Mobilizing for Maternal Health: Delivering on a Global Promise to Moms Everywhere

"It's a good thing you're not having this baby in North Dakota!" my silver-tongued obstetrician declared jauntily.  "This baby" turned out to be a tiny spark of a girl, born 11 weeks early and weighing 1 1/2 pounds, considerably less than she should have in the 29th week of pregnancy.  "My little chickie," the neonatal intensive care nurse, who held my daughter long before I did, would croon. When Jan began work as a NICU nurse decades earlier, there were no needles or tubes small enough to fit the little birds who'd fallen so soon from the nest. I had landed in a lucky spot on the space-time continuum: in 2002, I lived a few miles from a Connecticut teaching hospital with a high-level, high-volume NICU. Apparently, in other parts of the 21st century United States, hospitals still did not always

With my daughter in the NICU 

have the appropriate equipment or the experienced staff to give pregnancies and babies like mine the best chances of a "positive outcome."

"It's a good thing we didn't have either of our babies in Guatemala!" I mused to my husband.  There was no hint of jauntiness to his reply, as he knew that I almost certainly would not have made it out of my first pregnancy alive. A little over a year prior to the premature emergency delivery of my son, we had lived in the central highlands of Guatemala. I was doing anthropological fieldwork on community health promoter training in rural Maya communities. I was particularly interested in women's involvement in health activism, including the work of traditional Maya midwives and healers.

Maya midwives inspired me with their deep cultural knowledge of pregnancy and birthing, their nurturing relationships with women and families, and their tireless work under extremely difficult circumstances. They also shared stories of fear, mostly of ethnic discrimination, violence, and poverty but sometimes of the challenges of helping mothers and infants through the risky endeavor of reproduction. I think of their warm, wise faces and know that I would have been one of their professional nightmares. Honestly, my high-risk obstetrics specialists probably felt the same way.

Maya midwife

In both of my pregnancies, I developed one of the most common and least understood of pregnancy complications known as pre-eclampsia. In addition to posing serious risks to the mother's health, pre-eclampsia can cause growth restriction and other problems in the developing infant, including the need for a premature delivery. Difficult to detect, it can develop -- often quite rapidly -- into the seizures and coma of eclampsia, one of the leading causes of maternal death. According to the Preeclampsia Foundation, the condition causes an estimated 13% of maternal deaths and up to 20% of preterm births worldwide. It remains one of the reasons why every year nearly 300,000 women across the globe die and many more are disabled from pregnancy and birth-related causes.

That statistic is an improvement. The United Nations focused global attention on maternal death in 2000 when it established the 5th Millennium Development Goal (MDG 5), calling on nations to reduce the maternal mortality ratio by three quarters between 1990 and 2015. Increased global activism and investments have contributed to a 47% decline in maternal deaths in this period, but progress has been slow and inequities persist. The vast majority of maternal deaths, which are largely preventable, occur in developing regions as a result of unequal access to healthcare and other resources.   

http://www.un.org/millenniumgoals/maternal.shtml

At the end of this month in which we honor mothers, Women Deliver, a global advocacy group dedicating to improving the health of women and girls, will convene its third international conference. Thousands of representatives from government, NGOs, healthcare, academia, community groups, and other spheres will gather in Kuala Lumpur, Malaysia to brainstorm about how to continue to mobilize the international community to improve maternal health and the overall well-being of girls and women. As Women Deliver's President Jill Sheffield stated in a recent Huffington Post blog with Jennifer James that is part of the Global Mom Relay, "We have the solutions....We just need to scale them."

Musicians, writers, filmmakers, and other artists have joined this global movement to improve maternal health. For example, filmmaker Lisa Russell and singer Maya Azucena developed an innovative platform uniting artists and activists in their work to achieve MDG 5. Their interactive website, MDGFive.com, includes content by singers, poets, photographers and artists that can be remixed to create videos that raise awareness about maternal health and women's rights. As Russell and Azucena state, "we believe in the power of imagery, sound and the spoken word to inspire cultural exchange, unite international communities, and to promote social progress worldwide."

Like the dedicated Maya midwives and health promoters I came to know, these creative artists and activists inspire me to join in their efforts to understand, prevent, and solve maternal health challenges.  The pain within my own journey of pregnancy and birthing has no doubt lefts its scars, but by virtue of my privileged location within our global geography, history, and economy I was gifted with a tremendously positive outcome for my own life and that of my children. While I sometimes may forget amidst the busyness of raising my now 10-year-old daughter and 16-year-old son, my own aging face in the mirror and their vibrant, growing faces are my call to action: to increase the opportunities for health for all mothers, infants, fathers, and families, no matter whether they live in the inner cities of Connecticut or the highlands of Guatemala, in rural North Dakota or rural Nigeria, or in any other spot on our remarkable globe.

To learn more about the signs and consequences of pre-eclampsia, see the Preeclampsia Foundation.

The Women Deliver website has further information about the 2013 conference and other projects such as Catapult, a crowdfunding platform for advancing gender equality.

Information and resources related to MDG 5 are available at: United Nations Millennium Development Goal 5 and MDGFive.com 

CLIO TALKS BACK: What Do We Really Know About the History of Maternity and Motherhood in Sub-Saharan Africa?

Clio just read a recent, important article by a French colleague, Anne Hugon, who addresses the history of maternity in sub-Saharan Africa. As she remarks, everyone who knows about African societies agrees that maternity is an obligatory passage for black African women, and that the status of women is determined by their fertility – the more children they have, the higher their status. Sterility is grounds for suspicion and marginalization.

And yet, few scholars have actually studied maternity in southern African societies as a historical issue, one that concerns the changes over time in the experiences of women in pregnancy, birth, the post-partum experience of nursing and childrearing and that engages the experiences of both women and men. Until recently, this was a history that still cried out to be written, to be recovered from the shadows of “nature” and restored to “culture” and to history.

Anthropologists, according to Hugon, had looked mainly at kinship systems and rituals, but did not deal either with maternity per se, or with change over time. Historians have found means of studying maternity in several contexts, but primarily in the colonial periods where christianization of the populace entailed “educating” future wives and mothers for european-style domesticity. Another striking feature of the historicizing of maternity is the irony of preparing stay-at-home mothers in an economy where men did not support their families and the possibility of earning money was extremely low. A third important feature is the medicalization of pregnancy and birth, in the interests of maternal and infant survival but also in the interests of the colonial state. Hugon singles out for commendation a study by Lynn Thomas on the “politics of the uterus” in Kenya during the period between the world wars, where control of women’s sexuality and fertility became a central issue.

What seems to be missing in all this research, which is admittedly in its early stages, are the voices of the mothers and their own accounts of their coming to motherhood. Can these voices be recuperated? How did these mothers in the various cultures that constitute sub-Saharan Africa understand their own motherhood experiences? How do these mothers understand their motherhood experiences today?



Further reading:
Hugon, Anne. “L’historiographie de la maternité en Afrique subsaharienne,” Clio: Histoire, Femmes et Sociétés, no. 21 (2005), 212-229. This review article features over four pages of invaluable references to pertinent scholarship in French and English. Online at http://clio.revues.org

Thomas, Lynn. Politics of the Womb : Women, Reproduction and the State in Kenya. Berkeley & Los Angeles : University of California Press, 2003.

Tale of Two Mothers

[Editor's Note: The following is a guest post by Kate Grant, CEO of The Fistula Foundation. It was previously published in The Huffington Post on May 8, 2011. The Fistula Foundation is a partner of IMOW for our new online exhibition, MAMA: Motherhood Around the Globe.]

Nurse and patient in Ethiopia

In spring of 1999 a young woman named Cipriana got married in Huambo Province in central Angola, and became pregnant with her first child. That same spring, after a wedding I think my own mother thought would never happen, I too became pregnant with my first child in New York. Like most first time mothers, as my due date approached I was simultaneously anxious and thrilled, waiting for my big day. Cipriana too was excited about soon becoming a mother -- a role that would give her status and a place in her community. Her labor and mine began with the same universal pain, growing gradually excruciating as the day progressed. After nearly 24 hours we both remained in labor, and here our stories diverge.

When I went into active labor at midnight my husband and I headed off to the hospital. As night turned to day and day turned to night again, after four hours of pushing, my big baby was lodged in my small frame, not going anywhere; a C-section was ordered. I whimpered with a sense of personal defeat and disappointment. But, other than a bruised ego, the only sign of that agonizing labor left after delivery was a small line of staples below my "bikini line" where my healthy baby boy had been removed from my exhausted body.

Kate Grant and a fistula patient

For Cipriana a world away the end game of her labor could not have been more different from my own. Like most mothers in sub-Saharan Africa, she endured a traditional home birth, and with no emergency obstetric care available, her labor continued there even when it was clear she needed help. Forget pain killing drugs. Forget the C-section. Once the baby died in utero she expelled the lifeless body, swept into eternity on a tide of pain and unbearable heartbreak. That's an ugly and deeply, upsetting image. But, the hard truth is that every day that is the reality for thousands of women and their stillborn babies.

But, Cipriana's situation grew worse after her labor ended, when she discovered that she was left with a large obstetric fistula, an injury created by her extended obstructed labor that left her leaking urine constantly. Her young husband quickly abandoned her and she returned home to be cared for by her mother; both she and her mother moved outside their village because of Cipriana's odor and stigma. For a decade she lived as a social outcast sustained by the love of her mother, until she received much needed surgery to repair her fistula at the Central Evangelical Hospital in Lubango.

Cipriana was just one of the 2.6 million mothers who deliver a stillborn baby each year, and one of the estimated 100,000 who develop a fistula. Five to ten percent of births are obstructed, yet only four percent of women in most African countries get C-sections. You can do that math. That means of course that an awful lot of laboring women don’t get the help they need during labor; the result: lots of dead babies and injured women. We tiptoe around this tragic, often preventable reality. Think of the word "stillbirth". Sounds peaceful, serene, and almost divine. So much gentler than dead baby or grey lifeless body, with the word birth even being a cruel hoax, since the child will never take a breath and their mother's soul will be forever changed by an immutable, indelible loss.

Not a day goes by that I don't look at my own energetic freckle-faced fourteen year old boy -- brimming with life and possibility -- and recognize how very lucky I am to have him. Had I tried to deliver him in most places in sub-Saharan Africa, he would have died, a pure and simple 'stillbirth.' And me, who knows? Would I have awoken the next day to a urine soaked bed, the sure sign of a fistula, or would I have died in childbirth when my exhausted uterus ruptured?

The world renowned Egyptian Obstetrician/Gynecologist Mahmoud Fathalla, said it better than anyone "Women are not dying because of diseases we cannot treat. They are dying because society has yet to make the decision that their lives are worth saving." The same can be said for most of those stillborn babies and injured women. We know what works to stop this carnage: prenatal care, family planning services, access to skilled birth attendants and emergency obstetric care.

So today, open your mouth along with your mind and your heart; share this truth with someone you care about: each year millions of mothers are dying or being horribly injured and babies are dying needlessly. Then, if you're up to it, do something else. We are citizens of the richest and more innovative country the world has ever known. We've got the power collectively to bend the curve. If you are a letter writer, write your Senator or Congressman/woman and ask them to support US foreign aid for maternal and child health and funding for UNFPA. Or go on Google: find an organization that speaks to your heart. Act. Do it for your mother. Do it for your wife. Do it for your sister. Do it for your child. Do it for yourself. The late genius John Lennon had it right: "Apathy isn't it."

A Changing Mindset on Childbirth in Western Africa

Americans are a bit fascinated with polygamy. Big Love, Sister Wives – it seems men with multiple spouses are getting quite the media foothold in the United States.

In Senegal, polygamy is a daily, accepted reality. But ask a Senegalese person why it’s so commonly practiced here, and the most common answer you’ll receive is that it’s done for one primary reason: for procreation.

Children are revered here in West Africa. Having a huge brood is smiled upon, regardless of the resources one has to provide for a plethora of offspring. If there isn’t enough food to go around, extended family members have no problem pitching in. In general, the more kids, the better.

That’s why I’m curious to see how Senegalese president Abdoulaye Wade’s recent statements on family planning will resonate – if at all – with the public.

“We cannot impose on our people contraceptive methods, but should explain to convince them that they are responsible for the number of children they give birth to in terms of providing them with quality education, health, shelter and all the necessary basic needs in life,” President Wade said at a recent International Conference on Family Planning in Dakar.

My outsider’s viewpoint is that it’s going to take much more than just education and availability of contraceptives for family planning in Senegal to change or happen at all. It’s going to take a true cultural and mental shift, especially in rural places far outside the capital city.

The United Nations is determined to make it happen, though. The U.N.’s Population Fund is getting a grant-funded boost that will give underprivileged women in Africa contraceptive implants. The U.N. estimates the project will help prevent some two million unwanted pregnancies. But in Senegal, the pregnancies often aren’t unwanted (and despite the poverty, the quality of life isn’t nearly as bad here as in other African nations).

Do you think family-planning initiatives will have success in Africa? Why or why not?

MAKE CHANGE: International Planned Parenthood Federation

Planned Parenthood has been in the news a lot recently as a result of the budget crisis in Washington. While Democrats and Republicans squabble over how many resources Planned Parenthood clinics devote to abortions, a point not mentioned nearly enough is how much Planned Parenthood does to alleviate suffering internationally. The International Planned Parenthood Federation, to which Planned Parenthood is a subsidiary organization, supports women's health initiatives throughout the world.

A recent report by the US Center for Citizen Diplomacy highlights the work of the International Planned Parenthood Federation as an organization that works tirelessly to address the needs of women in the international community, particularly through the SPRINT initiative. The SPRINT initiative is a rights-based initiative that aims to uphold the right to life and security of persons as well as the right to the highest attainable standard of heath- including sexual and reproductive health -- for all people affected by conflict and natural disaster.

The SPRINT initiative identified a serious gap in response to women's health and reproductive issues during humanitarian crisis. Most often the humanitarian aid delivered to people in conflict zones or to areas affected by natural disasters is intended to address issues of food and shelter. While such assistance is needed to address basic human needs, oft neglected are equally basic needs such as maternal care. Childbirth is one of the most basic functions of life, yet maternal care is consistently one of the last services provided to women in crisis zones.

As the report makes clear, such organizations are absolutely fundamental to strengthening the well-being of women throughout the world and in making strides towards achieving the goals established at the 1995 Beijing Conference. Though much progress has been made in the last fifteen years, due in part to the wonderful work of organizations such as the International Planned Parenthood Federation, as the current fights in our own US Congress make clear, too many people are still undereducated on women's rights and health issues. In the spirit of Margaret Mead, who famously said, "Never doubt that a group of thoughtful, committed citizens can change the world…," the report identifies five ways the average citizen can get get involved to work to improve the lives of women everywhere:

• Utilize social media



• Create straightforward, informative, and creative awareness campaigns



• Facilitate direct contact with women in need



• Make fundraising efforts flexible and relateable to the average citizen



• Raise funds and spread awareness through the sale of tangible goods

For more ideas on what you can do to get involved, visit the US Center for Citizen Diplomacy.

Half the Sky: Revisited

Two years ago, journalists Nicholas Kristof and Sheryl WuDunn published the Pulitzer Prize winning book, Half the Sky. Derived from an old Chinese proverb, "Women hold up half the sky," the title invites readers to be reminded that the world is run on the shoulders of women and men, equally.

The book traces the lives of women struggling on a global scale and also the unsung heroes who have dedicated their careers to helping these women. Be it economically oppressed, physically abused, or otherwise ignored, women throughout the world and throughout history have been left in the shadows of silence. Therefore, many of the stories reported in Half the Sky vividly describe the violence faced by women around the globe: brutal rapes in the Democratic Republic of the Congo, girls as young as eight-years-old bought and sold within the sex trade in India, and women left in a state of total Pariah as a result of the cultural traditions created by misogyny.

Having first read the book shortly after it was released, the stories that have stuck with me most are those of the women left not as victims of violent crime, but victims of neglect. Specifically, I am talking about the women who bravely face childbirth without the protections afforded them by proper pre-natal and maternal care. For me, this was the first time I had read in such detail about the extreme suffering many women are subjected to for lack of proper care.

I frequently revisit the story of Mahabouba Muhammad, a young girl who was raped and left pregnant by a sixty-year-old married man. Embarrassed and afraid, Mahabouba ran away and had the child without the assistance of a midwife. Due to her young age, and consequently her immature reproductive system, Mahabouba ended up with an obstructed labor. Without medical attention, Mahabouba lay for days in agony as her child slowly rotted. This left her with a fistula, which happens when the wall between a woman’s vagina and the bladder or rectum tears.

Sadly, Mahabouba’s story is not unique. Thousands of women, mostly in under-developed countries, suffer fistulas -- and death -- each year as a result of inadequate access to prenatal and maternal care. In fact, each day more than 1,000 women die in pregnancy and childbirth. Of those 350,000 plus deaths annually, over 90 percent are preventable.

And, what is being done?