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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)

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

The villagers hoisted the pregnant woman onto their shoulders, carrying her in a crude stretcher made from a blanket and two sticks, and began trudging down the path to the nearest town.

The woman, 24-year-old Setew Tilahun, had gone into labour the night before. But the baby was twisted around inside her and could not come out. Nobody in her remote Ethiopian village could help her. And so her arduous journey began.

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When the villagers finally reached the nearest town, late at night, after carrying her on their shoulders for six hours, the people at the health centre said they could do nothing for her. They found an ambulance and sent her on to the next town, a four-hour drive.

At 2 a.m., medical staff in the town of Fitche looked at her and said they couldn't help either. They put her back on the road again. At 4 a.m., she finally reached a hospital in the capital, Addis Ababa, where doctors found that her baby had died.

The mother, too, was barely alive, and needed emergency treatment to save her life. "She looked like a dead woman," says her brother, Getachew Mesaye, a 27-year-old farmer. "She fainted and it took two hours to revive her."

It was the kind of small human tragedy that happens every day, all over the world. Close to 550,000 women die in pregnancy and childbirth every year - a rate of about one woman every minute - along with nearly 4 million infants who die within a month of birth. The grim statistics reflect one of the most stubbornly intractable and neglected crises in the world, which persists despite endless studies and debates and vague promises of help.

For women in Africa and Asia, the act of giving life - having a child - is one of the most dangerous risks they can take. Their chances of dying in childbirth can be more than 100 times greater than a Canadian or American woman would face.

This week, Prime Minister Stephen Harper became the latest in a string of politicians to pledge action. He promised that maternal and child health would be Canada's "top priority" at the G8 summit in June.

When Setew Tilahun had difficulty in delivering her baby, her brother Getachew Mesaye, left, and other villagers took her on an arduous journey to get help. By the time they finally reached doctors who could help, her baby was dead and she had almost died.

The commitment followed a campaign of quiet backroom lobbying by a coalition of Canadian advocacy groups, including the Canadian branches of CARE and UNICEF, which had written to Mr. Harper several months ago to urge him to use Canada's role as the G8 host to put maternal health at the top of the agenda.

Yet it will take more than political rhetoric to reverse the decades of neglect and broken promises. History shows that governments around the world have been willing to tolerate the deaths of millions of women without the furor that would surround an earthquake or an epidemic.

In 1987, at a major international conference in Nairobi, governments pledged to cut the maternal death toll in half by 2000. Nothing happened - except that the death toll kept climbing relentlessly.

When the United Nations set its new "millennium development goals" for the developing world a decade ago, it aimed to reduce maternal deaths by 75 per cent by 2015. Today this target has been the most dismal failure of any of the UN's eight millennium goals. At the current agonizingly slow rate, the target will not be met until 2076 in Asia - and many years later in Africa.

Carol Bellamy, who headed UNICEF from 1995 to 2005, has seen the promises come and go, and she has seen governments continuing to ignore the maternal-death crisis. "It's just so frustrating that it hasn't received more recognition over the years," she says.

"First and foremost, it's because it is women, and women are seen as second-class citizens. Governments are still more male than female. There's certainly been more progress on children's health, because politicians like to talk about kids."

Yet it would actually be easier for politicians to make progress on maternal deaths, compared to higher-profile issues such as AIDS or malaria, if they truly wanted to solve the problem, she says. "It doesn't require a scientific breakthrough, like AIDS or malaria. It just requires leadership, and a recognition that it exists as an issue."

Human-rights advocates Mary Robinson and Alicia Yamin put it more bluntly: "The reason that women are still dying is because women's lives are not valued, because their voices are not listened to, and because they are discriminated against and excluded in their communities and by health-care systems."

The problems are simple, the solutions cheap

Most maternal deaths are easily preventable when basic care is available. In fact, maternal deaths have been virtually eliminated in Canada and other wealthy countries. But the gap between rich and poor countries is shockingly wide. In Canada, the lifetime risk of maternal death is just one in 11,000. In Ethiopia, the risk is one in 27. In Angola and Liberia, the risk is one in 12. And in Niger - the worst in the world - the lifetime risk of maternal death is one in seven.

Of the 10 million women who have died in pregnancy and childbirth since 1990, three-quarters of the deaths were preventable, primarily in Africa and South Asia. Millions of other women have been left with crippling injuries or illnesses as a result of poor care in childbirth. One of the most common birth-canal injuries, fistula, leaves many women so incontinent that they are ostracized by their families and villages.

This Tanzanian hospital is often so full it has to put two expectant mothers in the same bed.

For every woman who dies in childbirth or pregnancy, another 20 to 30 are left with illnesses and injuries that can be debilitating for life. And the consequences for the surviving children can be devastating. The children face a much higher risk of malnutrition, dropping out of school, or even death. Among infants who were born alive to mothers that died of maternal causes in Afghanistan, a study found that 74 per cent of the infants subsequently died too.

Even as economies improve, the deaths persist. India, with its booming economy, still suffers more than 135,000 maternal deaths every year. Despite the boom, India's government spends only 0.9 per cent of its gross domestic product on public-health services - one of the lowest percentages in the world. Its public-health clinics and hospitals are so under-equipped that they often refuse to admit pregnant women for fear they will die.

In the richest countries, too, there are pockets of high maternal deaths, revealing the patterns of poverty and inequality.

In the United States, for example, the maternal mortality rate among black women is 3.4 times higher than the rate for white women.

Many of the solutions are not expensive. A new study, released last month by the United Nations Population Fund and the Guttmacher Institute, estimates that 70 per cent of the world's maternal deaths - almost 400,000 lives - could be prevented if an additional $13-billion was spent annually on health care and family-planning services. The cost would be just a few dollars per capita. "It's not rocket science," the authors say. "What has taken so long?"

Most maternal deaths are caused by a brutally simple problem: a lack of health-care services. In the poorer countries of Africa and South Asia, the vast majority of women give birth at home, often lacking basic hygiene, because they cannot afford to travel to a hospital or clinic. Yet 15 per cent of these women suffer complications in labour, and usually there is nobody to help them. Millions of women with major complications get no treatment at all.

'It's almost like going into a killing field'

Even when hospitals and clinics exist, they are often so filthy and badly equipped that a pregnant woman stands a serious risk of dying from infection or bleeding. She enters the hospital and never returns.

In one regional hospital in Nigeria, a shocking 12 per cent of women are dying in childbirth. Many hospitals and clinics have no blood supplies, no antibiotics, and no running water. "It's almost like going into a killing field," says Sharmila Mhatre, a health specialist at the International Development Research Centre in Ottawa.

Afghanistan, where Canada has spent billions of dollars on foreign aid and military intervention, still remains one of the world's most dangerous places for women giving birth. About 25,000 women die from pregnancy-related complications in Afghanistan every year, and more than 90 per cent of deliveries take place at home, usually without any health attendants. The lifetime risk of maternal death in Afghanistan is one in eight - one of the worst rates in the world.

In five of India's poorest states, more than 90 per cent of primary health clinics do not have any blood-storage facilities - dooming women to death if they are bleeding heavily during labour complications - and more than 90 per cent cannot perform a Caesarian section.

"There's no way they can handle an emergency," says Jashodhara Dasgupta, co-ordinator of a women's health organization in India. "They don't want a death on their hands, so they keep turning women away, and they die on the road."

In Ethiopia, the government has drastically boosted its training programs for doctors and health extension workers, yet it is still handicapped by the exodus of thousands of doctors and nurses, lured away by better-paying jobs in Canada, the United States and Europe.

"I wish we had a trained person in my village," says Getachew Mesaye, the farmer who carried his sister for six hours to the nearest town. "If we did, we wouldn't be forced to travel all this distance to Addis Ababa."

He was lucky: He was able to borrow the equivalent of a year's income from other villagers to pay for his sister's transport and medical costs. But the loan repayments will burden him for years.

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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