Though babies' sizeable heads may make birth dangerous for a certain percentage of women, the corresponding big human brains are good for something: they give us insight into how birth works, which translates into routine skilled support, as well as lifesaving interventions in an emergency. As I'm learning from recent books like Tina Cassidy's Birth and Jennifer Block's phenomenal Pushed (and as doulas and midwives I've encountered over the years have always maintained), for the most part, birth works. Usually, it's a natural, physiological process that women's bodies know how to manage, and that can be helped along with minimal intervention by a skilled midwife or other birth attendant. Of course, there can be complications – not all pregnancies and not all births are safe, and some put women and babies at risk. That's why we are fortunate to be living in a time when medical technology – properly applied – can save women and babies when things go wrong. We can't eliminate the risks entirely, but we can save a lot of lives.
So why is it, then, that every minute, a woman still dies as a result of pregnancy or childbirth? Ninety-nine percent of these deaths occur in developing countries (primarily in Africa and Asia), and the vast majority of them are preventable. Two recent issues of id21 – a publication that distills the latest development research on various topics – are devoted to understanding why improving maternal health remains, in the words of one editorial, "the most elusive of the Millennium Development Goals."
The first issue, "Improving the health of mothers and babies: breaking through health system constraints," takes a closer look at why pregnancy and childbirth still claim half a million women's lives every year, with a particular focus on how health systems and governments can address the crisis. One article looks at the shortage of skilled health professionals equipped to attend birth, one examines how weak health infrastructures impact the process, and one looks at how poverty and bad birth outcomes reinforce each other (poor women are more vulnerable to risky pregnancies and substandard maternity care, but complicated births can also deepen poverty when families have to pay for expensive lifesaving interventions).
I was particularly interested in an article dealing with the overmedicalization of birth in developing countries, which increases risk to both mother and baby. I assumed that the prevalence of non-evidence-based interventionist medical practices related to birth – including unnecessary c-sections – was primarily an issue for women in wealthy countries, but it turns out that women in the developing world are also subject to continuous fetal monitoring, overmedication, routine enemas and episiotomies, and laboring flat on their back with their legs in stirrups. Worse yet, in some developing countries, women of means are often urged into unnecessary c-sections, while poor women in the same countries often lack access to lifesaving emergency c-sections. As the article points out, "Exaggerating the risks of normal birth to women who are able to pay, or who can borrow the money, for both the convenience and the financial gain of medical institutions, is a damaging development in low-resource settings." No kidding.
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Another article breaks down the financial resources necessary to improve maternal health in the places where women are most at risk, and a final article speculates that it is not a lack of resources, but rather a lack of political will, that's keeping maternal mortality rates so high worldwide, even when we know what we must do to bring them down. As the lead editorial points out, "Debates in safe motherhood have emphasized various technical approaches to solve the problems inherent in reaching the MDG for maternal health. We now know that good maternal health is based on good sexual and reproductive health, including family planning and safe abortion care." Now the oh-so-elusive nature of the seemingly straightforward MDG 5 is beginning to make a bit more sense: to improve maternal health, we might actually have to talk about sex, pregnancy, reproductive choice, and how much societies value women. Now we're in trouble.
One in eight of those women dying every minute as a result of pregnancy and childbirth are women dying from unsafe abortions, after all–totaling 68,000 women every year, a figure that hasn't changed in nearly two decades. Nearly half of these deaths occur in Africa, where abortion is largely illegal, and rarely available even under circumstances where it is legal. Getting to the heart of the matter, a special id21 supplement focuses on the death toll, as well as the financial strain, caused by the global unsafe abortion epidemic. One article details the health risks associated with unsafe abortion, one looks at its global economic impact, one looks at how health systems can offer the procedure most safely and cost effectively, and one looks at unsafe abortion as a major cause of maternal death, matter-of-factly pointing out that "It is paradoxical to identify reducing maternal mortality as a priority but fail to put in place effective interventions to prevent unwanted births." Using Mexico City as a case study, another article compares the cost of providing safe and legal abortion (US$53 to US$143 per procedure) to the cost of dealing with complications from unsafe abortion when abortion is illegal (US$601 to over US$2,100 per woman suffering from complications).
Reading through all this, I'm reminded of the paradoxical nature of reproduction in women's lives. On the one hand, your experience of reproductive health is highly dependent on the specifics of your identity: your country's laws, customs, and resources; your race; your geographic location; your age; your socioeconomic class. On the other hand, pregnancy and birth – and reproductive oppression – cut across the female experience, and all women (rich and poor, Northern and Southern, rural and urban) suffer in a world where women's reproductive health and well-being is a low priority. Which is why the fifth MDG, elusive as it may be, affects us all. As id21's lead editorial points out:
Maternal mortality is an indicator of how well a health system functions, as it encapsulates a substantial part of both primary and secondary health care. However, maternal mortality has also been described as a "litmus test" for the status of women in a society. Given that most women will give birth, a health system that is not designed to cope with this does not value women and their babies enough to provide protection against possible death or disability.
They said it, not me.