Analysis: Hope for mothers around the world

NEW YORK — A trifecta of studies examining the death rates of young children and new mothers offers a glimmer of hope among dismal statistics.

The bad news, which isn’t really news at all to anyone who has opened a newspaper in the past decade, is that some 300,000 women die every year because they do not have any care whatsoever during pregnancy and childbirth. The good news — which really is newsworthy — is that we seem to be making headway in some places.

The reports come from data collected by Save the Children, which released its 11th State of the World’s Mothers on May 3; The Lancet, a British medical journal which published an international study on April 22; and Amnesty International, which ironically provided a very un-international report focusing on maternal mortality in the U.S., which is, strikingly, getting worse.

According to Save the Children, the 10 best places to be a mother (which simply means you are most likely to survive the process of becoming one) are: Norway, Australia, Iceland, Sweden, Denmark, New Zealand, Finland, Netherlands, Belgium and Germany. The 10 worst places (meaning, you are most likely to die) ranked from the bottom up: Afghanistan, Niger, Chad, Guinea-Bissau, Yemen, DR Congo, Mali, Sudan, Eritrea and Equatorial Guinea.

It is no coincidence that the top-ranking countries have the most skilled health workers per pregnant woman and child while the countries at the bottom of the chart have the fewest trained helpers. Among the losers in this rating this system, about one in 23 women die during childbirth and about one in six children die before the age of 5. The U.S. ranked a pathetic 28th.

According to the Amnesty International report, for every 100,000 women giving birth in the U.S. about 13.3 died, according to statistics collected in 2006, which is up from 6.6 in 1987. Part of the increase may be due to better data collection, but experts say the increase may also be the result of older women giving birth, obesity and lack of access to care among poor women.

With data collection so murky throughout the world, the key is not comparing the U.S. to other countries, which may not have accurate statistics, but examining which women in America are at greatest risk. African-American women, for instance, are more than four times as likely to die from pregnancy complications than women of other races, according to the Amnesty report. Maternal mortality rates among African American women have been high for the past two decades, and little has been done to change that.

Globally, there is hope. The Save the Children report points  to a six-week health-training course for rural women in Bangladesh that led to a 34-percent decrease in newborn mortality and a 53-percent cut in maternal mortality. Similar programs in Nepal, India, Bolivia and Ghana nearly cut childhood mortality in half. Health-worker training programs have been launched elsewhere — in Ethiopia and Hondoras, to name a couple, but it is too early to judge the outcome.

Sometimes simple low-tech solutions, such as so-called kangaroo care (when mothers hold their premature yet stable newborns against their skin to breastfeed), halved death rates among newborns. In essence, mothers’ warm skin serves as the incubator.

“We don’t want our report to sound as if the solution is just that it takes a village, because it requires a lot more,” said Mary Beth Powers, Save the Children’s Newborn and Child Survival Campaign Chief. “We are talking about workers on every level — doctors, nurses, midwives and local female health providers.” But, she added, the role of the frontline female health workers should not be underestimated.

The Lancet study found an overall decrease in women dying from childbirth from roughly 526, 300 in 1980 to 342,000 in 2008. Anyone in the business of tracking global maternal and child death rates knows these figures are rough estimates, but The Lancet investigators echo Save the Children sentiments attributing the decreased death rates to improvements in skilled birth attendants, better nutrition and education available for pregnant women.

But there’s the rub. What seems an easy fix can be an insurmountable obstacle in war zones where women are often barred from education and where many young pregnant women refuse the care of male attendants. It is no surprise that Afghanistan ranked rock bottom in maternal and newborn mortality. And becoming a trained health worker is not an easy sell in a country where educating women is shunned and several female health workers have been violently attacked.

In addition to the scientific papers, a recently released heart-wrenching documentary, "No Woman No Cry," tells the story of several poor women trying to survive pregnancy. Christy Turlington Burns, the director and narrator, followed, among others, a Maasai woman from Tanzania, who is nine months pregnant and walked five miles to the nearest health clinic that wasn't much more than a run-down shack. In Guatemala, she interviewed a doctor who runs a post-abortion clinic to treat women injured by unsafe abortions.

Dr. Wendy Chavkin, a professor of Clinical Population and Family Health and obstetrics and gynecology at Columbia University, said “It’s great that we have The Lancet, Amnesty International and Save the Children [reports] more or less simultaneously.” But she was appalled that The Lancet global study did not mention abortion, or rather the number of women dying from unsafe abortions. According to the International Federation of Gynecology and Obstetrics, more than 10 percent of maternal deaths are due to unsafe abortions.

She added that one of the things community health workers can do is provide contraceptives which save lives. But they cannot do cesarean sections, which are also needed at times and save lives too. As she said, “there are some very high-tech answers to this that require highly skilled nurses and doctors and there are some low-tech solutions as well.”

The bottom line is data collection is a good idea. The solutions sound good, but putting them into action is a huge challenge. Save the Children estimates that we need a bare minimum of 4.3 million health workers to fill the gap. Let’s hope we can use the new data (no matter how rough these statistics may be) as an impetus to implement viable solutions.

Randi Hutter Epstein,  M.D., is the author of "Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank."