Maternal mortality is on the decline

By Paul Farmer and Ophelia Dahl
Published: Sunday, May 18, 2008 12:34 a.m. MDT
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"Obscene" is still the word that comes to mind when we think of maternal mortality — and it has been almost 25 years since we first witnessed death in childbirth. In 1983, as students in one of central Haiti's fetid clinics, we prepared to celebrate a birth. Although we'd just met the young woman about to become a mother, her desperate expression as she began to hemorrhage haunts us still. National statistics could have predicted the outcome: A 1985 survey pegged Haitian maternal mortality at 1,400 deaths per 100,000 live births. By comparison, maternal mortality in the United States last year was 14 deaths per 100,000 live births.

Worldwide, 500,000 women die in childbirth every year — more than 90 percent live in Africa or Asia, and almost all are poor by any standard. Obscene though it is, death during childbirth isn't the end of the story. In the world's poorest areas, many orphaned children wind up destitute and on the streets within a few years of their mothers' deaths, sometimes resorting to desperate or criminal measures for food, shelter, clothes or school fees.

One of the 12 U.N. Millennium Development Goals is to reduce maternal mortality 75 percent by the year 2015. But we are moving too slowly to meet this goal, the United Nations says.

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Today, the maternal mortality rate in Haiti is less than half what it was a quarter-century ago. Across the broad swath of central Haiti where we work, we estimate the number to be well below 100 deaths per 100,000 live births — not good enough but a vast improvement, most of it occurring in the past decade. Change came largely for three reasons.

First, our nonprofit organization, Partners in Health, has worked closely with the Haitian Ministry of Health to strengthen public health infrastructure. We have rebuilt, equipped, staffed and stocked hospitals and clinics; trained nurse-midwives and other personnel, including more than a thousand community health workers; linked villages and health centers to district hospitals by modern telecommunications and ambulance service and established modern surgical services for obstetrical emergencies.

Second, we have broken the rule that high-quality health services are a privilege rationed by ability to pay, not a right. The case was made first for affordable medicines. Now it is being made for emergency Caesarean sections — an essential tool to reduce maternal mortality. Faced with evidence that maternal mortality was greater where fees were higher, the district health commissioner for central Haiti announced last August that all prenatal care and emergency obstetrical services would henceforth be available free to all patients. He was later echoed by Haitian President Rene Preval.

Third, we have linked prenatal and obstetric care to an all-out effort to improve access to primary health care. The presence of functional, accessible public clinics and hospitals restores faith in the health system, motivates people to seek care before they are critically ill and allows for preventive interventions such as prenatal care and family planning.

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