The Fate of Our Mothers: A Maternal Health Crisis

Amie Newman

We all arrive through pregnancy. You'd think with this kind of reputation, prioritizing maternal health might be a no-brainer for governments. What about the United States? Will our presidential candidates address the plight of mothers worldwide in the first debate?

Updated October 13th 10:08pm

There can be no baser connection for all humans than pregnancy and birth. As my friend and women’s health advocate, Heidi Breeze-Harris says, “We all arrive through pregnancy.”

You’d think with this kind of reputation, prioritizing maternal health might be a no-brainer for governments around the world, and for society at large. But so far the cries for our mothers over the crisis of maternal mortality have not been loud enough to create real, lasting change.

According to Women Deliver, a conference and initiative launched earlier this year to mark the 20th anniversary of the Safe Motherhood Initiative (PDF), maternal mortality is defined as “the death of a pregnant woman during her pregnancy or within 42 days of pregnancy termination.” And there has been very little decline in the rate of maternal mortality worldwide over the last fifteen years. Despite the Safe Motherhood Initiative’s global commitment, government promises and the inclusion of maternal mortality in the “Millennium Development Goals” (a set of agreed upon goals crafted by the United Nations member states and international organizations that include reducing poverty, reducing child/newborn mortality, and fighting AIDS around the world), we have not been able to save our mothers.  In this country, we are still waiting for our presidential candidates to recognize the global health of mothers as a critical foreign policy issue  – as an issue worthy of public discussion and debate. Will the fate of mothers be part of our next president’s agenda? Or will the issue remain in the shadows as the shameful secret we all share?

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Ann Starrs, president of Family Care International, the organization that helped launch the Safe Motherhood Initiative, and Women Deliver this year says,

“We need significant increases in U.S. funding for maternal and reproductive health and for programs that promote gender equality, and we need those programs to focus on known and effective interventions: family planning and other reproductive health services; skilled care during pregnancy and childbirth; emergency care for women and newborns with life-threatening complications, and immediate postnatal care.”

Breeze-Harris, an advocate for ending obstetric fistula, an entirely preventable childbirth injury occurring almost entirely in developing nations says, “The safety and security of birth must not be yet another of the maternal and women’s health components that is ignored by policymakers, governments, research and aid.”

Alex Allred, the mother of a 3-month old girl, faced a difficult pregnancy. Suffering from high blood pressure and with the threat of pre-eclampsia hanging over her head, Alex needed a c-section and delivered her daughter 3 weeks early. Had she been living in one of many developing nations, her chances of surviving pregnancy and childbirth would have been much slimmer. And she recognizes how crucial it is for our presidential candidates to address this issue in their agendas for reproductive health.

But she isn’t holding out much hope:

“My standards are so low for the presidential candidates on this issue that even for them to acknowledge that there is a crisis – a crisis of maternal health care around the world – would be adequate.”

We allow one woman to die every minute around the world from pregnancy or childbirth complications. We allow ten to twenty million women each year to suffer complications from childbirth that result in lifelong afflictions. Most of the deaths and complications are preventable. Millions of women can be saved with access to basic health care including family planning, contraception and safe abortion. These are the women from whom we came, the women from whom future children will come. And we are failing them; we are failing us.

"No nation, least of all the United States, should look the other way when women die while giving birth for lack of the most basic lifesaving care. Whether in Baltimore or Bangladesh, maternal mortality is the single greatest indicator of the failure of health systems to provide care to society’s poorest and most vulnerable women, said Theresa Shaver, Global Secretariat, White Ribbon Alliance for Safe Motherhood.

And while maternal mortality rates vary greatly from country to country, don’t think for a moment the United States is a model of maternal health. As noted above, the United States currently ranks 41st in the world for maternal mortality. Women here, as women around the world, suffer and die needlessly from complications that are preventable and treatable. According to the CDC, “The leading causes of pregnancy-related deaths in the United States are hemorrhage, blood clots, high blood pressure, infection, stroke, amniotic fluid in the bloodstream, and heart muscle disease.” Racial disparities in the United States reveal themselves in a shocking maternal death rate for African-American women that is four times the rate of white women’s maternal mortality. Economic disparities in the United States ensure that women for whom a safe pregnancy and birth should be guaranteed, where access to care should not be a barrier, are unnecessarily endangered.

Kris Lysaker, mother to two children ages 9 and 7 years old, tells the story of how economics impacted her pregnancy and birth. “I had a very traumatic birth. One that began with a day at home and a day at a birth center before being rushed to the hospital. I was unemployed so was receiving Medicaid. Only because I had the fortitude to complete the masses of complicated paperwork necessary for “low-income healthcare” was I able to finally go to a hospital. I can only imagine that thousands of other women [insurance-less women, not just Medicaid-eligible women], opt out of going to the hospital for fear of the overwhelming cost, and wind up injured – or dead.”

Breeze-Harris has another perspective, however, of what it’s like to birth in the U.S. for many woman as compared to women in developing nations:

“I had an extremely difficult childbirth.  I nearly died…despite the best medical care at a state of the art hospital.  I had an obstructed labor, an emergency c-section and then a second surgery where I had to have [a blood transfusion].  I am lucky to be alive and to have a happy healthy boy. I won the lottery, just by having my baby in the developed world; both my son and I skirted the deaths that would have been our fates in much of the developing world.

“I think we take these things for granted…but in a place like Niger, where 1 in 7 women will die in pregnancy and childbirth, there are just 10 OB/GYNs for a population of 10 million people.”

There are organizations and governments working hard on behalf of women and mothers, including at this week’s UN High Level Meetings on the MDGs. Still it is extremely unlikely we will see anywhere close to a reduction in maternal deaths of that magnitude by 2015 without significant investment from the United States.

Ann Starrs says,  “Improve Maternal Health” is the Millennium Development Goal that is farthest from reaching its 2015 target…Investing in women makes economic sense, and is fundamental to respect for justice and human rights.”

What kind of investment are we talking about?

According to the White Ribbon Alliance for Safe Motherhood, a coalition of 3,500 organizations in 91 countries,

“Experts estimate a package of maternal health services costing less than
US $1.50 per person could make significant improvements in women’s health in
the 75 countries where 95% of maternal and child deaths occur.”

Shaver elaborates, "It is past time for the
U.S. to meet its obligations at home and abroad to participate in
initiatives to reduce maternal mortality with no less urgency than
steps taken to fight the war on terrorism or secure the stability of
financial markets. Not only is an investment in women’s health one that
reaps enormous economic benefits, it is the right thing to do."

The Bush Administration has drastically cut funding for reproductive health care and family planning internationally, over the last eight years, which is one of the reasons for the near stagnation of maternal mortality rates globally.  In addition, President Bush has refused to release over $200 million over the last seven years for UNFPA programs critical to ensuring family planning and contraceptive services for women in developing nations.

But it’s not simply money that is needed to reduce the rates of maternal deaths.

Breeze-Harris says, “We must empower women with voices and choice and education. Educating a girl is the best way to keep her from marrying young, which is the best way to keep her from being pregnant too young, which could save her life…That is the most cost effective way to…stop maternal mortality.”

And according to Women Deliver, the “known and effective interventions” that will save women’s lives include programs and services that our next administration can and should certainly have a hand in providing; family planning, access to contraception, care during childbirth by skilled nurses, midwives or doctors…and education.”

UNFPA has recently launched an initiative that they say could reduce the number of women dying in pregnancy and childbirth by 75%. The initiative is a partnership with the International Confederation of Midwives and calls for an increase of 334,000 skilled labor and birth attendants in developing nations, along with follow up obstetric care. 

“By investing in midwives and universal access to reproductive health, millions of lives can be saved and we can reach Millennium Development Goal 5, to improve maternal health,” said UNFPA Executive Director Thoraya Ahmed Obaid.

International Planned Parenthood Federation estimates that 70,000 women die every year from unsafe or illegal abortions. Over one-quarter of the world’s women live in countries where legal abortion is inaccessible, leaving many women with little to no hand in their own fate. We need to work to ensure legal abortion worldwide.

But Ann Starrs is unequivocal about the United States investment, ““The U.S. government funding for reproductive and maternal health programs overseas has been both inadequate and marred by ideologically-driven restrictions that undermine, rather than promote, public health.”

Our next President has the ability to not simply sign-on to whatever plans have already been lain through the Millennium Development Goals and other global promises to women. Our next administration has an opportunity to take a leadership role on this issue by investing much more in reducing maternal mortality and by encouraging other developed nations to do the same.

Let’s compel the candidates to outline the ways in which they will address the loss of our mothers. We do know that Barack Obama would immediately do away with the Global Gag Rule, though John McCain has not said whether he would our wouldn’t. Obama would also return the more than $200 million Congress has allocated to UNFPA over the years, but that our president has refused to release. McCain has not said whether he would or wouldn’t but Jane Roberts doesn’t believe he would. We have also yet to hear from either candidate whether they support or oppose President Bush’s recent decision to cut critical funding for family planning services to international women’s health center, Marie Stopes, in six African nations. 

What about amending PEPFAR to include significant investments in reproductive health care, family planning and contraception, or a plan for addressing racial disparities in maternal mortality rates in our own country?

As Heidi wrote to me, “Whether you are in Niger or Chad, where they have a saying that pregnancy means you have one foot in the grave, or the U.S., where we are 41st in maternal mortality, an unconscionable statistic when you look at our wealth, we all have to pay attention to pregnancy and childbirth.”

 

Commentary Contraception

Hillary Clinton Played a Critical Role in Making Emergency Contraception More Accessible

Susan Wood

Today, women are able to access emergency contraception, a safe, second-chance option for preventing unintended pregnancy in a timely manner without a prescription. Clinton helped make this happen, and I can tell the story from having watched it unfold.

In the midst of election-year talk and debates about political controversies, we often forget examples of candidates’ past leadership. But we must not overlook the ways in which Hillary Clinton demonstrated her commitment to women’s health before she became the Democratic presidential nominee. In early 2008, I wrote the following article for Rewirewhich has been lightly edited—from my perspective as a former official at the U.S. Food and Drug Administration (FDA) about the critical role that Clinton, then a senator, had played in making the emergency contraception method Plan B available over the counter. She demanded that reproductive health benefits and the best available science drive decisions at the FDA, not politics. She challenged the Bush administration and pushed the Democratic-controlled Senate to protect the FDA’s decision making from political interference in order to help women get access to EC.

Since that time, Plan B and other emergency contraception pills have become fully over the counter with no age or ID requirements. Despite all the controversy, women at risk of unintended pregnancy finally can get timely access to another method of contraception if they need it—such as in cases of condom failure or sexual assault. By 2010, according to National Center for Health Statistics data, 11 percent of all sexually experienced women ages 15 to 44 had ever used EC, compared with only 4 percent in 2002. Indeed, nearly one-quarter of all women ages 20 to 24 had used emergency contraception by 2010.

As I stated in 2008, “All those who benefited from this decision should know it may not have happened were it not for Hillary Clinton.”

Now, there are new emergency contraceptive pills (Ella) available by prescription, women have access to insurance coverage of contraception without cost-sharing, and there is progress in making some regular contraceptive pills available over the counter, without prescription. Yet extreme calls for defunding Planned Parenthood, the costs and lack of coverage of over-the-counter EC, and refusals by some pharmacies to stock emergency contraception clearly demonstrate that politicization of science and limits to our access to contraception remain a serious problem.

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Today, women are able to access emergency contraception, a safe, second chance option for preventing unintended pregnancy in a timely manner without a prescription. Sen. Hillary Clinton (D-NY) helped make this happen, and I can tell the story from having watched it unfold.

Although stories about reproductive health and politicization of science have made headlines recently, stories of how these problems are solved are less often told. On August 31, 2005 I resigned my position as assistant commissioner for women’s health at the Food and Drug Administration (FDA) because the agency was not allowed to make its decisions based on the science or in the best interests of the public’s health. While my resignation was widely covered by the media, it would have been a hollow gesture were there not leaders in Congress who stepped in and demanded more accountability from the FDA.

I have been working to improve health care for women and families in the United States for nearly 20 years. In 2000, I became the director of women’s health for the FDA. I was rather quietly doing my job when the debate began in 2003 over whether or not emergency contraception should be provided over the counter (OTC). As a scientist, I knew the facts showed that this medication, which can be used after a rape or other emergency situations, prevents an unwanted pregnancy. It does not cause an abortion, but can help prevent the need for one. But it only works if used within 72 hours, and sooner is even better. Since it is completely safe, and many women find it impossible to get a doctor’s appointment within two to three days, making emergency contraception available to women without a prescription was simply the right thing to do. As an FDA employee, I knew it should have been a routine approval within the agency.

Plan B emergency contraception is just like birth control pills—it is not the “abortion pill,” RU-486, and most people in the United States don’t think access to safe and effective contraception is controversial. Sadly, in Congress and in the White House, there are many people who do oppose birth control. And although this may surprise you, this false “controversy” not only has affected emergency contraception, but also caused the recent dramatic increase in the cost of birth control pills on college campuses, and limited family planning services across the country.  The reality is that having more options for contraception helps each of us make our own decisions in planning our families and preventing unwanted pregnancies. This is something we can all agree on.

Meanwhile, inside the walls of the FDA in 2003 and 2004, the Bush administration continued to throw roadblocks at efforts to approve emergency contraception over the counter. When this struggle became public, I was struck by the leadership that Hillary Clinton displayed. She used the tools of a U.S. senator and fought ardently to preserve the FDA’s independent scientific decision-making authority. Many other senators and congressmen agreed, but she was the one who took the lead, saying she simply wanted the FDA to be able to make decisions based on its public health mission and on the medical evidence.

When it became clear that FDA scientists would continue to be overruled for non-scientific reasons, I resigned in protest in late 2005. I was interviewed by news media for months and traveled around the country hoping that many would stand up and demand that FDA do its job properly. But, although it can help, all the media in the world can’t make Congress or a president do the right thing.

Sen. Clinton made the difference. The FDA suddenly announced it would approve emergency contraception for use without a prescription for women ages 18 and older—one day before FDA officials were to face a determined Sen. Clinton and her colleague Sen. Murray (D-WA) at a Senate hearing in 2006. No one was more surprised than I was. All those who benefited from this decision should know it may not have happened were it not for Hillary Clinton.

Sometimes these success stories get lost in the “horse-race stories” about political campaigns and the exposes of taxpayer-funded bridges to nowhere, and who said what to whom. This story of emergency contraception at the FDA is just one story of many. Sen. Clinton saw a problem that affected people’s lives. She then stood up to the challenge and worked to solve it.

The challenges we face in health care, our economy, global climate change, and issues of war and peace, need to be tackled with experience, skills and the commitment to using the best available science and evidence to make the best possible policy.  This will benefit us all.

News Health Systems

The Crackdown on L.A.’s Fake Clinics Is Working

Nicole Knight

"Why did we take those steps? Because every day is a day where some number of women could potentially be misinformed about [their] reproductive options," Feuer said. "And therefore every day is a day that a woman's health could be jeopardized."

Three Los Angeles area fake clinics, which were warned last month they were breaking a new state reproductive transparency law, are now in compliance, the city attorney announced Thursday.

Los Angeles City Attorney Mike Feuer said in a press briefing that two of the fake clinics, also known as crisis pregnancy centers, began complying with the law after his office issued notices of violation last month. But it wasn’t until this week, when Feuer’s office threatened court action against the third facility, that it agreed to display the reproductive health information that the law requires.

“Why did we take those steps? Because every day is a day where some number of women could potentially be misinformed about [their] reproductive options,” Feuer said. “And therefore every day is a day that a woman’s health could be jeopardized.”

The facilities, two unlicensed and one licensed fake clinic, are Harbor Pregnancy Help CenterLos Angeles Pregnancy Services, and Pregnancy Counseling Center.

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Feuer said the lawsuit could have carried fines of up to $2,500 each day the facility continued to break the law.

The Reproductive Freedom, Accountability, Comprehensive Care, and Transparency (FACT) Act requires the state’s licensed pregnancy-related centers to display a brief statement with a number to call for access to free and low-cost birth control and abortion care. Unlicensed centers must disclose that they are not medical facilities.

Feuer’s office in May launched a campaign to crack down on violators of the law. His action marked a sharp contrast to some jurisdictions, which are reportedly taking a wait-and-see approach as fake clinics’ challenges to the law wind through the courts.

Federal and state courts have denied requests to temporarily block the law, although appeals are pending before the U.S. Court of Appeals for the Ninth Circuit.

Some 25 fake clinics operate in Los Angeles County, according to a representative of NARAL Pro-Choice California, though firm numbers are hard to come by. Feuer initially issued notices to six Los Angeles area fake clinics in May. Following an investigation, his office warned three clinics last month that they’re breaking the law.

Those three clinics are now complying, Feuer told reporters Thursday. Feuer said his office is still determining whether another fake clinic, Avenues Pregnancy Clinic, is complying with the law.

Fake clinic owners and staffers have slammed the FACT Act, saying they’d rather shut down than refer clients to services they find “morally and ethically objectionable.”

“If you’re a pro-life organization, you’re offering free healthcare to women so the women have a choice other than abortion,” said Matt Bowman, senior counsel with Alliance Defending Freedom, which represents several Los Angeles fake clinics fighting the law in court.

Asked why the clinics have agreed to comply, Bowman reiterated an earlier statement, saying the FACT Act violates his clients’ free speech rights. Forcing faith-based clinics to “communicate messages or promote ideas they disagree with, especially on life-and-death issues like abortion,” violates their “core beliefs,” Bowman said.

Reports of deceit by 91 percent of fake clinics surveyed by NARAL Pro-Choice California helped spur the passage of the FACT Act last October. Until recently, Googling “abortion clinic” might turn up results for a fake clinic that discourages abortion care.

“Put yourself in the position of a young woman who is going to one of these centers … and she comes into this center and she is less than fully informed … of what her choices are,” Feuer said Thursday. “In that state of mind, is she going to make the kind of choice that you’d want your loved one to make?

Rewire last month visited Lost Angeles area fake clinics that are abiding by the FACT Act. Claris Health in West Los Angeles includes the reproductive notice with patient intake forms, while Open Arms Pregnancy Center in the San Fernando Valley has posted the notice in the waiting room.

“To us, it’s a non-issue,” Debi Harvey, the center’s executive director, told Rewire. “We don’t provide abortion, we’re an abortion-alternative organization, we’re very clear on that. But we educate on all options.”

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