GENEVA — Humanitarian worker Maha Muna recalls an encounter with an elderly woman in Sudan’s Darfur region recovering from a common and debilitating condition.

The woman had finally succeeded in reaching a hospital and undergoing a relatively simple procedure to cure her fistula — a medical condition in which a hole is torn in the birth canal, usually during a prolonged delivery without proper medical care.  

On the day of Maha's visit, the woman spoke of her relief. "Now I can die in peace," she said.

Maha, a specialist for the United Nation’s Population Fund, asked what she meant.

"All these years,” the woman said, "I thought it was the devil that had taken possession of my body."

For years, the woman had suffered from incontinence as fluids seeped through her wound. Women who suffer from the condition are often ostracized because they smell of urine and feces.  

"Now I realize that all I needed was a medical procedure, and that all this could have been avoided," the elderly woman said.

In a way, she was lucky. According to the latest report from UNICEF, an estimated 500,000 women — roughly one per minute — will die this year while giving birth. Ninety-nine percent of them will be in the developing world and 84 percent will be in sub-Saharan Africa. And despite the efforts of developed countries and non-governmental institutions to implement agreed-upon solutions, the problem persists.

In Niger, which has one of the highest rates of maternal mortality, about one woman out of seven dies while giving birth. The rate in Sweden is one death for every 17,400 births. And about 15 percent of women giving birth in the developing world experience complications, such as fistula.

Many of the countries with the worst maternal mortality rates in Africa are either caught up in a civil war, or have just finished one. "You have good development policies," says Maha Muna, "and then you have conflict, and that undermines it all." But war is not the only obstacle.

Dr. Peter Salama, UNICEF’s chief of health services, points out that unlike ordinary diseases that can often be cured by administering antibiotics or a simple drug, emergency obstetric care requires a high level of knowledge and a stable, robust health system.

"You can’t just use community health workers to deliver that kind of care," he says. "It is probably the best indicator of whether a health system is functioning."

Another critical factor is the empowerment of women. Janet Myers, a senior reproductive health specialist for CARE International’s Emergency Group, says that in some cases husbands won’t allow their wives to seek medical attention because they think it costs too much.

"We hear many stories of women who wanted to go to antenatal care or wished to deliver at a health facility but their husbands or key decision makers in the family did not allow them to go," she says. "There are very basic societal norms that can be addressed by working with communities to discuss gender norms and sexuality."
Most experts talk about three delays to improving measures to prevent death during childbirth in the developing world: The delay at home in recognizing that there is a problem that needs expert care, the delay in getting to the health facility, and the delay at the facility if the staff are not properly trained and don’t really understand what is happening.

The four counter-steps that aid agencies are now promoting start with proper family planning. Currently, about 200 million women would like to delay or avoid pregnancy if they had the means to do so. At least 19 million resort in desperation to unsafe abortions each year, and 68,000 die in the process. In addition to family planning, women could be saved if they were provided access to a trained medical team when it is needed, if those teams had the capacity to provide emergency obstetric care, and access to post-natal care.

All of these services would require investment. In theory, a framework for this investment is provided under the Millennium Development Goals, a U.N. agreement between nations and leading development institutions. These MDGs intend to eliminate extreme poverty and to reduce maternal mortality 75 percent by 2015.  So far the global reduction has been less than 1 percent per year.
“The real indicator of the failure of the MDGs so far is the maternal mortality index,” says Allison Woodhead, who leads Oxfam’s campaign on maternal mortality. “Half a million women dying a year in childbirth doesn’t just tell you about health services. It tells you about girls’ access to education, whether there is enough food on the table, whether women are able to work or vote. What it really tells you is that women are dying because there are not enough health services. It is a really useful indicator of progress on poverty.“

On a more positive note, UNICEF's Salama points out that some of the world’s poorest countries — Eritrea, Nepal, Laos and Bangladesh — are in line to achieve the MDG targets on reducing the mortality for children under the age of five by 50 percent.

“When Eritrea can do that,” says Salama,” it basically proves that any country with the right level of commitment, program choices and funding can do it.”

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