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Does Birth Have to Lead to Death?

We visited the young pregnant woman as she was going into labor. She was pacing outside her home, a small mud hut surrounded by rows of corn, a pig, mangy dogs, and dirt roads. Pretty and petite, she tried to smile through obvious pain. She barely looked old enough to be pregnant, but this was not her first child. One of our field workers, a traditional birth attendant, was explaining in Spanish what would happen next. The expectant mother would not be brought to a hospital or seen by a doctor. She would deliver the baby on a dirt floor, and hope for the best.

I was part of a public health research team in the rural Guatemalan highlands, but we were not there to deliver babies. We were collecting data on indoor air pollution, a major contributor to morbidity and mortality in developing countries. But as we hiked through the steep mountains, populated by poor, indigenous Mayan farmers, it was impossible not to see other causes of illness and death: malnutrition, lack of clean water, and risky births. When two of our researchers, an OB/GYN and a nurse practitioner, saw the young mother-to-be, they decided to stay and help. They had little in the way of supplies—headlamps, alcohol hand wipes, a fortuitous pair of latex gloves—but their expertise could be crucial. Miles of unpaved, bumpy roads separated us from a medical center, and a serious complication could prove fatal.

Even though I was aware of the many challenges facing poor women in rural communities, it was still shocking to see the reality that lay before us. My mind immediately jumped to the cleanliness: Isn’t the floor dirty? What about infections? Are there any clean towels around? Hot water? This cannot be clean—she is standing next to a pig! In my alarm, I had not stopped to register that this is how the majority of the world’s women give birth—at home, either alone or with an untrained birth attendant.

Of the approximately half million women that die in childbirth every year, it is not surprising that ninety-nine percent of them are in developing countries. Death due to obstetrical hemorrhage (severe bleeding), infection, and obstructed labor is relatively uncommon in countries like the United States, where most women give birth in well-staffed and well-supplied hospitals. A trained midwife usually oversees home births, and access to emergency care and medicine is rarely more than an ambulance ride away.

Although solutions to birthing complications often have a straightforward, medical answer, poverty and gender inequality pose significant roadblocks for women in low-resource settings. Suellen Miller, PhD, CNM, director of the Safe Motherhood Program at the Women’s Global Health Imperative, notes four main obstacles. One is the lack of trained birth assistants, who may not be able to recognize a complication early enough. Because of women’s low social status, neither the pregnant women nor her assistant may have the decision-making power to go to the hospital if a problem is recognized. Will the head of the household, or village leader, deem this woman’s condition serious enough to warrant action?

Then there is the problem of transportation. I could not imagine how the pregnant woman in Guatemala would get to care if she needed it. Few families had access to a car, we were mountainous miles from a bus stop, and ambulances were unheard of in rural areas. With obstetric hemorrhage, which causes the greatest proportion of maternal mortality, timing is critical, as severe bleeding can kill a woman in as little as two hours. A further problem arises for women who do make it to a hospital or treatment center—in low resource countries, they may not have the necessary intravenous fluids, blood replacement, or skilled staff to deal with the problem.

“So, women bleed to death at home, on the road to the hospital, and at the hospital,” notes Dr. Miller.

In the lowest resource settings, like Africa, a woman’s chance of dying in childbirth is one in sixteen, compared to about one in 3,000 for women in high-income settings. Dr. Miller, who started her career as a midwife in the San Francisco Bay Area, notes this as a reason why she started researching ways to make motherhood safer worldwide. One of these ways is through an anti-shock garment called the Life Wrap. When severe bleeding occurs, a woman can go into shock, resulting in an accumulation of blood in her lower extremities. The Life Wrap returns blood to her vital organs, and buys her time to get to necessary treatment.

Other public health researchers are working to increase availability and access to Misoprostol, a drug that prevents postpartum hemorrhage. The drug has few side effects, is easily stored, and is off patent, so it can be offered at low cost.

Perhaps the most critical component in reducing maternal mortality is the presence of a trained midwife or health worker during a birth. These professionals are able to make timely diagnoses of problems, administer medicines, and identify the need for emergency services. Professional midwifery training is becoming more widespread, but in rural, indigenous populations like the one we were in, it was still rare.

I did not know how much training the birth assistant in Guatemala had, though surely the two researchers with medical training and car were a welcomed addition. After spending a cold and rainy night helping deliver the baby, they arrived in the morning, looking tired and bedraggled but bearing good news: mother and baby were fine.

In Guatemala, like in many countries, it was easy to see how critical moms were to the overarching structure of a community. The women we saw filled many roles: caretakers, farmers, wood gatherers, food makers, wage earners. I could not imagine what would happen if these roles were left empty. I was happy not to know.

We went to visit mom and baby the next day. The child was amazingly tiny—about five pounds. Mom held him close, looking tired and relieved.  

For more on maternal mortality, see “Family Care International (Part 1),” by Kathleen J. King.