It is tragic when a woman dies in childbirth. The family is changed forever. We need to ask ‘Why did she die?’ Usually there is not just one answer to that question. Often there are lots of problems mixed up together. Imagine many pieces of string tangled up in a ball. We have to untangle the ball to see the different pieces of string. Then the problems are clearer and we can start to see some solutions.
If a woman dies in a clinic or in hospital, the medical factors leading to her death are written on medical notes as the official causes of death. If the examples below seem frightening, remember that they tell you what went wrong in the woman’s body, but they do not tell you about any of the other factors, such as whether she would have survived if she had received help earlier. Most of these medical problems will not lead to death if they are recognised and treated soon enough.
Many women bleed to death. This is the leading cause of women dying in childbirth all over the world. According to the World Health Organization, about 800 women die in childbirth every day. This adds up to about 300,000 women a year. About a third of these women bleed to death after their baby is born.
Other direct medical factors that may cause a woman to die in pregnancy or childbirth include:
- obstructed labour – when the baby does not progress normally through the birth canal
- ruptured uterus – a tear in the womb
- eclampsia – a condition involving high blood pressure
- ectopic pregnancy – when the baby starts to grow in the tube leading to the womb rather than in the womb
- unsafe abortion.
The three delays
Many experts agree that ‘three delays’ are often responsible for women dying in childbirth.
- Delay at home or in the community – for example, the traditional culture is to give birth at home, danger signs are not recognised soon enough, there is no money for health care.
- Delay getting to a health centre or hospital – for example, the roads are bad, there is no transport or no money to pay for it, phone communication is bad, the health centre is far away.
- Delay at the health facility – for example, not enough staff, lack of suitable equipment, no means of arranging transfer to hospital.
Most couples expecting a baby should be able to make plans and take actions that will significantly reduce the risk of being affected by the first two delays.
Appointments during pregnancy (often called antenatal appointments) are very important. Even if a woman feels well during pregnancy, there are things that need to be checked that could lead to problems later. Women who go to at least four antenatal appointments are less likely to die from problems in pregnancy or childbirth. A family is more secure if there are plans in place to deal with any potential problems.
Health services not good enough
In many places there are no health services nearby or health services are unreliable. You could spend money to travel there and find that there is no trained midwife, or the clinic is closed and there is no number to call for emergencies.
This can lead to fear and apathy in a community. All it takes is one bad experience for the rumour to spread that trying to find health care for childbirth is a waste of time, effort and money.
What can we do?
- Ask for better local services.
- Spread accurate information about what services are available, where and when, and encourage others to use them.
- Ask for free antenatal appointments.
Lack of education and money
Many people avoid seeking medical help because they fear they will not be able to pay for it. When it comes to pregnancy and birth, it is prudent to make savings, no matter how small, to pay for medical costs or transport to health centres. Self help groups and savings groups can provide mutual support in this way.
If a family never or rarely uses health care services because they are poor and/or illiterate, they may not know that antenatal appointments are important. They may be suspicious and prefer to use traditional medicines that could be ineffective or harmful.
If a family cannot read, it will often be more difficult for them to get health care and to learn about good health. An illiterate person cannot read an appointment card, medical notes, or a notice board at a clinic.
What can we do?
- Promote saving money for health care costs.
- Advertise the importance of antenatal appointments using word of mouth.
- Teach women to read.
Harmful cultural practices
Some cultural practices increase the likelihood of a woman dying in childbirth.
Child Marriage Girls and women under the age of 20 can suffer problems in labour because their bodies are not ready. Girls aged 10–14 are five times more likely to die in childbirth and those aged 15–19 are twice as likely to die in childbirth.
Female Circumcision Altering a girl’s body by cutting away parts of the genitals is very harmful. Female circumcision (sometimes called female genital mutilation or FGM) is often practised in communities where fertility in women is highly valued, yet studies show that it makes it much harder for women to deliver babies safely. Scar tissue from where cuts were made and infibulation (sewing up of the birth canal) prevent normal births. A woman who has been cut often needs more specialist health care that may not be available locally, and may not be affordable. This increases the risk of both mother and child dying.
Preference for boys Families who want boys, and are able to pay for a scan to find out the gender of their unborn child, sometimes decide to abort girls. If the abortion is unsafe, the mother may die from complications or infection.
When boys are preferred in a family, girls are sometimes given less food or different, less nutritious foods. If a girl does not eat enough nutritious foods such as milk and eggs, her body will not grow strong to prepare her for childbirth when she is older. When a poorly nourished girl or woman becomes pregnant, she is likely to suffer problems.
What can we do?
Cultural practices change over the course of generations, not overnight! However, for the examples given here, faith-based teaching on the equal value of women in God’s sight can make an important difference. Individual decisions by men and women to change their practices – even when this will make family relationships difficult – will sow the seeds of future change in families and communities.
Lack of family planning services
Pregnancies too early or too close together can make life harder for families. The mother and children are more likely to be weak. A woman who has many pregnancies close together (less than two years between deliveries) is more likely to suffer health problems in pregnancy and childbirth than women whose children are more evenly spaced.
In some places family planning services are available but the deliveries of supplies such as condoms and pills are not frequent enough and people cannot afford to buy a large number at once.
What can we do?
- Advertise local family planning services and encourage others to use them.
- Ask for better services and more frequent deliveries of supplies.
- Make sure family planning services include advice for women to help them recognise when the chances of pregnancy are greatest.
A father’s role
In many cultures a father has a ‘gatekeeper’ role. He has the power to make important decisions for the family. This can affect maternal health. Many of the causes of death can be prevented if men understand the risks better. For example, the decision to seek medical attention in pregnancy and childbirth is often made by a husband. If he delays, his wife could die. If he understands the need to plan ahead with his wife for childbirth, she and the baby are more likely to survive.
Fathers can also prevent harmful traditional practices and encourage the education of their daughters. They can discuss family planning with their wives and decide they will try to have children at least two years apart in age. They can set an example in seeking information about better health in pregnancy and childbirth in order to protect their families.
Written with help from Caroline Onwuezobe, who manages antenatal services at Faith Alive Hospital in Jos, Nigeria, and Andrew Tomkins, Emeritus Professor of International Child Health at University College London.