altering labor in her
remote village and Sessay’s needless death, an hour from receiving saving care,
demonstrate the destructive nature of the three delays in getting to and
receiving healthcare. Their stories are
reflective of the experience of hundreds of faceless women whose suffering
cannot be understood or recognized through statistics alone.
As of 2010, women in 40 different
developing countries are living lives similar to those of Halima and
Sessay. These 40 countries all have
appallingly high maternal mortality rates (death per 100,000 live births), the
highest MMR rates exist for Chad (1100/100,000), Somalia (1000/100,000), Sierra
Leone (890), Central African Republic (890), Burundi (800), Guinea-Bissau
(790), Liberia (770) and Sudan (730) just to name a few. The brunt of maternal
deaths exists in almost all of Sub-Saharan Africa, due to extreme poverty, lack
of medical infrastructure and the HIV/AIDs pandemic which attributes to 10% of
all maternal deaths. (WHO, UNICEF, UNFPA & The World Bank 2012).
Successes and Challenges
Although the problem at large
remains imposing and challenging, the progress made towards reducing maternal
mortality should not be ignored. In the
last decade substantial progress has been made towards improving maternal
mortality; Eastern Asia, Northern Africa and Southern Asia’s maternal mortality
rates have reclined by an estimated 2/3rds (United Nations, 2013). Within developed countries the rates of women
utilizing skilled birth attendants to aid with labor have increased from 55
percent to 66 percent from 1990 to 2010, slow progress to be sure but progress
non-the-less (United Nations, 2013).
Continuous and passionate research on the persistent challenges of
maternal mortality offer a multitude of solutions to help alleviate the burden
placed on women. Increased use of
oxytocin and misprostol would prevent an estimated 41 million cases of
postpartum hemorrhage, saving approximately 1.4 million lives (Greene E. M.,
Robles J. O., Bathala, S. & Risi H. L., 2013). Organizations such as the UN End Fistula
Campaign, the Fistula Foundation and the USAID-funded Fistula Care initiative
are all working towards increasing the number of staff available and capable of
treating fistulas and other women’s health issues (United Nations 2013) (Greene
E. M., Robles J. O., Bathala, S. & Risi H. L., 2013). Within developing countries grassroots
organizations are also working towards alleviating the burdens of maternal
mortality.
The Edna Adan Maternity Hospital
established in Hargeisa, Republic of Somaliland is a prime example of
sustainable solutions to maternal mortality.
Established as a non-profit charity and built by Edna Adan Ismail
through the donation of her UN pension and personal savings on January 1st
1998; Edna Adan’s hospital has served to dramatically lower the maternal deaths
in Somaliland. Strategically built in
the less affluent area containing 1/3rd of Hargeisa’s city in a
central location served by public transit, between 2002 and 2010 the Hospital
has dramatically reduced Somaliland’s maternal mortality rate below the
national average. With an average of 41 deaths out of 9822 women who delivered
at Edna’s Hospital, the maternal mortality rate for the Edna Adan Maternity
Hospital is 41.73/100,000; a dramatic and progressive step in the right
direction (Edna Adan Maternity
Hospital 2002). Global successes
and local successes cannot be ignored, but there still exist many challenges to
reducing global maternal mortality.
One of the most obvious failures of MDG
5 is the primary focus on maternal death, without any concern for maternal
morbidity. Goal 5 does not set standards for dealing with the thousands of
women who survive childbirth only to suffer with debilitating post-birth
ramifications, i.e vaginal fistulas. For
every woman who dies in childbirth another thirty suffer the crippling physical
trauma or illnesses related to postpartum pregnancy (Global Health
Initiative). It is a failure of MDG 5
that women rendered disabled due to complications in childbirth are not
considered, suggesting that a woman’s worth is dependent upon her maternal
ability, to produce and rear children.
Furthermore, the Global Gage Rule
(GGR) continues to waylay women’s fight for control over their fertility. First implemented from 1984 to 1993 and
reinstated by President George W. Bush in 2001, the Global Gag Rule (Mexico
City international family planning policy) states that US aid toward family
planning “would only be awarded on the condition that abortion services and
information be struck from the recipient program, even if non-US funds were
used to provide them (Cohen 5) (Rohdenburg).
With the GGR, family planning services face the ultimatum of losing
US-funding if they do not concede to the US’s anti-abortion stance. This in turn has resulted in limited funds
for organizations that offer safe abortions services and the GGR has in essence
bullied other institutions into removing abortions services all-together
(Rohdenburg). MDG 5’s failure to protect
abortion as a human right does not prevent women from seeking abortions,
instead it hinders women’s ability to have safe abortions; increasing the
likelihood of maternal death’s resulting in botched abortions.
Perhaps what the Millennium Development
Goals truly need is a genderless health goal focusing on universal reproductive
and sexual education, as it stands today MDG 5 is too heavily gendered and
seems to pay little heed to women’s health up until the point of birth. Maternal mortality cannot be truly handled
without the inclusion of men in the educational process. MDG 5 is treating the symptom of the larger
problem without attacking the root cause, lack of infrastructure, poverty,
gender inequality and cultural beliefs.
What
If the US Were an MDG Country?
Data collected from the 2010 World Fact
Book places the United States 137th on a list of 184 countries,
right below Hungary with an average MMR of 21.
For a highly developed country, representing the ideal of development
for so many Third World countries, the United States as a dangerously high
maternal mortality rate. Even though the
United States spends more on healthcare than any other country and has invested
in maternal health more than any other type of hospital care, women in the
United States “have a higher risk of dying of pregnancy-related complications
than those in 49 other countries, including Kuwait, Bulgaria, and South Korea”
(Amnesty International 2010). Regardless
of spending over 86 billion dollars a year on healthcare, a woman giving birth
in the United States is five times more likely to die than a woman giving birth
in Greece, four times more likely than Germany, and three times more likely
than Spain (Amnesty International 2010).
Of the estimated 1.7 million women a year who give birth in the United
States, nearly a third experience pregnancy complications that have adverse
effects on their health. It was also
found that African-American women carry a higher risk of dying during child
birth, nearly four times more than for Caucasian women (Amnesty International
2010). The focus of reducing maternal
mortality has focused primarily upon the developing south, but there remains a
lot of work to be done at home. (Amnesty
International, 2010)
Moving Forward: Dealing
with the Facts and Moving Forward
One key aspect to moving forward
is facing the numbers and the sinking reality that the global problem of
maternal mortality is worse than the statistics disclose. MDG 5 faces an uphill battle in accurately assessing the extent that
progress has been made towards reducing maternal mortality due to fluctuating
methods of reporting. The tenth revision
of the International statistical
classification of disease and related health problems (ICD-10), the World
Health Organization defined maternal mortality as
“the death of a woman while pregnant or
within 42 days of termination of pregnancy, irrespective of the duration and
site of the pregnancy, from any cause related to or aggravated by the pregnancy
or its management but not from accidental or incidental causes” (Trend in
Maternal Mortality).
By this definition, maternal fatalities
fall into one or two categories; direct and indirect maternal deaths. Direct maternal deaths are identified as
deaths resulting from obstetric complications of pregnancy including delivery
and postpartum; such as incorrect treatment, hemorrhage, hypertension disorders
or caesarean complications. Indirect
maternal deaths are a result of illnesses, previous existing or developed
during pregnancy that are worsened by effects of pregnancy.
The difficulty in acquiring accurate
numbers for maternal mortality despite the standard definitions set by the International statistical classification of
disease and related health problems arises within countries. Inconsistencies of identification and
classification of maternal mortality continue to exist within numerous
countries. These fluctuations of
recording are further exacerbated by developing countries lack of record
keeping and the many challenges of properly identifying cause of death vs
accidental deaths. Lacking functional
civil registration systems, developing countries underreport the number of
women to die from childbirth. A
2006-2008 study conducted by the Confidential Enquiry into Maternal Deaths
states that upwards of 60% of maternal deaths go unreported in the civil
registration system. This discrepancy in
the numbers is a result of several factors: 1)not all deaths of women of
reproductive age are recorded, 2) pregnancy status of women is not always known
and therefore cannot be accounted for death, 3) most developing countries lack
medical certification of death. (WHO, UNICEF, UNFPA & The World Bank, 2012)
It is also fair to assume that with most births taking place at home, outside
of hospitals, many maternal deaths occur separate of venues where people would
report cause of death.
The scope of maternal mortality
cannot truly be understood because current data representing MMR is unreliable,
keeping the plight hundreds or thousands of women invisible to the world.
Why
it matters
Preserving the human dignity of
women worldwide is an ethical issue which must be considered and addressed
globally. The suffering of thousands of
women is a humanitarian atrocity of unsurmountable proportion as well as
socially and economically detrimental to developing countries wishing to enter
the threshold of global advancement. Maternal
mortality destroys developing country’s economies by reducing the global work
force and keeping women and their families stuck in the poverty trap. Within developing countries, women are
important contributors to families and communities, a total of 40% of the
global labor force and over 60% of agricultural labor in Sub-Saharan Africa and
accomplished by women (global health incentive). Parental death and maternal morbidities
incapacitate large segments of the workforce of developing countries, forcing
family members to supplement the income that would otherwise have been done by
women.
This creates a perpetual cycle of poverty,
forcing women suffering from post-birth complications to sell assets and
undertake loans which leave them indebted, to pay for health services. Studies done in Ghana and Benin found that
complications during pregnancy accounted for 1/3rd of women and
their family’s annual financial expenditures.
Women in Burkina Faso suffering from “. . .severe obstetric
complications reported more frequent sale of assets, more borrowing, and slower
repayment of debt in the following year” (WHO, UNICEF, UNFPA & The World
Bank, 2012) global health incentive, 6).
Further impoverishment of the household and incapacitation or death of
the mothers negatively affects the economic standing of communities and
countries and further inhibits children from obtaining the schooling needed to
lift themselves and their families out of poverty.
Maternal loss reduces capital
investments in children, thereby continuing generational poverty and ensuring
that Millennium Development Goals 1, 2 and 3 remain just out of reach. Survival and flourishing of women has proven
to be one of the most effective ways of improving child education and health,
while men often squander their earnings, women often re-invest in their
families. The deaths of mothers has a
negative impact on children, orphans in low-income countries have worse health
and have less schooling. South African
studies have supported these conclusions and research conducted in Tanzania
estimate that the consequences of maternal death for the remaining children are
one less year of schooling than children with mothers (global health
incentive). In the case of Sri Lanka,
after reducing maternal mortality by roughly 70% between the years 1946-1953
through government prioritizing of maternal mortality, the number of girls sent
to acquire an education increased (WHO, UNICEF, UNFPA & The World Bank,
2012)
The effects of maternal mortality are
trans-boundary and have negative bearings on developing countries as a
whole. Loss of market laborers and
pertinent care providers for communities and children leave villages in a
perpetual state of poverty, non-conducive to the aspirations of developing
countries or the MDGs. Recurrent deaths
of mothers within unindustrialized countries create turmoil within the
populous, threatening the stability of the village, ultimately the country and
by extent, the global nation.
No comments:
Post a Comment