An invisible emergency
Read on for the appalling global figures of pregnancy-related death, and how
little it would cost to bring an end to what the World Health Organisation
[WHO] calls an "invisible emergency".
According to the WHO, "Ultimately, the critical need may be one of
generating sufficient political and social will at international and
national levels to overcome this avoidable tragedy."
Regrettably, both "political and social will" are scant when it comes to the
world's mothers! - Lynette
Frontline Volume 22 - Issue 9, April 23 - May 06, 2005
An invisible emergency
Photo: ANITA KHEMKA/UNICEF: Bhadu Rajwar with her eighth child,
at her village home in Purulia district, West Bengal.
In Visakhapatnam's remote tribal village, Bhagya (23) just lost her eighth
child during delivery after a three-hour struggle by her relatives to save
the baby. Married at 13 and having delivered her first child at 14, Bhagya
lost three babies within 20 hours of their birth. Fatigued with failure and
wasted effort, Bhagya's relatives cut the umbilical cord but left the
placenta intact, leaving her to the risk of post-partum haemorrhage.
This risk is not unique to Bhagya or because she lives in a tribal village,
but common to deliveries that happen at home, which accounts for
three-fourths of all child birth in India. Thus, both this year's World
Health Day (April 7) and the World Health Report, "Every Woman and Child
Counts", focus on maternal and child health. In this era of high technology
and medical advances, the death every year of 11 million children and over
half a million mothers around the world seems senseless. Ironically, most of
these deaths are preventable and caused mainly by malnutrition, infections
and lack of access to even basic healthcare and transportation. Almost all
the deaths happen among the poor of the developing countries primarily
because, as U.N. experts say: "This is not a high enough priority for many
governments or the international community."
In 1990, leaders from 189 countries pledged to achieve by 2015 the
Millennium Development Goal of reducing child mortality by two-thirds and
maternal mortality by three-fourths. But can this happen?
The statistics are hardly encouraging: Every minute, across 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 of a pregnancy-related cause. Globally, some 550,000
pregnancy-related deaths are reported every year and 90 per cent of these
deaths happen among the poor in the developing countries. Rightly, the World
Health Organisation (WHO) calls maternal mortality "scandalous" and an
Social and cultural practices, which are largely 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 aged between 17 and 35 receives prenatal care while more than half
of them are anaemic. Hardly 20 per cent of mothers receive complete prenatal
WHO defines maternal mortality as the death of a woman while "pregnant or
within 42 days of termination (by delivery, miscarriage or abortion) of
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). All, easily preventable.
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 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. In
India it is 407, it is 95 in Vietnam, 60 in China and Sri Lanka, 15 in New
Zealand, 12 in Japan, nine in Singapore and six in Australia.
There is, however, a wide regional difference in MMR within India. In Kerala
and Punjab it is very low, while in 10 of the 15 major States (Assam, Bihar,
Gujarat, Haryana, Karnataka, Madhya Pradesh, Orissa, Rajasthan, Uttar
Pradesh and West Bengal) it is over 400; and in three States (Assam, Madhya
Pradesh and Uttar Pradesh) it is over 700.
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 in the world. For
every woman who dies, at least 30 suffer injuries and often, permanent
disability. Maternal mortality is the main factor that considerably lowers
the life expectancy of women. 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
Says Joy Phumaphi, Assistant Director-General, Family and Community Health,
WHO: "Pregnancy is a normal, life-affirming state. Women should not die
giving birth. Their deaths are preventable even in the poorest countries."
But many women have no role in decision-making even when it comes to their
In India, only 9.7 per cent of married rural women (15-49) have a hospital
within the village and 40 per cent live more than 10 km from a hospital. In
such cases a skilled health worker is a boon. Thus, Unicef has taken up
"ensuring skilled birth attendance for every birth" as a rallying point for
this year's Safe Motherhood Day on April 11.
One of the biggest health concerns in India is the issue of young mothers.
More than 10 per cent of girls below 20 are already mothers. According to
the National Family Health Survey, 6.4 million women under 18 are married;
11 per cent of all under-20 women are mothers. According to the survey, the
average age of marriage for women was 16 and the first baby was born at the
age of 19.
Says Dr. Ardi Kaptiningsih of the WHO: "Many women die not only because they
are too young but also because of repeated pregnancies for the sake of a son."
Three important ways by which maternal deaths can be controlled are: (a)
family planning - that is, every pregnancy should be a wanted one; (b)
skilled attendance at child birth - all pregnant women must have access to
skilled medical care; and (c) essential obstetric care - all pregnant women
must be able to reach a manned and equipped healthcare facility if
Mandatory antenatal investigations for all pregnant women will dramatically
lower pregnancy-related risks. They help in detecting and treating existing
problems and complications and providing counselling thereafter to help the
women prepare for birth and advise them 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. Only 15 per cent of pregnant women receive
complete antenatal care and only 58 per cent receive iron and folate tablets
or syrup. Hardly two-thirds of deliveries are attended by skilled birth
attendants and only a-third receive some postnatal care.
Maternal mortality and morbidity are more likely in nations and cultures
that give little priority to the needs, status and situation of girls. In
many of these cultures, maternal illness and suffering are viewed as
natural, inevitable, and part of what it means to be a woman.
Girls routinely face discrimination in many cultures. In South Asia, the
cycle of discrimination starts at birth because of a preference for sons and
the perception of girls as an unwanted financial burden. Parents are
reluctant to invest in girls' health and education because they will get
married young. Studies have shown that female babies in South Asia are
breastfed less frequently than male babies, and are often not treated for
illnesses. In most households women eat last and the least, their growth is
stunted by nutritional deficits. They marry early, do not use
contraceptives, become under-weight and anaemic mothers; they are further
weakened by frequent childbearing. Malnourished mothers have low-weight
babies, who have few chances for survival.
One of the key words in the World Health Report (WHR) is `exclusion'.
"Women," it says, "are being excluded from essential services, and
governments have a responsibility to do something about it." U.N. Population
Fund Executive Director Thoraya Ahmed Obaid says: "One sure way to make
every mother and child count is to guarantee universal access to
reproductive health, as was agreed at the International Conference on
Population and Development [which was held in Cairo in 1994]."
Noting that pregnancy would be a death sentence for half a million women
this year, Obaid stressed that more than 200 million others have an unmet
need for safe contraception. "This is a public health crisis and a moral
outrage as it can be easily dealt with," she says.
The WHR notes that every year, 68,000 women die from botched abortions. Dr.
Ian Smith, adviser to WHO Director-General Dr. Lee Jong Wook, argues that
family planning should be an integral part of women's overall health and
each pregnancy should be made safe and desired.
The WHR puts India on the list of 51 "slow progressing'' countries with
respect to infant, child and maternal mortality. The decline in the infant
mortality rate is slow; the fall is lesser for neonatal mortality (NMR) and
there is almost no change in the rate of stillbirths. Every year, as many as
10 per cent of all new-borns do not live to see their fifth birthday. In
absolute terms, India accounts for 25 per cent of the over 10 million
under-five deaths worldwide every year. Nearly half of these deaths occur in
the neonatal period.
Vaccine-preventable diseases such as measles - the biggest killer- continue
to claim children in thousands. Non-administration of Tetanus in newborns
remains a major problem in at least five States - Uttar Pradesh, Madhya
Pradesh, Rajasthan, West Bengal and Assam.
Says Vinod Paul of the All India Institute of Medical Sciences' paediatrics
department: "A majority of infant deaths can be averted through affordable
interventions such as breast-feeding, clean delivery, maintaining warm
temperature for the baby and antibiotics."
As there is a clear correlation between the health of the new-borns and
their mother's risk during and after delivery, the WHR points out that
maternal and child deaths can be reduced through a "continuum care''
approach - from pregnancy to a safe delivery, followed by adequate
post-natal care for the mother and the infant. This means a massive
investment in health systems, particularly the deployment of more doctors,
midwives and nurses, since millions of women are giving birth at home
without professional medical care.
According to the WHR, the availability of resources for the health sector is
a major challenge. Says Dr. Ian Smith of the WHO: "Most problems need simple
cost-effective solutions." There is, however, a need for about $90 billion
every year over the next 10 years in 75 developing countries. He says: "It
is simply a question of what the Governments priorities are?"
Not that the government is not aware of all this. In fact, the latest
National Population Policy of India focuses on the government's commitment
to safe motherhood. Among the goals identified for 2010 are: reducing MMR to
below 100, IMR to below 30; NMR to below 20; 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.
To make childbirth safer, the Health Ministry last year decided to pay
midwives to bring pregnant women to hospitals for check-up 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.
For the pregnant women who are caught between a poor and inadequate
government health system and an unaffordable private one, midwives are
godsend. But most important is that the midwives are trained to perform
clean deliveries, recognise danger signs in the mother and the new-born, and
be able to make appropriate referrals. Moreover, training can be beneficial
only if the midwives are part of the larger health system and are provided
the basic necessary equipment such as a disposable delivery kit.
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."
Dr. Ann Tinker of the international NGO, Save the Children, says: "Simple
delivery kits that provide a clean blade to cut the umbilical cord, soap for
hand washing and a plastic sheet to place the baby can go a long way in
saving the mother and the child during delivery." According to her, the
child's survival is closely linked to the mother's.