Friday, February 24, 2012

Losing sight of invisible women: Behind the maternal mortality statistic

Transport for women with obstetric complications
in the Democratic Republic of Congo

Observers of global public health are rightly encouraged by new figures on the extent of maternal mortality in the world.  Both the data of the University of Washington’s Institute of Health Metrics and Evaluation and new data from the United Nations show that the stubborn figure of over 500,000 maternal deaths per year that had been cited for so long may finally be replaced by the still alarming but encouraging figure of about 350,000 annual deaths.  The new data arrived in time to generate encouragement at the September 2011 session on the Millennium Development Goals.

While the new data represent an achievement that should be both celebrated and studied in more detail, optimism around these figures must continue to be tempered by the reality that women in most of sub-Saharan Africa and probably the poorest women in most countries did not enjoy the gains represented by the new data.  As an obstetrician from Chad, one of the poorest countries in the world, I see these new figures with a mixture of optimism and continued concern about how the world understands the phenomenon of maternal death and injury.

I have been privileged to observe maternal health services in a number of African countries for over three decades.  When I graduated from secondary school in 1970, there were two Chadian medical doctors in the country, neither of them focused on maternal health.  The common saying “a pregnant women is a woman who has one foot in the tomb” was illustrated only too graphically for all Chadians, including myself, as I watched relatives and other women of my acquaintance die from complications of childbirth.

I wish that I could say the situation has greatly improved in Chad and many African countries.  As the new data show, maternal death is entrenched at high levels in a number of countries.  As WHO has noted, in some countries HIV is a barrier to reducing maternal death, but in other countries the intransigence of maternal mortality reflects the difficulty of women’s struggles against many kinds of subordination.

I wonder whether the global policy-makers who will be poring over the new statistics understand the circumstances that add up to maternal death in my country and too many others.  When I worked briefly in Ethiopia, for example, I was struck to find there what we also see in Chad – that there are remote areas where it is well known to everyone that rural women die waiting alongside roads, hoping to find a car that can bring them to a maternity hospital.  Too often, their active labor does not come on the market days that may be the only time when a vehicle may come by.  Naturally, it is not the better-off women who have this problem.  Somehow the many women, especially rural women, who do have it, are practically invisible.

But women are so subjugated that in some places, even the better-off ones are constrained by gender-based subordination as they struggle to save their own lives.  As a practicing obstetrician in one of Chad’s main hospitals, I remember dealing with a woman who was related to a high-level official, so not among the most marginalized of my patients in social terms.  She was suffering in obstructed labor from a breech presentation of the fetus, indicating the urgent need for delivery by caesarean section.

But in her ethnic group, it was a strongly held view that “real women” should not deliver babies by caesarean section.  She feared that a caesarean would cause her husband to reject her and take other women as wives.  In the hours that I had to spend talking to her and her husband, we came close to seeing her add to the mortality statistics.  This is the situation of even the better connected women in my country.

In my current position in RAISE, a program affiliated with Columbia University that works to bring reproductive health services to war zones and other emergency settings, I have seen how women are once again the most vulnerable to the worst effects of political instability and insecurity.  Though I had witnessed the subordination of women in so many communities in Africa, it has been deeply shocking to me to see the health effects of the use of rape as a weapon of war in Congo.

When communities are threatened by violent soldiers or rebels, somehow society tolerates a situation where men stay at home to avoid insecurity, but women are sent to work on the crops or fetch water or fuel.  I have met so many women in that situation – women who were raped and gang-raped with horrible life-long injuries simply because only women do the chores that sustain the household.

I was honored to be invited to observe the activities of the health system in Honduras that have led to improvements in maternal health outcomes in that small country.  Honduras is better off than Chad in per-capita income, but it still faces very severe resource constraints for health services.  With the limited resources at their disposal, health officials and service-providers in Honduras assessed the maternal death situation and realized that the risk of death was highest among low-income rural women, including those in remote mountain areas.

Making it a political priority to solve this problem led officials and communities to work together to ensure that women could find transportation to get to health facilities and that those facilities would have the basic services needed to prevent the vast majority of maternal deaths.  This experience for me was both moving and maddening.  Making a difference in the statistics should not be so hard for Africa, but women just don’t count for much.

A lifetime of advocacy for government attention to the relatively simple measures that need to be taken to reduce needless deaths and disability linked to childbirth among Chadian women makes me concerned that the message of the new maternal mortality data will be that the victory is won and we can rest on our laurels.  Rather, in my country and many of its neighbors, we must urgently seek ways to re-energize a focus on maternal death that is based on women’s right not to die as well as the right of all women to comprehensive reproductive health services.

In the aftermath of the Millennium Development Goals discussions, every leader who praises the countries that have reduced maternal mortality must also be concerned about places where the lack of progress is link to the continued atrocity of treating women as less than human.  Maternal mortality should always be spoken of as a symptom of the more pernicious pathology of failing to give political priority to women’s rights, humanity and dignity.  

- Grace Kodindo, MD, Assistant Clinical Professor of Population and Family Health