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WENDING their way along the forest path came two men bearing an improvised
stretcher on which lay a young woman, moaning softly. A few of her friends
followed close behind. The little procession was heading for a small, white-washed
hospital run by followers of Gandhi deep in the interior of Maharashtra
State in India. The woman, from a tribe known as the Madia Gonds, had been
struggling without success to produce her first child for many hours. Her
family knew from experience that her best chance of survival now lay in
getting her to hospital – and indeed she was delivered safely, with the
aid of forceps, soon after arrival.

This woman was lucky. Had she not reached hospital the chances are she
would have died at home of obstructed labour – just one of the half million
women worldwide who are estimated to die in pregnancy and childbirth every
year. All but 1 per cent of these maternal deaths take place in the Third
World, where the average lifetime risk of dying as a result of pregnancy
is between one in 25 and one in 50: this compares to a lifetime risk of
between one in 4000 and one in 10 000 for a woman in the developed world.

The rates of maternal mortality in rich and poor countries show a greater
disparity than any other public health indicator, with rates in the Third
World frequently more than 200 times higher than those in Europe and North
America. In developing countries death in childbirth accounts for about
a quarter of all deaths of women of childbearing age, whereas the figure
for the US is less than 1 per cent. According to the World Health Organization,
maternal death rates per 100 000 live births average 640 in Africa, 420
in Asia and 270 in Latin America, compared with an average of 30 for the
developed world as a whole.

This state of affairs is not new. But because those who suffer generally
live in remote places, and are poor, illiterate and politically powerless,
little action has been taken. Furthermore, the world was largely unaware
of this silent tragedy until recent years when some good community studies
of women’s reproductive experience began to appear. These studies, which
found that the vast majority of women in developing countries deliver at
home, with fewer than half of the births attended by professionally-trained
personnel, were stimulated mainly by the United Nations Decade for Women
which ended in 1985.

The enormity of this state of affairs is nevertheless still hard to
grasp, prompting Malcolm Potts, an obstetrician with extensive experience
of the developing world, to use the analogy of an aircraft accident to give
the statistics dramatic impact. ‘Imagine,’ he says ‘that every six hours,
day in, day out, a jumbo jet crashes and all on board are killed. The 250
passengers are women, most in the prime of life, some still in their teens.
They are all either pregnant or have just delivered a baby. Most of them
have growing children at home, and families that depend on them.’

The biggest killers are haemorrhage, infection, toxaemia, obstructed
labour and unskilled abortion, which between them account for 75 per cent
of all maternal deaths. But narrowing the focus to the last hours of a woman’s
life gives a very incomplete picture of the causes of maternal mortality.
In many developing countries maternal death rates are significantly higher
in rural areas than in urban, and this underlines a crucial point: that
lack of access to hospital for routine delivery or in emergencies is often
a root cause of death.

Probably about a fifth of all pregnancies develop complications, and
a woman who lives far from medical help is obviously more likely to die
as a result. In many places health facilities are unduly concentrated in
urban areas. For example, of 200 obstetricians working in Nigeria in 1980,
90 per cent were based in the national or state capital cities. The situation
is typical of Africa, despite the fact that most people still live on the
land.

Women living in the country and who want to reach hospital for either
routine delivery or in emergencies face many obstacles. Roads from villages
or remote homesteads may be rough, or even impassable at certain times of
the year; transport may be nonexistent or unreliable because there are no
spare parts or fuel to keep vehicles on the road. Some of the highest maternal
mortality rates in the world have been reported from Gambia (more than 2000
per 100 000 live births): a study in the Farafeni area between 1982 and
1983 revealed that women needing specialist treatment faced a journey of
200 kilometres, including a ferry crossing of the River Gambia, to the capital
city, Banjul.

The cost of health care can also constitute barriers as formidable as
distance to people who are very poor. In her investigation of individual
maternal deaths in Ethiopia, Barbara Kwast, then lecturer in Community Obstetrics
at Addis Ababa University, found that one woman died of haemorrhagic shock
shortly after arrival in hospital after enduring a 24-hour journey by public
transport because she could not afford the fuel cost for the ambulance –
at US$47 (Pounds sterling 28) equal to a third of the average annual income.

In another case, Kwast discovered from a distraught husband that his
wife had died of convulsions three days after being discharged from hospital
following a normal delivery simply because he had been unable to afford
to take her back for treatment when she developed fever. ‘The truth was
he had paid US$90 for his wife’s stay in hospital, which should not have
exceeded US$15 for a normal delivery,’ reports Kwast. ‘The watchman had
to be given a considerable tip before she could be admitted, and her husband
could borrow no more money.’

Efforts to extend proper medical care to the corners of society – which
everyone agrees is essential for saving women’s lives – are hampered by
the reluctance of educated people to bury themselves and their families
in rural areas where conditions are primitive.

Kwast says this was not sufficiently recognised by many countries when
they began investing in the training of high-powered registered midwives
in the mid-1970s at the expense of less qualified, enrolled midwives and
traditional birth attendants already working within communities. ‘I think
that in striving for progress in maternity care, some of these countries
have created a vacuum instead,’ says Kwast. ‘The registered midwife is not
prepared to function at the periphery because she is an educated person;
she has perhaps married a person who can’t function at the periphery, and
she has children for whom she wants an education.’ In the most effective
systems, all three levels of health care workers are recognised, trained
and cooperate with each other, she said. Each level supervises people at
the next level down and relieves them of the cases they are unqualified
to handle.

Women from remote areas frequently arrive at hospital so desperately
sick that it is too late to treat them effectively. But delay on the road
may not be the only obstacle to survival. Many health facilities lack sufficient
resources and are overwhelmed by heavy workloads: they are short-staffed,
short of beds, and short of the most essential supplies such as drugs, blood
and transfusion equipment, and even clean linen and antiseptics. One study
in Gabon showed that treatment of patients in Libreville’s main hospital
has to wait until their families fetch the necessary drugs from the pharmacy.
And in Kenyatta National Hospital, Nairobi, patients often have to share
beds, leaving them vulnerable to cross-infection.

Reports from many parts of the world show how common and how catastrophic
the lack of blood supplies can be. In Vietnam, for example, 36 per cent
of deaths from haemorrhage in one study occurred because there was no blood
for transfusion. And in parts of Tanzania swapping a pint of beer for a
pint of blood with a suitable donor off the street is common practice when
a transfusion is necessary.

An inquiry into all maternal deaths in Jamaica between 1981 and 1984
concluded that poor quality of care was a contributory cause in 68 per cent
of cases, with errors and inefficiency by staff being the biggest problem.
This is not unusual: reports from countries as diverse as Colombia, India,
Tanzania and Vietnam have cited shortcomings in their staff as contributory
factors in between 11 and 47 per cent of the maternal deaths.

Hidden within this general picture of underdevelopment and over-stretched
services is another potent factor in maternal death: sex discrimination.
It is no coincidence that the highest rates of maternal mortality are found
in societies where the status of women is lowest. Yet sex discrimination
as a contributory cause has been largely ignored: poverty is mistakenly
assumed to put everyone – men, women and children – at equal disadvantage
in health terms.

For many women the only paths to fulfilment and social status are through
marriage and motherhood. This is their destiny from birth, and not to achieve
it would carry an unbearable stigma. A high proportion marry while still
in their teens, become pregnant soon after, and continue to bear children
throughout their fertile years. Such a pattern is fraught with hazards.

The safest age to give birth is between 20 and 24 years, and many studies
show an increased risk of death for very young and older women. In Nigeria
one study found a maternal mortality rate among 15-year old girls seven
times higher than that of women aged 20-24, and in Jamaica women over 40
had a death rate five times higher than that of women aged 20-24.

In Africa and the Indian subcontinent more than half the teenage girls
at any one time are married, with the highest proportion being in Bangladesh
where more than 75 per cent of women marry before their 19th birthday. Seven
per cent of these are married before they are 14-years old, often to relieve
poor families of a liability: daughters do not become wage earners, nor
do they support their parents in future. ‘They are therefore brought up
as transitory members of the family, and are sent to take up their ultimate
work of good wife and dedicated mother at the earliest opportunity,’ writes
Mahmuda Islam, associate professor of sociology at the University of Dhaka.

Too young to bear children

Because the pelvis is not fully mature until several years after the
onset of menstruation, obstructed labour is a particular hazard for teenage
mothers. In several African societies, prolonged labour is taken as a sign
of marital infidelity, and she is left alone with her agony until she confesses
(in which case she may be helped), delivers or dies. This practice has been
reported from Zimbabwe, Ethiopia, Uganda and southern Sudan.

Kelsey Harrison has worked as an obstetrician in northern Nigeria where
teenage marriage is common, and has seen many cases of obstructed labour.
‘It is taboo to talk about pregnancy, so the typical young girl is totally
ignorant,’ he said. ‘Every decision about childbearing is made for her by
someone else – usually her husband. She can do nothing without his permission,
even if she has problems. And if he happens to be away from the village,
no one else will be prepared to make the decision to take her to hospital,
however ill she is.

‘Usually the relatives are very anxious about prolonged labour,’ said
Harrison. ‘They know it’s dangerous so they often apply their own traditional
remedies, many of which are unfortunately very harmful. Leaves or dirty
hands are inserted into the vagina; but worst of all is local surgery –
the ‘gishiri cut’ in which the vagina is slashed with a dirty razor blade
to try to relieve obstruction.’ Many women bleed to death at home from such
operations without ever being seen in hospitals or entered in the statistics,
believes Harrison.

Those who survive their first, relatively risk-prone pregnancies without
incident are likely to find the subsequent two pregnancies equally trouble
free. But thereafter the risk of serious complications such as haemorrhage,
ruptured uterus and infection begins to rise steadily. In Portugal, for
example, women giving birth for the fifth time were three times more likely
to die than women in labour for the second time.

High fertility is the hallmark of women’s low status. And although large
families are often necessary in poor communities to spread the workload
and to provide sons to look after parents in old age, many women bear children
continuously throughout their fertile years because they have no alternative.
Their social status depends on it, they are not trained to support themselves
outside the family, and family planning is either illegal, inaccessible,
unknown to them, or a decision made only by men.

The World Fertility Survey shows that a huge proportion of childbearing
is in fact unwanted: more than half the women who told researchers they
wanted no more children were not using contraception. The highest proportion
of women not using contraceptives were women with little education. Studies
show that women with seven or more years schooling are three times more
likely than their unschooled sisters to use effective contraception: they
have, on average, only half as many children.

Unwanted pregnancy is in itself a killer. Every year somewhere between
40 and 60 million women seek abortion, most of them resorting to dangerous
backstreet operations that take a terrible toll on lives. Abortion causes
more deaths among women of childbearing age in Latin America than any other
single cause, and is cited as a major factor, if not the dominant one, in
reports of maternal death from all corners of the world.

Although death from abortion is accidental, many maternal deaths are
not the tragic misfortunes they appear at first, but the last stage of a
chronic disease that has been developing since childhood. In many parts
of the world where women’s status is low, girl children are neglected from
birth; they are given less food, less medical attention, and less education
than their brothers. In families where there is not enough of anything to
go round, such particular neglect of daughters leads to stunted and distorted
physical growth and extremely limited horizons, both of which help to lay
the foundations for the death of so many women in childbirth.

A survey of 898 villages worldwide revealed a predominant pattern in
which, at all economic levels, women’s nutritional needs took second place
to those of their menfolk. Furthermore, researchers studying sex discrimination
in Uttar Pradesh, India, found evidence that baby girls were breastfed for
shorter periods than baby boys. Sometimes this was due to the fact that
a woman’s first child was a daughter: anxious to raise her status within
the family by producing a son, she quickly became pregnant again and stopped
breastfeeding the little girl in the belief that it could retard the growth
of the fetus. The researchers found, by contrast, that women who produced
sons tried to delay the next pregnancy so that they could give all their
attention to their sons. The pattern was repeated in neighbouring Haryana
where researchers found nearly twice as many girls as boys were bottle fed
after four months, and thereby made more vulnerable to malnutrition, infections
and diarrhoea. The Uttar Pradesh study also found that young girls, though
given as much of the regular foods such as rice and vegetables as their
brothers, received less of the specially nutritious foods such as eggs,
milk and butter.

Deadly discrimination

There are also reports from many countries of discrimination against
girls in health care. A children’s clinic in Lagos, Nigeria, reports that
a higher proportion of boys than girls use the facility. And a study in
Bangladesh found that, although the incidence of diarrhoea was comparable
between girls and boys, 66 per cent more boys than girls were taken for
treatment.

Sometimes it is financial considerations that tip the balance: a health
project in Korea, for instance, found that equal numbers of boys and girls
were brought for immunisation against measles when the service was free,
but as soon as a small fee was introduced the proportion of girls being
vaccinated fell to about 25 per cent of the boys.

On the Indian subcontinent, sex discrimination is so pervasive that
every sixth death of a female infant is due to neglect. The health of those
that survive neglect in childhood is often undermined to the extent that
it increases the risk of dying as a result of pregnancy. There is, for example,
a direct relationship between a woman’s height and the size of her pelvis;
those who are stunted through malnutrition are at increased risk of obstructed
labour.

Anaemia, too, is extremely common among malnourished women. As well
as being a direct cause of maternal death, less severe anaemia plays a part
in death from other causes. It undermines the body’s capacity to fight infection,
making women who have just given birth more susceptible to potentially fatal
blood poisoning, or puerperal sepsis. And an anaemic woman cannot tolerate
blood loss to the same extent as a healthy one: the loss of a litre of blood
will not kill a woman with normal haemoglobin, but the loss of as little
as 150 millilitres may be fatal to a very anaemic one.

Harrison believes all the evils associated with the low status of women
are linked to underdevelopment, and that education is the single most important
weapon to combat it. ‘I think we in the Third World should study the history
of the developed countries, because the whole gamut of our problems – social
inequality, cruelty to women, poor nutrition, poor communication systems,
inaccessibility of health services, you name it – hinge on development,’
he said. ‘But development cannot take place in a situation where the majority
of the people cannot read and write: unless we eradicate mass illiteracy
through formal education, we are not going anywhere.’

Measures to raise the status and living standards of women will undoubtedly
reduce the number who die in childbirth. But Harrison warns that such measures
are not an alternative to providing good quality maternity services. Countries
need to act on all fronts at once, because when complications arise – as
they inevitably do in any social setting – only skilled and timely care
will save a woman’s life.

* * *

Home births with a difference: building on tradition in the bush

WHEN ZIMBABWE won its independence in 1980 few women were attended by
medically trained personnel during childbirth. Most babies were brought
into the world by traditional midwives – generally older women with families
of their own, who with age had gained wisdom and respect within their communities.

Traditional midwives supervised most births partly because medical facilities
were sparse in the rural areas where most people live, and partly because
women felt happier with the system they knew than with the prospect of an
impersonal hospital far from home. Furthermore, hospitals tend to ignore
the spiritual rituals of childbirth which, especially with the first birth,
are still very important in traditional communities. But whatever the personal
preferences, experience from all over the Third World shows that the risks
for mothers and newborn babies who do not have access to modern maternity
care are considerable.

Zimbabwe will not be able to provide professional maternity care to
all its people in the near future. So it has decided, as an interim measure,
to make improvements to the existing system by up-grading the skills of
the traditional midwife and bringing her into the health network.

The idea was piloted in Manicaland. On a visit to Rowa village a few
kilometres from Mutare, where some 20 traditional midwives were gathered
for training at the local clinic, the provincial nursing officer, Aletta
Mashama, explained: ‘Our philosophy is to change only those traditional
practices that are harmful and to encourage those that are good.’

First and foremost trainees are taught the principles of hygiene. It
often happens that the traditional midwife is out in the fields when she
is called to a mother in labour; she will have dirt under her fingernails,
and would cut the umbilical cord with anything that came to hand such as
a sliver of bamboo, said Mashama. She would also dress the baby’s cord with
cow-dung or dust to dry it out. Not surprisingly, neonatal tetanus is a
common problem under such conditions. And because the traditional midwife
would put her hands into the birth canal – and sometimes apply crushed leaves
believed to ease delivery – mothers would frequently become infected.

Such unhygienic practices are discouraged during training, and every
traditional midwife is given a special delivery kit. This consists of a
bar of soap, a nail-brush, a razor blade (broken in half to deter menfolk
from using it to shave), a sterile tie and surgical spirit for the baby’s
cord, a plastic sheet to spread on the earthen floor, and several clean
cloths for wiping the baby’s eyes and the mother’s perineum, and for wrapping
the newborn baby.

Sterile razor blades and soap are supplied at the nearest clinic, but
other things in the kit are readily available: the plastic sheet is usually
a washed mealie-meal sack, the nail brush is the dried hairy pip of a local
plant, and the cord tie is from a stringy plant washed with soap and dried
in the sun.

Traditional midwives are also taught to recognise the difficulties in
childbirth that only skilled medical staff could handle. Pregnant women
judged during antenatal care to be ‘at risk’ are referred to the district
hospital with facilities for life-saving procedures such as caesarian section
and blood transfusion. Women who have had complicated pregnancies before,
or previous caesarian section or stillbirth, those expecting twins, or complaining
of headaches or swollen legs, are referred, as are women who have already
given birth several times. Contrary to popular belief, practice in childbirth
does not make per fect, and the risk of haemorrhage, high blood pressure
and infection increase significantly after the third birth.

The challenge to trainers is to make the scientific information more
convincing than folk beliefs, because training does not so much fill a vacuum
of knowledge as replace a system established over centuries.

Many of the traditional midwives have never been to school, but illiteracy
is no obstacle to training. Lessons are learnt through discussion, visual
aids, songs, dance and drama, and are generally lively sessions. By the
end of the course the group usually has play-acting down to a fine art.
Half the trainees will sit in the shade of a tree watching and commenting
as the other half acts out a delivery as conducted by an untrained midwife.
Harmful practices are illustrated, and the actors usually carry the story
to a tragic conclusion, with the sick baby being taken to the village healer
who cannot save it from tetanus. Much noisy keening follows.

Then the spectators take their turn on the dusty stage, to illustrate
a birth conducted by a trained midwife. This time the outcome is happy,
the midwife emerges from the hut holding the cleanly-wrapped baby and singing
a traditional song with veiled references to sexual organs that are meant
to inform the anxious father of the sex of his new baby.

At the final ‘graduation ceremony’ the trained traditional midwives
are given badges to wear. They are not paid by the health service, so this
small symbol of increased status within their communities is specially important.
Continued supervision and encouragement are also ex tremely important to
the success of the scheme, and the traditional midwives are supposed to
be in close contact with the local health centre.

‘We did have some problems at first with scientifically-trained staff
rejecting the idea of working with non-professionals,’ said Mashama. ‘But
we really encouraged dialogue between the two groups and now the clinic
staff see that they get fewer emergencies when they cooperate with traditional
midwives and accept that they have a role to play. Today traditional midwives
aren’t afraid to bring even their mistakes to the clinic to ask how they
could have handled things better.’

The confidence of the trained traditional midwives attached to Rowa
clinic was evident. At the end of the session they broke into an animated
discussion about AIDS. Couldn’t they have gloves, they asked Miss Mashama?
And while on the subject of equipment, what about kit bags like the village
health workers (another group of paramedics involved in primary health care?
Village health workers have kit bags supplied by UNICEF, and everyone recognises
them walking through the village, they explained.

Such requests are taken seriously. But because of limited cash for health
care the trained traditional midwife must look to satisfied clients for
her reward. Few statistics are yet available to show the effective ness
of training in terms of lives saved, but Aletta Mashama says ‘mothers are
obviously confident that they are in safer hands with a trained traditional
midwife because their services are much in demand.’ The training scheme
has now been adopted as national policy in Zimbabwe.

Sue Armstrong is a freelance journalist and editor (with Erica Royston)
of Preventing Maternal Deaths, available from the World Health Organization.
The WHO also produces the newsletter Safe Motherhood: for free copies write
to Division of Family Health, World Health Organization, 1211 Geneva 27,
Switzerland.