26th October 1997


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Every minute, a woman diesWoman

Throughout the world, it is estimated that 585,000 women die from maternal causes every year. Hiranthi Fernando meets experts in the field Dr. Pramilla Senanayake and Prof. Fred Sai

Incredible though it may seem, every minute of every day, one woman dies from complications related to pregnancy and childbirth. Throughout the world, it is eastimated that 585,000 women die from maternal causes every year. Of these deaths, 99% are found to occur in developing countries. "The greatest threats to women's health in the developing world are pregnancy and childbirth," says Dr. Pramilla Senanayake, Chairperson of the Inter-Agency Group for Safe Motherhood.

"In addition to the deaths, they are responsible for 50 million illnesses, injuries and disabilities per year. The real tragedy is that motherhood could be made much safer at a very low cost."

In an effort to raise global awareness of this tragic situation and to find effective remedies, the Safe Motherhood Initiative was launched in 1987. Its goal was to halve the number of maternal deaths and illnesses by the year 2000. Although this goal is unlikely to be achieved in terms of numbers, much progress has been made in improving maternal health in many communities.

Today, the Safe Motherhood Initiative has developed into a dynamic partnership of women's health supporters around the world. The combined resources of governments, private agencies, local, national and international organizations, professionals, donors and the media in over a hundred countries have been harnessed to the cause under the cosponsorship of The World Bank, World Health Organization, UNICEF, UN Population Fund , International Planned Parenthood Federation (IPPF) and the Population Council. During the last ten years, Safe Motherhood Partners have endeavoured to develop effective means of improving maternal health and reducing the high incidence of maternal mortality and illness throughout the world.

Over 200 international experts gathered together in Sri Lanka at a technical Consultation on Safe Motherhood held at the Trans Asia Hotel from 18th - 23rd October. This meeting was convened to review the progress made during the past ten years and reach a consensus of what needs to be done to make motherhood safer. "We have embarked on this unique partnership with the single purpose of bringing this issue to a higher level of priority. We are here in Sri Lanka because of the great achievements this country has made for safer motherhood," said Jill Sheffield, President of Family Care International, the organisers of the meeting.

Prof. Sai"The Safe Motherhood Initiative was launched in 1987, following a WHO survey on maternal mortality carried out two years previously," said Dr. Fred Sai, Honorary Professor of Community Health, University of Ghana, who was associated with the initiative since its inception. Dr. Sai who was then attached to the World Bank, masterminded the Safe Motherhood Initiative for the World Bank. "We knew maternal mortality was high but we realised just how high it was after this survey," Dr. Sai said. "The figures were most upsetting. In many countries, maternal mortality was found to be over 500 per 100,000 live births. The survey also highlighted the great disparity between the developed countries and the developing countries. Maternal mortality in the developing countries is eighteen times more than in the rich countries," added Dr. Pramilla Senanayake. "This is greater than in any other field of health."

"When causes were looked at, it was found that the technologies were available. It was not lack of knowledge but something else that made the difference. Was it a lack of political will, lack of money or any other reason. This had to be addressed," Dr. Sai continued. It has been found that in developed countries, maternal health services are accessible to 99% of the population, whilst in developing countries only 52% of the people have access to maternal health services. Between 25% -30% of all deaths to women of reproductive age in the developing world are found to be as a result of pregnancy or childbirth.

"Maternal mortality has been considered as a health issue in many countries. Although it has to involve the health service, it is beyond the health service alone," Dr. Senanayake said. "It concerns the whole socio cultural milieu the woman lives in. The solutions are in the hands of a wider audience." She said that since the first conference in Nairobi in 1987, although the maternal mortality figures have not changed much, they have better tools for analysing the situation. "Today, we know what works. We have found solutions that are workable and cost effective."

Dr. Senanayake quoted a simple practical solution which was put into practice in Ghana where maternal mortality is very high. "Many women live too far away from a hospital and transport is not available to take them to a hospital," she said. "We talked to the Truck Drivers Association. They were willing to help. Whenever there was a woman in trouble and needed to be taken to a hospital, a flag would be stuck out on the street. Seeing the flags, truck drivers would stop and the women were taken in the truck to the hospital."

At the Technical consultation on Safe Motherhood in Colombo, a number of reproductive health issues as well as maternity services that should be available to women, were discussed. "Sixty percent of maternal deaths occur after delivery, usually in the first two days, 16% during delivery and 24% in pregnancy", Dr. Senanayake said. She stressed the importance of having trained birth attendants at the delivery of the child. "Only 53% of births take place in the presence of skilled birth attendants such as doctors or midwives," she said. "Some women do not wish to go to a hospital where skilled birth attendants are available, through sheer ignorance. Lack of transport facilities or lack of money also denies them access to skilled attendants at the birth. "Although this problem is not evident in Sri Lanka, people in many developing countries have lived with traditional birth attendants. Usually elderly, untrained women, these traditional birth attendants often carry out inadvisable and dangerous practices such as massaging the abdomen during delivery and even sitting on it. By replacing the traditional birth attendants with skilled ones or training the traditional attendants, maternal mortality could be greatly reduced."

"We are happy with the progress made in Sri Lanka in this field," Dr. Senanayake commented. Maternal mortality has been reduced to 66 per 100,000 live births. In some African countries it is as high as 500 per 100,000 live births. Better status of women, empowerment, education and later marriages have resulted in reducing maternal mortality.

"Research carried out through the Safe Motherhood Initiative has shown that motherhood at an early age does not have a favourable impact on the health and well being of girls and women. The best age for motherhood is seen to be between 20-29.

Over fifteen million pregnancies per year have been found to occur among teenaged girls. "Adolescent pregnancies carry a higher risk to both mother and child," Dr. Sai said. In developed countries, with easy access to maternal care, one may survive without mishap. In developing countries, adolescent girls are often of small stature. Many are malnourished. They suffer more pregnancy related complications such as toxemia, anemia, premature delivery and prolonged or obstructed labour. Obstructed labour can cause fistula -holes in the birth canal that allows leakage from the bladder or rectum in to the vagina. Dr. Sai says there is a hospital in Ethiopia which caters entirely for such cases.

"Unsafe abortions is a major factor causing maternal mortality," Dr. Senanayake said. "80,000 to 100,000 women die from complications related to unsafe abortions each year. Many more are left maimed sometimes for life. Whatever the laws of the states may be, adequate care should be provided to those suffering the consequences of unsafe abortions. There are 50 million abortions taking place every year, which means they are unwanted pregnancies. 55,000 unsafe abortions are carried out daily causing 200 deaths. If these unwanted pregnancies are reduced by providing access to family planning and contraception, maternal deaths will reduce. The Safe Motherhood Conference is addressing both deaths and the consequences caused by unsafe abortions.

Infection with HIV and AIDS is another factor that has to be considered. In some African countries 10% to 25% of pregnant women are infected with HIV. An average of 30% of mothers infected with HIV will pass on the infection to their infants. In some countries the rate of infection is said to be as high as 70%. "We are looking at women with HIV, to provide access to family planning services and other forms of protection," Dr. Senanayake said.

"Every pregnancy is at risk," says Dr. Senanayake. "Every pregnant woman needs care at least for the delivery. No woman should die giving birth to the next generation. This meeting is part of a two years strategy. We are looking at the problems causing maternal mortality and strategies to alleviate the problems. We have worked out a two year plan of action. The Technical Consultation in Colombo is putting together the latest research and knowledge in all aspects covering ten relevant issues. The message from Sri Lanka will be taken to a large meeting in Washington scheduled for World Health Day in April 1998, which has been designated Safe Motherhood Day by the WHO. Several Heads of State will be invited for this meeting as well as business people, the media and celebrities. We are asking them through their own forum to propagate safe motherhood and help mobilise resources. Many publications will also be put out after the conclusion of the Colombo meeting."

"In the last ten years, the rhetoric of making governments understand has gone far," Dr. Sai said. "Many countries have started taking action. The ICPD and the Women's Conference held in Beijing singled this out as an important issue for governments to address. Essentially, our aim is not only to cut down maternal mortality but approach all avenues that will make motherhood safer."

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