On Maternal Mortality, Why Africa Falls So Far Behind
A very distraught old woman came to Edna Adan Maternity Hospital in
Hargeisa, Somaliland, appealing to us to help her transport to the
hospital a woman who had given birth five days earlier and who still
had the placenta inside her. Those of us at the hospital are not
sure how this could be possible and we ask her again whether she
means five hours. She is sure about the number of days, and quotes
the day the woman had delivered which, indeed, was five days
earlier. She also tells us that the woman may not be alive by the
time we get to her.
We prepared the ambulance, put in our emergency obstetric kit and
set out towards the home at the opposite end of town from our
hospital. We come to a hut with quite a few neighbors and onlookers
standing around.
Before we get to the patient, we
could have been guided to the woman by the smell coming from inside
the hut. We find a woman who has bled for several days, is very
infected, febrile, dehydrated, has no recordable blood pressure and
a weak, rapid pulse. We cannot understand how she could have
survived this long in this condition. Answers to our questions would
come later, but right now, we needed to get an IV line going, and
once in, we put her in the ambulance and headed for the hospital
where blood transfusions and medical care would be ready for her. We
also brought along the baby.
Once she picked up, we got the placenta out, started her on high
doses of antibiotics and the woman miraculously recovered and went
home a week later.
Our burning question was why did they wait for five days before they
looked for help when the placenta refused to come out after the baby
was born?
The unfortunate answers were: (1) We thought we would wait and hoped
that it would come out later. (2) When it took too long to come out,
her husband suggested that they try Somali Traditional methods to
get the placenta out. (3) When this failed, they tried spiritual
chants and prayers. (4) By the third day, they feared that if they
report this to the hospitals, the old woman who had attended the
delivery would be denounced to the government. (5) Finally, the
woman became so ill that they feared they would not be able to
afford the cost of the medicines she would need to treat her.
Luckily, they got the courage to come to us and we were able to
treat her free of charge, although we had our conditions for this
free treatment: the woman who had attended the delivery would have
to agree to spend five days at our hospital to be shown how to
conduct a normal delivery and to know which conditions to refer
immediately. To this, she agreed, and hopefully, this situation
never will be repeated.
This was just one example of what
practicing midwifery in our part of the world entails. My theory is
that women in Somaliland die because of ignorance on their part and
on the part of those assisting them. Poverty is a strong factor that
prevents women from seeking help because they convince themselves
that they cannot afford the cost of modern medicine and would rather
consult the local traditional healer who often causes more
complications.
Pregnancy, Childbirth Still Killing Women
In 1945, diplomats representing the countries of the world at the
end of the Second World War gathered in New York and proposed the
formation of a global health organization. In April 1948, the
constitution of the World Health Organization was passed, with its
first article stating, "Health is a fundamental Human Right."
Sixty years later, that noble declaration seems to have had little
effect on the maternal mortality rate of women in the developing
countries. The women continue to die of causes that have been
eliminated in countries where efficient, safe and adequate health
care have been made available for their women.
As far as African women are concerned, we seem to have very few
rights, particularly in the area of safe reproductive health care.
We fare the worst compared to women in other continents. In my
48-year experience as a midwife, I see very little improvement in
the conditions under which our women progress through their
pregnancies and childbirth. It's a situation that shocks me even
more today when I witness the advances that have been made in
medical care elsewhere during the past half-century.
Why Africa Falls Behind
What leads the women of our continent to their graves during
pregnancy and childbirth? As I describe below, the reasons fall into
six categories: nutrition, education, high fertility, female genital
mutilation, improper care at delivery and inadequate health
facilities.
Nutrition: Sub-Saharan countries are affected by increasing
degradation of the environment -- which we commonly call
desertification -- due to frequent droughts, cutting down of trees,
soil erosion and poverty. Superimposed on this are frequent wars and
instability that cause displacement of peoples and which negatively
affects the nutritional status of those living off the land.
While little girls are the mothers of tomorrow, we all know that
they are fed the leftovers from whatever the family is eating. If
lucky, she occasionally gets a bone to nibble at. During her
childhood, who thinks about the growth of the bones of these little
girls? Does anyone worry that her growth may become stunted because
of chronic malnutrition and anemia? That she might develop a
contracted pelvis? What will happen when she gets married and her
narrow pelvis cannot permit the passage of the babies she will be
expected to bear and produce? How many women have access to a health
facility that can perform a Caesarean section to save the lives of
the baby and its mother before the labor becomes obstructed?
Education: Quite often, when a family has to decide which of their
children can be sent to school, it is often the girls who are left
behind. We find that illiteracy affects the health and survival
outcome of women. The lower their education level, the higher their
risk of health problems, including those associated with their
reproductive life.
An illiterate woman is not able to seek her rights because she is
not even aware that she has any rights at all. She considers herself
"owned;" first by her family, then by her husband and later by his
sons.
High Fertility: Once the girl is married, immediate and frequent
fertility is expected of her without taking into consideration
whether or not her body can take care of the baby she will conceive.
Our women, therefore, produce as many children as they can to ensure
their place in their new home. In my work, I often witness women
having baby number 9 or 10, and also some having baby number 12, 13,
14, 15 or 16 and, once, baby number 21!
FGM: As if all her other misfortunes were not enough in themselves,
harmful traditional practices such as female genital mutilation (FGM)
are performed on them and affect the health of women and children in
many African countries, including mine. FGM affects and damages the
perineum and the pelvic floor muscles of women and is a major cause
of laceration of the perineum during childbirth, as well as damage
to the urethra and rectum resulting in fistula formation.
This is among the most tragic situations and has shocked me so much
that I became the first Somali woman to publicly cry out against FGM
in 1976, well before those who would like us to believe that they
are fighting against a new enemy that they have discovered. Thirty
years later, even though umpteen campaigns have been held and many
have joined the struggle, millions of little girls continue to be
cut, mutilated and affected.
To show the extent of the problem, I developed a study at the Edna
Adan Maternity Hospital on the status of women who come to our
clinic and FGM. Regretfully, and contrary to anecdotal reports
stating that there has been a decline in the practice, we discovered
that 97 percent of the women attending our prenatal clinic have some
form of FGM, and 98 percent of them have the most severe form of it.
I am still working on the final results of this report, but it is
clear that there has to be an FGM strategy that is different and
more effective than that which has been used in the past.
Time of Delivery: Women having babies who are at a time of their
greatest need for skilled medical or midwifery assistance are often
at the mercy of relatives or other individuals who have received no
or insufficient training in the care of women during childbirth. The
woman does not know nor seek proper medical care because she does
not know that this is her right. Many women die of obstetrical
mismanagement with her relatives blaming her misfortune on "evil
spirits" or "the evil eye of other women who were jealous of her
baby."
Health Facilities: The health facilities are so ill-equipped and
poorly staffed that even if women get taken there, there is very
little that can be done for them. More often than not, women arrive
at these health facilities when their situation is too advanced and
cannot be helped. How can infections be avoided when many health
facilities have no water, gloves, disinfectants, sterilizers or
dressings?
Charting a Better Path
Delegating women to a second-class status does not necessarily raise
men to a first-class status. When when they do, they are denying
their sisters, wives and daughters the education, decision-making
and the possibility to rise to their fullest potential. In short,
men lose when they prevent women from becoming full partners in all
the challenges that life brings.
The prevention of maternal mortality is the basic right of all women
and must be made a priority in all developing countries. The urgency
of the situation warrants vastly heightened attention. Otherwise,
the pledges and statements of health as a human right will continue
to be words printed on paper made from the wood of the trees that
have been cut down -- and thus only contributing to more degradation
of the environment, poverty and misery.
Source:RH Reality Check
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