Last December, as intense civil fighting erupted in South Sudan, I spoke with several doctors and nurses about its impact on the health of the 11 million people who call the country home. The problems accessing health care in South Sudan were already vast, and the emergence of violence would only make things worse – perhaps no more so than for expectant mothers.
I was working in New York with the communications team at Doctors Without Borders/Medecins Sans Frontieres (MSF), which provides vital care across South Sudan and nearly 70 other countries around the world. As part of my role, I debriefed MSF aid-workers like Miriam Czech, an American nurse who had just returned from a mission, and considered their experiences for sharing more widely with the media and public.
For three months, Czech had trained local nurses to provide better care for pregnant women. But the challenges were great. Czech told me about a frail 24-year-old woman who had walked three days from her village to the maternity unit in the city of Aweil. The woman was in the ninth month of her pregnancy, and her husband had to carry her part of the way because she also was suffering from terminal tuberculosis. Czech helped the woman give birth to a baby boy, fragile at only 1.2 kilograms — less than half the cutoff for low birth weight. But the mother could not endure the stress of childbirth.
“She was in the act of dying when she came [and] giving birth pushed her over the edge,” Czech said.
In hearing this story, and many others while at MSF, I realized that in times of conflict as in peace, pregnant women were among the most vulnerable, at risk for dying – and yet they don’t need to be.
A mother’s legacy
Nearly 287,000 women around the world die of pregnancy-related complications every year, according to the World Health Organization. A vast majority of these deaths are avoidable. Ninety-nine percent occur in developing countries, the result of poor access to health care, poverty and a variety of other factors.
I first realized the gravity of the maternal health problem — and how timely and good health care can prevent many of these deaths -- years earlier, thanks to my mother, who was an obstetrician in our hometown of Amritsar, India, and who cared deeply about maternal issues.
I was still in medical school in 2011 when she admitted 32-year-old Dumri Devi, who was pregnant for the sixth time but who had only one living child. Most of Devi’s other pregnancies had resulted in still-births, because her pelvis was too small to deliver the babies. The traditional birth attendant in her village had been unable to handle this complication, which could have been fatal for Devi as well.
Worldwide, nearly half of expectant mothers experience some complication. In 15 percent of these cases, the complications can be life-threatening, according to United Nations Population Fund figures from 2011.
This time around, my mother wanted to make sure Devi did not endanger herself or her child’s life again. Caesarian section would be crucial for Devi, and my mother worked with her family to ensure they were not held back by financial constraints. She had all Devi's tests and checkups done at regular intervals in the city hospital.
As a result, Devi was admitted to the hospital well in time and gave birth to a healthy baby girl. Today, a hospital in my hometown named in memory of my mother works to provide care to pregnant women of lower socioeconomic backgrounds.
The most critical intervention
Skilled attendance at birth, by personnel trained in safe delivery practices and in handling complications, is considered to be the single most critical intervention for ensuring safe motherhood. It ensures timely delivery of emergency care when life-threatening complications arise, both for the mother and the child.
Still, a report published Tuesday from Save the Children found that 40 million women deliver babies without any trained help. About a third of pregnant women in developing countries have no access to or contact with health personnel before delivery, and only 63 percent give birth with a skilled attendant present.
Over the years, in medical school and beyond, I’ve heard other doctors, nurses and midwives share their experiences working with expectant mothers in countries that lack the infrastructure to provide basic care, especially to more rural village populations. They often have to work in the face of established cultural practices of home-births and a widespread lack of awareness of the importance of skilled birth attendants.
While at MSF I learned that in Burundi, for example, a 23-year-old was brought to the MSF hospital in severe pain and with obstructed labor, after 24 hours of unsuccessfully trying to deliver at home by an untrained birth attendant.
“By that time the baby had already died, and she was in a poor condition,” said Séverine Caluwaerts, the MSF obstetrician who admitted her. The staff had to do a C-section to remove the dead baby to save the woman, whose uterus was infected. She survived but ended up staying in the hospital for two months.
“In many cases pregnancy can be a death sentence,” said Caluwaerts, adding that timely detection of complications and skilled attendance could save many lives. “Even though the [traditional] birth attendant has experience, they are illiterate and not trained to handle complications,” she said.
Such complications are often determined by chronic conditions prevalent in the developing world. For instance, chronic malnourishment among girls can stunt their growth, increasing the likelihood of obstruction during labor. Nutritional anemia, which affects approximately 50 percent of girls in developing countries, increases the risk for miscarriage, stillbirth, premature birth, and maternal death.
When cultural norms put a woman’s health in jeopardy
While reporting on child mortality last summer from the district of Panna in central India, I met many expectant mothers with severe malnourishment and nutritional anemia. One mother, Pooja, was so anemic and underweight that her twins were born weighing barely a kilogram each. One of the babies eventually succumbed to an infection, a common complication resulting from low birth weight. As a result of maternal malnutrition, in Panna as in many parts of the world, premature births and very low birth weight are the norm, rather than the exception.
Cultural norms often determine the health status of women.
“In many cultures there is a hierarchy of who gets food. The men get it first, then the children and the women get it last,” said Ruth Kauffman, a midwife and obstetrics nurse who has worked on MSF missions in South Sudan and Uganda, among other countries.
I saw the effects of this firsthand, in Panna, where the social norms and poverty made it near impossible for women to have appropriate nutrition during pregnancy.
In countries like Afghanistan and Pakistan, it is the husband who makes all the decisions during childbirth, added Caluwaerts, who has worked as an MSF obstetrician in both countries.
In Pakistan in 2010, a pregnant woman whose uterus had ruptured due to an obstructed delivery was brought to the MSF mission in serious condition. The baby had died already at home. While operating on the woman, the doctors realized that repairing the womb was not possible and the only way to save the woman was to remove the uterus. But the husband refused to consent to the procedure, arguing that his wife had to bear more children.
“You can’t go against the wishes of the Afghani or Pakistani husband,” said Caluwaerts. “The woman is considered the property of the husband.” The repair was unsuccessful and the woman could not be saved.
Pregnancy does not have to be a death sentence
From my work as a doctor and journalist, I’ve seen that you do not need state-of-the-art facilities or equipment to save many women’s lives. What you need are simple, low-cost solutions and timely interventions. For instance, severe bleeding after birth, which can be fatal, can in most cases be controlled by massaging the uterus and injecting oxytocin immediately after birth. And infection after childbirth can be eliminated by practicing good hygiene and recognizing early signs.
It is also vital to prevent unwanted and adolescent pregnancies. Enabling women to use contraceptives to plan pregnancies could prevent 1 in 3 maternal deaths, according to the WHO.
It is the most basic right of every woman to get the best possible health care during pregnancy and childbirth. Empowering women and ensuring timely management when problems arise can translate into many positive stories, even in settings with limited resources.
The woman from Burundi with obstructed labor became pregnant again a few months later and came back to the hospital well in time, delivering a healthy baby.
As Caluwaerts put it, “One story like this gives you hope.”
Harman Boparai is a doctor and freelance journalist who was a Kaiser Family Foundation fellow in global health reporting at GlobalPost in 2013. He recently completed a four-month fellowship at MSF in New York where he worked with doctors, nurses and logisticians engaged in projects around the world and helped manage the organization's advocacy and communications work. The names of the women mentioned have been withheld for patient privacy. For more on MSF visit http://www.doctorswithoutborders.org/
More from GlobalPost: Step by Step: The path to ending child mortality