Safe motherhood
Chandra Mani Dhungana writes on safe motherhood in Nepal and his experiences working in rural communities.
Photo by: Chandr Mani Dhungana
Auxiliary Nurse Midwife conducting normal delivery
in remote health post of Nepal
Safe motherhood means ensuring that all women receive the care they need to be safe and healthy throughout pregnancy and child birth. Every minute of every day, somewhere in the world - most often in developing countries where poverty, malnutrition, illiteracy, strict taboos, conflict, and less priority on safe motherhood exists - a women dies from complications related to pregnancy or child birth. In my home country of Nepal, every two hours a mother dies from complications related to pregnancy and child birth. The majority of deaths occur in remote areas and most often in homes, making maternal mortality the health indicator with the largest disparity between the urban (accessible) and rural (inaccessible) areas.
Pregnancy related complications are among the leading causes of death and disability for women of reproductive age. For every woman who dies, 30 to 50 women suffer from injury, infection or disease. Most of these deaths are preventable. The low status of women, illiteracy, poor access to health facilities and services, and lack of affordability prevent women from utilizing health services, making them more vulnerable to death. Most deliveries occur in homes without the presence of a trained health worker which further increases the chance of mortality. Relatives, friends, and elderly handling the delivery are unaware of the danger signs which further increase the vulnerability of mothers.
Maternal deaths are associated with medical causes and social factors. A large number of social factors revolve around mothers increasing their chance of death. These factors come into play from conception and follow till death. The most common social factors are:
- Age at marriage
- Age at child birth
- Parity
- Too close pregnancies
- Family size
- Poverty
- Malnutrition
- Illiteracy
- Lack of maternal services
- Ignorance
- Lack of health staff
- Lack of transportation facilities
- Prevalent social customs, taboos and practices
When a mother dies, children lose their primary care giver, communities are denied her paid and unpaid labour, and countries forego her contributions to economic and social development. Maternal death, apart from being a personal tragedy, represents an enormous cost to the mother’s nation, community, and family. Any social and economic investment that has been made in her life is lost. Her family loses her love, her nurturing and her productivity.
From my experience working as a safe motherhood officer in a remote Himalayan region - visiting remote villages, working with the community, directly observing the health facilities and the staff - I have come to the conclusion that maternal deaths can be prevented if:
- the community has knowledge of the danger signs
- the delivery takes place in a healthfacility
- the delivery is conducted by a skilled health worker
- the health facility is well equipped
- there is Comprehensive Emergency Obstetric Care (CEOC), Basic Emergency Obstetric Care (BEOC) and Essential Obstetric Care (EOC) facilities available
- there is provision of a 24 hrs facility
- the staff are available when needed
- the facility is accessible
- the service provided is affordable
- transportation to the facility is available
- an emergency health financing scheme is available
From the above, it is evident that saving a life of a mother needs a comprehensive approach. A single initiative and effort from a single organization or sector is not enough to prevent this tragedy. There should be heavy social, national and international investment and commitment. Thus, safe motherhood depends upon good management and facilities equipped with good technology.
Being a Nepali, I have seen many mothers dies in my country. Everybody knows the causes that kill our mothers, either by direct or indirect causes. One of the most important areas to intervene in is to equip the hospitals in the remotest districts with facilities that help to perform caesarians for pregnant mothers. Until and unless we have caesarian section available in each district hospital we will not be able to prevent maternal mortality. Once during a workshop, when I asked whether caesarian section could be made available in the district where I worked, I was told, “caesarian section will be available in areas that have populations of more than a half million”. That night I could not sleep and wondered who would help change these types of laws in countries like Nepal, where it takes more than four days to reach some district centres (districts are the administrative divisions of the country; in Nepal there are 75 districts) that have a health facility with a medical officer. With no availability of caesarian section in geographically difficult areas, how will we be able to save mothers? Is not it our responsibility to change such laws and make it suitable according to the need? Is not it the responsibility of governments to increase such sites, despite the laws and regulations? In addition, the largest share of maternal mortality is caused by hemorrhaging. During my work, I did not find the primary health facilities to be able to stop hemorrhaging. Even though we do have the proper equipment and we do have supporting agencies, we do not have technical human resources, such as doctors who could deal with obstetric problems.
Who should be responsible? I boldly say government. Why is the government reluctant to send an obstetrician into each district? Why is the government not training medical doctors in sufficient quantity to work for safe motherhood? I again say, even the health minister does not have the answer. The structural adjustment policies implemented by the World Bank (WB) and the International Monetary Fund (IMF) have forced countries like Nepal to cut down government spending so that we can pay the loans. Subsidies have been cut and the poor are forced to pay high costs or don’t visit health facilities and are left to die in their homes. WB and IMF are trying to privatize everything in the name of efficiency and quality. But they forget the other side of the coin that there are people in the world who die after privatizing everything. I again blame the proponents of globalization and neo-liberalization and ask the question: what have these policies done for the poor of the world?
Thus, reducing maternal mortality requires sustained, long-term commitment and the input of a range of partners. Governments, non governmental organizations, international assistance agencies, donors, and others should share their diverse strengths and work together to promote safe motherhood. Programs should be developed, evaluated, and improved with the involvement of community people, health providers, and leaders. National plans and policies should put maternal health into its broad social and economic context and incorporate all groups and sectors to support safe motherhood.
Chandra Mani Dhungana
Student of Masters in Public Health
BP Koirala Institute of Health Sciences, Dharan, Nepal
cmdhungana@gmail.com