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May 26, 2009

When Childbirth Means Risking Your Life

Midwives may be one major factor in offsetting Africa's high maternal mortality rate.

LaVonne Neff

"Pregnancy and childbirth kill more than 536,000 women a year, more than half of them in Africa," writes Denise Grady from Tanzania in the May 24, 2009, New York Times. Her article, "Where Life's Start Is a Deadly Risk," contrasts the World Health Organization's (WHO) estimate of Tanzania's maternal mortality rate - 950 maternal deaths per 100,000 live births - with Ireland's: 1 per 100,000.

800px-Niodior2.jpg

In other words, a Tanzanian woman has a 1 in 24 lifetime risk of dying in childbirth; an Irish woman's risk is 1 in 47,600. (U.S. statistics, which you can check at the WHO website: a mortality rate of 11 deaths per 100,000 births, with a 1 in 4,800 lifetime risk.)

"The women who die are usually young and healthy, and their deaths needless," Grady writes. "The five leading causes are bleeding, infection, high blood pressure, prolonged labor and botched abortions."

Most women give birth at home (50%) or in local clinics (30%), going to a hospital - sometimes by bicycle! - only when they have been in labor for days and realize they need a caesarean. Because hospitals are understaffed and overcrowded, the surgery may be performed by a physician's assistant, and the woman may end up sharing a twin bed with another woman. This is scary enough to read about, but the shock value is even higher in the series of 21 photos, "Childbirth in Tanzania," accompanying the article.

And yet "to persuade more women to give birth at the hospital instead of at home, [Berega] hospital is sending health workers with that message to marketplaces, churches, village elders and religious leaders." For women who live far away, they are creating a maternity waiting home and are trying to get government funds for an ambulance.

As I read this, I wondered if this is an example of well-intentioned Westerners making a bad situation worse. It's good to improve hospitals, to make them more easily accessible, to train health-care workers. But will better hospitals make a big difference in infant and maternal mortality rates in a culture where many women prefer to use traditional birth attendants, where many men insist that their wives give birth at home, where the journey to the hospital is long and difficult, where most people can't afford even the low hospital fees, and where the hospitals themselves have high rates of infection?

Google sent me straight to the Horizon Solutions website. An article by Joyce Mulama titled "Africa: Upgrading Traditional Midwives' Skills" discussed the high mortality rates, the conflict between traditional birth attendants and hospitals, attempts made to discourage the use of midwives, and the eventual realization that midwives and hospitals need to work together.

According to Warren Naamara, country coordinator in Ghana for the Joint United Nations Programme on HIV/AIDS, drawing traditional birth attendants into the health system will involve providing them with the means to work in a clean, safe environment - and also with education.

"It is all about training TBAs in how far they can and cannot go. There are some things they cannot do, like surgery," he noted.

"Where they anticipate complications, let them refer such cases to the nearest delivery point, because their work has trained them to detect a woman who may not deliver smoothly."

Interestingly, 30% of Dutch births take place at home, whereas fewer than 1% of U.S. births are home based. And yet the maternal death rate in the Netherlands is only about half that of the United States. Improving African hospitals is good, but training African midwives may save more mothers.

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Posted by Katelyn Beaty on May 26, 2009 8:48 AM

Comments

P.S. I've been researching my family history, and I just discovered the death record for my great-grandmother. She died in childbirth in 1887, at the age of 18.

So I went looking for U.S. maternal mortality records in the 19th century, and I found an interesting article here: http://www.ajcn.org/cgi/content/full/72/1/241S . American records aren't available, but records from England and Wales indicate a maternal mortality rate in the 1880s of about 500 per 100,000 births (or roughly half that of Tanzania today). Interestingly, the article's authors say: "Historical data show that maternal mortality rates were lowest for home deliveries undertaken by trained and supervised midwives with no exceptions.... Maternal mortality rates were very high in countries, states, regions, or areas where most deliveries were performed by physicians, especially in the hospital."

Posted By: LaVonne Neff | May 26, 2009 2:05 PM

If I remember correctly from a class in grad school (early American lay devotional literature) about 1 in 5 women died in child birth in early New England. Many Puritan women journaled their thoughts on death and childbirth.

Posted By: Adam S | May 27, 2009 12:10 AM

LaVonne Neff sez: "Maternal mortality rates were very high in countries, states, regions, or areas where most deliveries were performed by physicians, especially in the hospital."

This was caused by doctor arrogance that they knew more than unschooled midwives. Unfortunately doctors didn't know about the germs they were carrying from birth-mother to birth-mother. See the Wikipedia history of Puerperal fever (childbed fever). By 1900 the need for antiseptic techniques became general practice.

Posted By: MonkeyBoy | May 30, 2009 5:42 PM

They didn't know about germs, period; and they carried them from corpses to new mothers. "Puerperal fever" or septicaemia was the term for fever after childbirth, and it was largely caused by doctors. When one doctor, Semmelweis, discovered that disinfecting hands could cut the rate of fever to about 1/15 of the usual rate, he was ignored by some and ridiculed by others; his recommendation of cleanliness was uniformly rejected. He died without being able to stop the usual practice.

Posted By: Mona Albano | June 12, 2009 9:15 PM

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