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When it came time to deliver twins, Nakbibi, 18, travelled three hours from her home in Faizabad, Afghanistan, to get medical help. Afghanistan still remains one of the world's most dangerous places for women giving birth. (Manca Juvan/Manca Juvan/Corbis)
When it came time to deliver twins, Nakbibi, 18, travelled three hours from her home in Faizabad, Afghanistan, to get medical help. Afghanistan still remains one of the world's most dangerous places for women giving birth. (Manca Juvan/Manca Juvan/Corbis)

Focus

Maternal mortality: <br/>Why it's a crisis Add to ...

More health workers and better clinics, which could save millions of lives, would be the easiest response to the maternal-mortality crisis. Sri Lanka shows what is possible, even for a relatively poor country. By emphasizing health services and family planning, including a massive training program for midwives and health workers, Sri Lanka has drastically reduced its maternal deaths, to the point where the death rate is only one-fifth of the rate in neighbouring India.

But some of the causes of maternal deaths are much more complex. Traditional cultural practices and social inequalities - from early marriage and early pregnancy to female genital mutilation and domestic violence - are among the biggest factors in maternal mortality. These are among the toughest obstacles to overcome.

Expectant women wait inside a women's hospital in Allahabad, India: With its booming economy, India still suffers more than 135,000 maternal deaths every year.

Young mothers are among the most vulnerable

Consider the case of Lakshmi, a girl in the northern India state of Rajasthan, who was forced into marriage at the age of 13 because her parents were poor. She was expected to prove her fertility, so she became pregnant almost immediately after her marriage. Because she had been poor all her life, she was severely anemic and had a premature delivery at five months. The baby did not survive, and Lakshmi died soon after from excessive bleeding.

Indu Capoor, director of a health education centre in India, tells the story of Lakshmi as evidence that maternal mortality is often a question of poverty and inequality.

"You can imagine a 13-year-old girl trying to negotiate with her husband or her family to take her to a hospital," Ms. Capoor says. "She is working almost 20 hours a day, she is malnourished, and everyone is exploiting her. We need to delay marriages, but it's hard in many regions where it is the cultural norm. The younger the girl, the easier it is to get her married."

Maternal health is increasingly seen as a human-rights issue, since so many women are almost deliberately excluded from health care. In many African and Asian countries, up to 70 per cent of women say their health-care decisions are made exclusively by their husbands. In a landmark decision last year, the UN Human Rights Council declared that maternal mortality is a human-rights issue.

Unsafe abortion and lack of contraceptives are also key factors. More than 15 per cent of maternal deaths in South Asia are a result of botched abortions. More than half of women in developing countries want to delay or prevent pregnancy, yet a quarter of them are not using modern contraceptives, usually because of poverty, lack of education or lack of services.

Neil Andersson, an epidemiologist who is working on maternal health in Nigeria as part of a Canadian-funded project, found that many maternal deaths are an indirect result of genital mutilation, domestic violence or overwork.

"Maternal deaths are part of a spectrum of violence against women," Mr. Andersson says. "The violence they experience throughout their lives is accentuated through pregnancy and childbirth, when they are most vulnerable."

Ms. Mhatre of the IDRC says there is no "quick fix" to these issues. "Maternal health sounds like motherhood and apple pie, but the root causes are very difficult," she says. "How do you push the system to deal with issues like domestic violence?"

While the experts debate and politicians make their promises, Africa's women continue to endure the threat of death whenever they give birth.

In the drought-stricken village of Gerebana Korkede, about 150 kilometres south of Addis Ababa, a woman named Alemnesh Markos is eight months pregnant. She expects to deliver her baby at home, in her small dirt-floored hut, just as she did with her previous four children.

If there are any complications, the nearest health centre is a one-hour walk from her hut. The nearest hospital is much further.

"Of course we are worried," she says, sitting with her children in the thatched-roof hut where all of them were born.

"We don't know what will happen," she says. "Sometimes the child dies inside the mother before she can reach the hospital. Sometimes it takes a long time to wait for a car. Sometimes the baby comes halfway out and stops, and there is bleeding. We are in God's hands."

Geoffrey York is The Globe and Mail's correspondent in Africa.



The care gap

  • 123 million Number of women in the developing world who gave birth in a health-care facility in 2008 and needed care
  • 62 million Number who received care 
  • 5.5 million Number who needed care for hemorrhage 
  • 1.4 million Number who received it 
  • 7.2 million Number who needed care for sepsis 
  • 1.7 million Number who received it 
  • 6.8 million Number who needed care for hypertension 
  • 1.6 million Number who received it 
  • 7.6 million Number who needed care for obstructed labour 
  • 1.8 million Number who received it 
  • 8.5 million Number who needed care for complications of an unsafe abortion 
  • 5.3 million Number who received it


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