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A Hidden Tragedy: Birth as a Human Rights Issue in Developing Countries
by Vicki Penwell
© 2010 Midwifery Today, Inc. All rights reserved.
[Editor's note: This article first appeared in Midwifery Today Issue 94, Summer 2010.]
Every minute of every day, 150 babies are born somewhere in the world.(1) Every minute of every day, one mother dies while attempting to bring forth new life.(2)
This would be just another sad statistic, except for the fact that 99% of maternal deaths occur in the under-developed nations, with most occurring in sub-Saharan Africa and Southern Asia. That means only 1% of the worlds maternal deaths occur in the United States, Canada, Europe and Australia combined. This distribution of maternal death is injustice by any measure.
When Jan Tritten, editor-in-chief at Midwifery Today, first spoke to me about writing on the theme of birth is a human rights issue for an upcoming issue of Midwifery Today magazine, that concept really resonated with me. Like many midwives, I have seen women in American hospitals being bullied, coerced and threatened with bodily harm if they did not comply with the treatment the hospital personnel wanted to administer. I have seen injections and episiotomies (a form of surgery) done expressly against a womans will in the absence of any complication and in the presence of her verbal protestations or sometimes even pitiful begging to not be cut or injected. I have also seen, in developing countries, women in labor hit, kicked, slapped and pinched on the inside thighs to the point of bruising. I have seen healthy women physically restrained (strapped down, eagle-spread) for normal births. I have also witnessed many cases of vicious verbal abuse, and once or twice even witnessed the line being crossed into behavior that appeared to be blatant sexual abuse.
However, knowing that Jan and others will be writing for this issue of Midwifery Today about these common (albeit inexcusable and intractable) examples of human rights violations during childbirth, I want to concentrate this article on the issue of inequality: the human rights violation currently happening to three-fourths of the worlds women due to poverty. Maternal mortality is the health indicator with the most disparity between developed and developing countries, at a rate 100 times greater in poor countries than in richer nations.
Many readers in North America or Europe may not think of themselves as wealthy or rich. Yet think about this: only 10% of the worlds population owns a car. Therefore, by definition, if you own a car, you are in the top 10% of richest people in the world. Its the same if you have access to clean drinking water, or education, or a trained midwife…you get my point.
Michelle Maiese of the Conflict Research Consortium has a helpful viewpoint on what it means to violate human rights: There is now near-universal consensus that all individuals are entitled to certain basic rights under any circumstances. These include certain civil liberties and political rights, the most fundamental of which is the right to life and physical safety. Human rights are the articulation of the need for justice, tolerance, mutual respect and human dignity in all of our activity. Speaking of rights allows us to express the idea that all individuals are part of the scope of morality and justice. To protect human rights is to ensure that people receive some degree of decent, humane treatment. To violate the most basic human rights, on the other hand, is to deny individuals their fundamental moral entitlements. It is, in a sense, to treat them as if they are less than human and undeserving of respect and dignity.(3)
All women are fully human and deserving of respect and dignity. When we think about our sisters in sub-Saharan Africa or Southeast Asia, we may not know how endangered they still are in childbirth and how few real choices they have. It has been said that, in developing countries, the most dangerous occupation is motherhood. Ethical people have a duty to act on human rights violations, once those violations have been made known. This article is to make that known; what you do with this information is up to you. I believe the answers will come if we can move beyond pity into action.
First, we must understand the injustice of the disparity. In 2010 we know how to keep women from dying in childbirth. It is not rocket science, and as we know from numerous studies in developed countries over the past 30 years, the place of birth is not the important factor in healthy outcomes. Homebirth and out-of-hospital birth centers have been proven to have as safe or safer, outcomes than hospitals for normal deliveries. The important factor in whether childbirth will be safe or unsafe for a woman is three-fold: the overall health of the woman, her place in society, and the presence of a skilled birth attendant. Poor women, those who come to the place of birth malnourished and often unattended, die 100 times more often than their wealthier sisters.
Women in rich countries can die in childbirth too, as we know, and the overuse of cesarean delivery and labor induction is driving up the maternal mortality rate in the United States. Having said that, it remains a truism that most modern women dont fear dying in childbirth. While maternal mortality can happen anywhere, the lifetime risk of maternal death in the United States is 1 in 2,500. Compare this to a lifetime risk in Sierra Leone and Afghanistan of 1 in 6.(4)
In Africa, women who are starting labor say goodbye to loved ones, just in case they dont survive the process. In the Philippines, there is a native saying that a pregnant woman has one foot in the grave. It is common for women in developing countries to say some variation of this phrase to their older children: Mommy is going on a journey to fetch you a new brother or sister, but the journey is long and dangerous, and I may not return.
Yet even within poor countries, the disparity between richer and poorer women is a matter of injustice based on economic restraints. In Bangladesh, for example, among the richest 20% of women, almost half have a skilled birth attendant at the time of giving birth. Among the poorest 20% of women in Bangladesh, only 4% are helped by any trained person. In Peru, almost all rich women have a midwife or doctor attend their birth, while only 20% of the poor get this basic right.(5)
Part of the problem is that there is a worldwide shortage of midwives. The world needs at least 300,000 more midwives immediately to begin to address the problem of maternal and newborn survival.(6) All midwives should be teaching and apprenticing other women who desire to be midwives. That is something we can all do that will make a big difference. The World Health Organization says that skilled health workers at delivery are key to improving outcomes, and further states, Investing in human capital such as midwives for childbirth is the wisest investment that we make, to ensure sustainability, ownership, fulfillment and consistently high results.(7)
Not only are mothers dying in childbirth at unconscionable rates, but they are also losing their babies to death out of all proportion to what happens in the West. Based on the data, as many as 50% or more of neonatal deaths could be averted through improved maternal nutrition status and infection prevention, as well as skilled care of the mother during pregnancy and labor.(8) Maternal health is an important determinant of neonatal survival, and maternal health interventions during pregnancy and birth dramatically affect neonatal health and survival. Since more than four million newborn babies die in the first weeks following birth, and three-and-one-half million are delivered stillborn, that represents a multitude of grieving parents. Like maternal death, neonatal deaths are also disproportionate to the worlds population, with 99% of all infant deaths occurring in developing countries. Is that a violation of our basic human rights also, then, to have our children die at rates out of all proportion to richer nations of the world, when the solutions are as simple as having a midwife present for delivery?
All the nations of the world are currently working to achieve the Millennial Development Goals laid out by the United Nations. Goal Number 5 proposes to reduce by three quarters, between 1990 and 2015, the maternal mortality rate, and to increase the proportion of births attended by skilled health personnel. Right now, only 60% of the women in the world have a midwife, or doctor or nurse with midwifery skills to assist at their childbirths.(9)
Ban Ki-moon, UN Secretary-General, seemed to hint that this was indeed a human rights issue when he made this statement: Ours is the generation that can achieve the development goals and free our fellow men, women and children from the abject and dehumanizing conditions of extreme poverty.(10)
The bad news is that, globally, maternal mortality ratios essentially have not changed since the 1990 estimates, denoting more than 500,000 maternal deaths annually for a world rate at an estimated 400/100,000 live births (11), with 14 countries having a rate more than 1,000/100,000.(12)
The five direct causes of nearly two-thirds of maternal deaths worldwide are all things we have learned to prevent, treat or correct, making it all the more unjust that woman are dying of these childbirth complications. They are:
- Obstructed labor
- Complications of abortions
Every single minute that we delay in taking action, a mother somewhere in the world is dying from complications related to pregnancy and childbirth. Yet maternal deaths can be prevented. The midwife model of care is a powerful tool, when used in conjunction with World Health Organization standards and protocols for advanced skills in midwifery. Mercy in Actions model birth centers have proven this in the Philippines. We have kept detailed statistics that show a maternal mortality rate and neonatal mortality rate far below the nation we are serving.(13)
So, you may ask, what can I do to help? Think about raising money for a safe motherhood project or supporting a midwife who is using the Midwifery Model of Care in a developing country. Perhaps you could give a percentage of your birth fees to help women overseas. Or train yourself in how to translate your skills into what is needed to organize and staff a maternity service in a developing country by attending one of Mercy in Actions Midwifery Volunteerism in Developing Countries Seminar, accredited by MEAC for 13.5 CEUs. For more information on training and internships, and ideas of ways to help, visit www.mercyinaction.org.
Allow me to end this article with a quote that helps us see this human rights problem, and its solution, in a different light:
Women are not dying because of diseases we cannot treat; they are dying because societies have yet to make the decision that their lives are worth saving.(14)
Vicki Penwell is a licensed midwife and CPM who has practiced for 30 years, first in Alaska and then in Asia for the past 20 years. She and her family founded a nonprofit charitable organization named Mercy in Action that trains midwives and establishes birth centers in poor countries. For a complete description and birth statistics, read Vickis chapter in the book, Birth Models That Work, edited by Robbie Davis Floyd, et al., Berkeley, California: University of California Press, 2009.
- Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2008 Revision, June 26, 2009. www.un.org/esa/population/.../wpp2008/wpp2008_highlights.pdf.
- UNICEF www.unicef.org/media/media_7594.html.
- Michelle Maiese. Beyond Intractability Newsletter, 2003. http://www.beyondintractability.org/essay/human_rights_violations/.
- World Health Organization. 2000.
- Global Health Learning Courses, www.globalhealthlearning.org.
- State of the Worlds Children Report. 2005. http://www.unicef.org/publications/index_24432.html.
- Joy Phumaphi, Assistant Director-General, Family and Community Health, World Health Organization http://www.who.int/making_pregnancy_safer/events/news/international_midwives_day/en/index.html.
- Stanton and Deller. 2007. www.globalhealthlearning.org.
- United Nations MDG Report. 2008. http://www.un.org/millenniumgoals/maternal.shtml.
- Ban Ki-moon, UN Secretary-General, 2007 Report of the UN Secretary-General on the Work of the Organization. 2007. http://www.un.org/documents/secretariat.htm.
- WHO, UNICEF, and UNFPA. 2004. www.globalhealthlearning.org.
- Maternal mortality in 2005 : estimates developed by WHO, UNICEF, UNFPA, and the World Bank. www.globalhealthlearning.org.
- Davis-Floyd, Robbie E., et al. 2009. Birth Models That Work. Berkeley: University of California Press.
- Dr. Mahmoud Fathalla, Professor of Obstetrics and Gynecology, former Dean of the Medical School at Assiut University, Egypt, and Chair of the WHO Advisory Committee on Health Research. Professor Fathalla has been an international campaigner for Safe Motherhood and a founder of the Safer Motherhood Initiative. http://linkinghub.elsevier.com/retrieve/pii/S0020729203005435.
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