Local Context Matters to Women’s Lives: A Report from Delhi

Sara Stratton

There are many ways to save women’s lives, but the success of any given intervention depends on local context. What works in one locale may not work in another.

Rewire is partnering with the Maternal Health Task Force to cover the Global Maternal Health Conference of 2010 underway in New Delhi, India from August 30th through September 1st 2010.

To the business world, it’s location, location, location. Here in Delhi, though, at the Global Maternal Health Conference, the mantra is context, context, context. There are many ways to improve and save women’s lives, but the success of any given intervention depends on local context. What works in one country or one community may not work in another. Many people here are talking about the importance and value of understanding how and why an intervention succeeds or fails at the local level. This means investigating and evaluating not just how widely an intervention reaches or the quality of the services, but also the specific, local factors that play into its uptake and impact. How do these realities affect whether an intervention that saved lives in one place would work equally well somewhere else?

This idea of the importance of the local context became woven into presentations on the first day of this groundbreaking conference. In one session, a representative of the SEWA Rural Society for Education, Welfare and Action, Rural (SEWA Rural) talked about how they had found that in Gujarat, India, a woman’s decision to deliver at home or in a hospital in her last pregnancy often influences where she delivered in a subsequent pregnancy. The question for us all to ponder was raised: is the key to saving women’s lives to encourage them all to deliver in hospitals? If so, how much would this cost? Can governments really afford this now? How far would women have to travel to a hospital? The reality, though, is that for some communities, encouraging hospital- or health facility-based delivery may be part of the answer, but in others it may still be an impractical approach. This question led to a discussion about home delivery versus institution-based delivery—as well as the value of traditional and trained birth attendants.

Whether we are talking about where women deliver, how they deliver, who helps them deliver, what we are really talking about is how we evaluate and minimize a woman’s risk during pregnancy and childbirth. Where distance and a lack of health facilities make facility-based delivery improbable, a community may need programs that improve the quality of care offered by trained birth attendants during a home delivery even though in an ideal world there would be another option. What I’m hearing in Delhi is, in some ways, what I already know. There are no easy answers. We must support communities to succeed within the context of their own limitations in terms of the availability of and access to health facilities and health workers. At the same time, we have to remain committed to helping communities to change these limitations.

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Commentary Maternity and Birthing

Having a Severely Premature Baby Strengthened My Support for Every Woman’s Right to Choose

Dallas Schubert

When our daughter was born at just under 24 weeks, we faced a choice: to let her die in our arms, or head down the uncertain and complicated road of medical intervention. We chose the latter, and that experience has only strengthened my commitment to and support for women’s access to later abortions.

When I was 24 years old I got pregnant. My husband and I weren’t “trying” to get pregnant, but we weren’t trying not to either, and we were both very happy when we got the news. I was young, and it wasn’t written into a plan, but it was very much what I wanted.

I threw myself wholeheartedly into that pregnancy, ate all the right things and exercised appropriately. We talked about names and I daydreamed about the baby growing in me and who it would be. I loved the feeling of movement. I had mild morning sickness. I was on top of the world.

At 23.5 weeks I started spotting, and in a matter of hours found myself in a downward spiral from doctor’s office to ambulance to hospital with a level 3 neonatal intensive care unit (NICU) on the other side of town. My cervix was dilating, the baby was coming, and I was diagnosed, in the insensitive language of medicine, with an “incompetent” cervix. For almost 24 hours they worked to stop the progress. I was positioned with my head lower than my feet, in the Trendelenburg position, to try to enlist the help of gravity. I was given magnesium sulfate to slow preterm labor and dexamethasone, a steroid, to speed fetal lung development. I was hooked to a monitor that showed I was having contractions that at first I couldn’t even feel. We found out by ultrasound that it was a girl. A nurse sat by my bed all through the night.

Sometime the next morning the doctors discovered that my membranes had ruptured and that it was not going to be possible to put off delivery. They also discovered that the cord lay between my cervix and my premature daughter, meaning that natural childbirth would be fatal, and if we planned to try to save her life we would need an emergency c-section.

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Whether or not we planned to save her life was not a given. Sober-faced doctors laid out in detail what our choices were. We were told that she had no chance of survival without extraordinary medical intervention. We were told that she had about a 25 percent chance of survival if we resuscitated, and that if she survived she had an over 75 percent chance of significant disability and chronic medical need.

We had a choice. We could accept what was happening—that we were losing this baby we so very much wanted, deliver her, and hold her briefly in our arms while her heart, if it was still beating after delivery, stopped. She would go, peacefully, painlessly, and we would begin the grieving process. Or we could resuscitate, intubate, and head down the uncertain and complicated road of medical intervention.

I couldn’t let her go. Lying there pumped full of magnesium, scared and tired, I couldn’t let go of the idea of that child I had become attached to over those almost six months. I couldn’t let go of my expectations of parenthood. I couldn’t accept the inevitability of grief. And so I said, “Do everything you can.” The NICU team was called, I was whisked to surgery, and we began the next stage of our journey.

The risks to a severely premature infant are many. Our daughter was born at just under 24 weeks, weighing 590 grams and measuring just 12 inches. She could not breathe on her own, and was put on the ventilator she would remain on for seven weeks, putting her at high risk for chronic lung disease. IVs were placed in veins no thicker than a strand of hair. We were told many times every day that the slightest infection could take her life. The doctors and nurses were engaged in a constant balancing act over the amount of oxygen that should be in the air pumped into her lungs. Her brain and body needed enough to survive and grow; too much could cause blindness and brain damage. At any moment the delicate veins and arteries in her brain could rupture and bleed, with the potential of death or severe physical and mental disability. I sat by her side every day, but couldn’t hold her until she was taken off the ventilator. She received two transfusions of my blood.

Gradually she grew. I pumped milk from my breasts to be fed to her through her nose. She avoided infection, there were no bleeds in her brain, and eventually she breathed on her own. After that, she learned to suck and breathe at the same time, and to regulate her own body temperature. Finally, after 100 days in the hospital, with a bill to insurance of almost $1 million, she came home, wearing a monitor to let us know if she stopped breathing. We endured months of isolation as we avoided contact with any germs from the outside.

Today my daughter is 16. She is smart, healthy, and happy. She has plans for the future; she is the joy of my life. We were lucky. We were amazingly, extraordinarily lucky. She beat all the odds. Underneath the joy of seeing how well she has done and her presence in our lives is a profound and constant relief—a relief that the decision I made did not bring her a lifetime of difficulty and pain. It could have.

I do not regret the decision I made. How could I? I have this beautiful, wonderful girl. And I know that if we had not been so lucky, we would have dealt with whatever problem or disability came our way. We had the resources and the insurance to care for her, and plenty of family support. She would have been loved, and valued, and she would have brought value to the world. I am, however, profoundly aware that the decision to resuscitate and take advantage of what modern medicine—with all its miracles and imperfections—has to offer was not a clear-cut decision ethically, or medically.

The choice regarding my daughter’s care was mine, as it should have been. It was both my moral right and my responsibility. I was her mother. She was growing in me. The complex decisions about her life were mine to make, and I made them as best I could.

I have been asked many times since whether my experience changed my commitment to and support for women’s access to later abortions. Absolutely not. If anything, it has made my support and empathy for women facing those decisions stronger. I held my daughter’s life, and the potential quality of that life, in my hands. I made a choice that was born of my hopes, my dreams, the degree of attachment I had to that pregnancy, and my expectations about motherhood. I made a choice to avoid immediate grief and pain. That choice could have condemned her to a more painful death, or a painful life. The consequences of that decision were not just mine to live with; they were hers as well. I believe it is from that very same place that most women make the decision to have an abortion, or any other number of decisions regarding pregnancy and parenting. With the ability to bear children comes the awesome and often difficult power to make decisions about that life.

I had tremendous levels of support around my choices and in the early years of parenting—privilege and the “miracle” of Emma’s good outcome ensured it. No one questioned my unplanned pregnancy. Everyone assumed her premature birth was beyond my control, not the result of bad prenatal habits or behavior. Everywhere I went, family, friends, and complete strangers affirmed my decision around her birth, applauded my strength, and labeled me a “good mother.” But in the hours I spent by her Isolette I doubted my choice to try to preserve her life, and even many years later I recognize its ethical ambiguity and how lucky we really were. Had I made the other decision, the difficult decision to let her go, would the world have embraced me so strongly? I am hopeful that it would have. If my decision had been different, if the pregnancy had not been welcome, and the considerations of my hopes and dreams and the quality of my child’s life had led me to an abortion, would society have supported and embraced me? I know that it would not have. I can’t imagine what it would have been like to have my choice taken from me, or to have endured shame and stigma from society for it. I deserved no more and no less support, understanding, and compassion than any other woman facing the complex and difficult decisions that come with being pregnant.

Analysis Maternity and Birthing

In Malawi, Banda’s Succession to Presidency Could Dramatically Improve Women’s Lives

Jessica Mack

With all due respect to the late President Bingu, his death opened a rare window for reform Malawi, and golden opportunity – especially for Malawi’s women. Joyce Banda is a widely respected and heralded champion for women’s rights and health, and has never been shy to speak her mind about it.

Malawian President Bingu wa Mutharika died of a heart attack suddenly this month, enabling Vice President Joyce Banda to succeed the helm. This will almost certainly change – and perhaps save – the lives of millions of Malawian women.

Banda, the country’s first female Vice President and leader of the opposition party, had been embroiled in a political struggle for months as Bingu had tried to remove her. Bingu’s move to edge her out was part of his tightening grip overall, foreshadowing what could have been another stubborn and potentially bloody transfer of power after 2014 elections, and almost certainly not to Banda.

With all due respect to the late Bingu, his death opened a rare window for reform Malawi, and golden opportunity – especially for Malawi’s women. Joyce Banda is a widely-respected and heralded champion for women’s rights and health, and has never been shy to speak her mind about it.

Banda is Southern Africa’s first female head of state, and the continent’s second (after Liberia’s Ellen Johnson-Sirleaf). Isobel Coleman at the Center for Foreign Relations recently called her “a remarkable person who despite the odds, just might be able to put Malawi on a positive path,” as compared to her “disaster” of a predecessor. Banda left an abusive marriage as a young mother of three, and went on to found several small businesses and organizations for women before being elected to Parliament in 1999.

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She is a woman of both voice and action. Almost immediately upon taking office, she issued a directive to the Ministry of Health to appoint two OB/GYN specialists to the Ethel Mutharika Maternity Hospital to support deliveries there. In a recent press conference, she said she would do anything in her capacity to ensure that the country’s maternal mortality rate is reduced. Banda herself suffered excessive bleeding after giving birth, and nearly lost her life. Though the United Nations estimates that maternal mortality in Malawi was nearly halved between 1998 and 2008, still 3,000 women a year die needlessly in pregnancy and childbirth. Just 42 percent of married women report modern contraceptive use. 

Cultural taboos around women’s sexual and reproductive health, as well as the sheer inaccessibility of services define reality for many Malawian women. A lack of skilled personnel, whether doctors, midwives, or community health workers, to help women deliver safely is also a major factor in maternal deaths. Unsafe abortion is likely a major contributor as well. Abortion in Malawi is prohibited entirely, except to save a woman’s life, and even then spousal permission is required. Perhaps this is something Banda might be willing to step up and address. Systemic devaluation of women’s lives is a problem too, prompting Banda to single out village chiefs as gatekeepers for maternal health in the largely rural nation.

“They are the custodians of our culture and tradition. If you don’t include those chiefs, if you don’t integrate them, you can’t win in the area of maternal health.”

The year 2015 is the deadline to meet the Millennium Development Goals (MDGs), eight major targets to improving the lives and health of the world’s poorest. A recent report by the Malawian Government says the country is on-track to meet five of the eight goals, though MDG 5 – to improve maternal health – is not one of them. African leaders are under increasing pressure from their constituents and donors to turn things around for women in their countries and there are few glimmers of hope. Banda could make huge waves on this issue in just a short while.

Banda is not only an advocate for women’s health, but economic empowerment too. In 1997, she won the Africa Prize for Leadership for the Sustainable End of Hunger. Landlocked Malawi is one of the poorest countries in the world. Its economy relies heavily on agriculture, and women farmers form the engine that runs it. Banda has noted that women in Malawi are conspicuously absent when it comes to economic decision-making, and that it is critical to put more of the country’s money in the hands of its mothers. If anyone can do that, it looks like she can.

Banda is also a staunch supporter of girls’ education. Last year, in a Q&A with the Global Post, she told the story of a childhood friend forced to leave high school after the $12 school fees became too high.

“I went on to go to college and I became the vice president of Malawi. She is still where she was 30 years ago. The vicious cycle of poverty kept her there and took away her options. I made up my mind … whatever would happen in my life, I would try to send girls to schools.”

Such clarity of vision forward and backward is rare in a leader, but seems to be Banda’s defining trait.

She has already distinguished herself as a committed and articulate leader on women’s health and rights. Now with the reigns, in a historic twist of events, she can finally demonstrate what that vision, realized, can do for women. 


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