No More Taj Mahals: We Can Reduce Maternal Deaths


This article was changed at 1:07 pm Wednesday, April 21st 2010 to correct an error.  The sentence in question should have read: “This study reports that the maternal mortality rate has indeed declined since 1980 from 442 globally to 320 in 1990 and down further to 251 in 2008.”

That great reformer Martin Luther said, “If [women] become tired or even die, that does not matter. Let them die in childbirth — that is why they are there.” Luther never recanted this statement. I guess he had other fish, or indulgences, to fry.

In the days before modern obstetrical care and antibiotics, maternal death was an equal opportunity killer, killing mothers in all classes of society in about 1 percent of births. Among the historical victims of maternal mortality were Queen Mumtaz Mahal (during the birth of her 14th child, whose grieving husband built the Taj Mahal as a memorial); Henry VIII’s mother and two of his six wives; Mary Wollstonecraft, author of A Vindication of the Rights of Women; Abraham Lincoln’s sister; and Theodore Roosevelt’s first wife.

Today in the developed world, maternal mortality is mostly a thing of the past (the rate being about 0.01 percent). This is a reduction of two orders of magnitude since the 1930’s. Maternal mortality is, however, not a thing of the past in the developing world, and the United Nations Millennium Development Goals include one of reducing maternal mortality by 75 percent between 1990 and 2015, along with a goal of reducing child mortality by two-thirds during this same period.

While some conventional wisdom says that a nation needs to develop economically in order to reduce its maternal mortality rate, historical evidence shows otherwise. Poverty is not necessarily the major determinant of a country’s maternal mortality rate, though it is of its infant and child mortality rate. In the late 19th century, as improved standards of living were introduced in Europe and America, i.e. better nutrition, hygiene and housing, leading to attendant better health, child and infant mortality rates began to decline and life expectancy increased. Maternal mortality rates, however, did not begin to decline until the 1930’s. The risk of women dying in childbirth in 1930 in England was the same as it was in 1850, though the country was far more developed.

Ironically, and the reverse of today, in 19th century England the maternal mortality rate was highest among the wealthy and middle class, who were attended by physicians in hospitals. The lowest rate was among poorer women delivered at home by trained midwives. Doctors often interfered unnecessarily and disastrously in the labor process, including with forceps delivery, anesthesia, and manual removal of the placenta. These interventions too often proved fatal. Trained midwives, who did home deliveries, let nature take its course with better resulting maternal outcomes.

The 1930’s brought sulfonamides, which fought childbed fever, as well as blood transfusions, ergometrine and, later, penicillin, as well as better training and organization of obstetrical services. There was also a coincidental reduction in the virulence of the streptococcus virus in the 1930’s. All these led to a decline in the maternal mortality rate throughout the Great Depression, indicating that, in general, poverty is not a determinant of maternal mortality, though starvation level poverty may be.

Assuming that the leading causes of maternal death in Europe and America in 1850 are the same as in the developing world today, this gives hope that maternal death can be successfully combated. Since puerperal fever caused about 40 percent of maternal deaths in 1850 and almost none today in the developed world, this would seem the first priority for attack.

Until this week, it was thought that the maternal mortality rate had not declined substantially in the past 20 years. Maternal mortality was thought to kill over half a million women a year at a rate similar to 1990. The rate in the developing world was thought to be 400 per 100,000 live births today, only marginally less than the rate, 430, in 1990, or about 7 percent less, and virtually identical to the rate in England in the 19th century. Reducing the rate was proving to be stubborn.

Last week The Lancet reported a study from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington and collaborators at the University of Queensland. This study reports that the maternal mortality rate has indeed declined since 1980 from 442 globally to 320 in 1990 and down further to 251 in 2008. The annual deaths are not over 500,000, as previously thought, but 343,000. Until this week, policy makers had been depressed and frustrated at the lack of progress in reducing maternal mortality. This report gives us reason to hope that our interventions are making a difference. The report also pointed out that progress would have been greater but for the HIV epidemic, which leads to about 50,000 of those 343,000 maternal deaths.

Prior research has pointed out that the decline in the rate over the past 75 years has been largely independent of social and economic class. This recent study confirms this. Large declines since 1980 have been revealed in poor countries such as Egypt, Romania, Bangladesh, India and China. Reductions in maternal mortality can happen if obstetrical services are better organized. Previous studies revealed that in one town in northern England in the 1930’s, the health community organized better obstetrical care, and within a few years the maternal mortality rate declined from 900 to 170 with no change in the poverty rate. This was contrasted with a prosperous religious community in Indiana, which refused all outside medical care, including obstetrical, with the result that their maternal mortality rate in 1980 was 872, as opposed to 9 in the rest of the state.

The recent Lancet study confirms that when women time, space, and limit their births, their mortality, and that of their children, declines. Prior studies show that about 30 percent of maternal mortality could be prevented with universal access to family planning. Most of the rest could be prevented with access to trained midwives, modern obstetrical treatment, pre-natal care, blood transfusions and antibiotics. Many deaths could be prevented by access to safe abortion services. The Lancet study says that the reduction in maternal mortality can be attributed to four factors, among others: a reduced birth rate, increased income, increased maternal educational attainment and attendance by skilled birth attendants.

Martin Luther was wrong. Death in childbirth is not women’s inexorable fate. Yet, in the United States it is increasingly so. In 1987, there were 6.6 deaths for every 100,000 pregnancies. The number of deaths has climbed to 13.3 per 100,000 in 2006, the last year for which figures are available. Thus, the rate of maternal mortality has doubled in the last twenty years. Lest our northern neighbors get too smug, the rate has also increased in Canada, as well as Norway. The reasons are many, including a different way statistics are recorded, but, according to previous studies, the deaths are mostly among poor and minority mothers. Insufficient access to health care, including pre-natal care, is one factor. Others include the facts that women are increasingly obese and older as they give birth. There are also more Caesarians, which are risky for mothers, a return perhaps to the 19th century experience where medical intervention could do more harm than good.

A comparison of mortality rates between mothers and children is sobering: while 343,000 women die annually from pregnancy-related causes, 8.8 million children under five die annually, approximately 25 times more. The rate of child mortality has declined since 1990 in developing countries from 90 to 65 deaths per thousand, (about a 28 percent reduction) while the maternal mortality rate is only slightly less at 22 percent. In least developed countries, the child mortality rate is 130 per 1,000 annually. Poverty is the major determinant of child mortality, with the proximate causes being lack of access to safe water, malaria, pneumonia, other infections, lack of oxygen at birth, and preterm delivery. Vaccines, antibiotics and other low cost interventions would prevent about half of child deaths. There is some intersection between interventions to reduce maternal deaths and those to prevent infant deaths, like pre-natal care, improved obstetrical care and antibiotics, but other interventions for the infant are separate and dependent on a public health care and economic system being functional, especially with vaccines, safe water and mosquito netting to prevent malaria.

In historical times, the difference in annual deaths between mothers and children was greater. It is estimated that the child mortality rate in ancient times was about 50 percent. In other words, one half of babies born did not survive to adulthood. Estimates range from child mortality rates of 50 percent in Rome in 200 B.C.-200 A.D.; 48 percent in Japan in 1300-1400; 50 percent in France and Sweden in 1600-1700; and modern hunter-gatherer tribes of 46 percent.

There was an extraordinary difference between the evolutionary mortality rates between mothers and children: 1 percent for mothers and 50 percent for children. Modern medicine, carefully applied, along with fewer births, well spaced and timed, have reduced these awful death tolls. The millennium development goals of reducing these rates further are laudatory. It shows that the world cares and is watching. This is not the time to be disheartened. Progress has been made in our time as well as in the time of our grandparents. I hope our grandchildren will be able to say the same.

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  • mjm9352

    Humbly, if your grandmother did not believe in controlling the populations of economically disadvantaged women why are clinics always located in economically challenged neighborhoods. I like to see the best in people but it’s hard to feel good about any agency that refers minors to abortion clinics without parental knowlege. This is completely unacceptable. Parents have a God given right to advise their children and your agency has interfered with this. Are you aware there are minors having abortions without parental knowledge going home and having complications that result in their death because there parents are unaware an abortion has been performed? Are you aware that there are women whose children are being born alive after a failed abortion and these children are not being giving medical help? If you want people with a soul and conscious to be encouraged then do your research and do something that is really good for women. Because I believe in seeing the good in people please do something that will bring sunshine to these clinics.

  • jodi-jacobson

    Could you kindly provide citations and sources for these claims?

    minors having abortions without parental knowledge going home and having complications that result in their death because there parents are unaware an abortion has been performed? Are you aware that there are women whose children are being born alive after a failed abortion and these children are not being giving medical help?

    Could you also explain why your judgment about the existence of clinics in communities should prevail over that of the representatives of the people living in those communities and to whom said clinics are providing urgently needed basic reproductive and sexual health care?  Does the existence of community health centers in low-income communities mean those people are being “targeted” for primary health care for some nefarious reason, or that their actual health care needs are being met?  Would the existence of sliding scale dental clinics in said communities mean they are being targeted for unnecessary root canals? Or that their unmet needs for dental care are being met?

    People have unmet needs for basic primary health care–reproductive and sexual health care, primary preventive care, dental care–and moreover they have a right to have access to such care.  Your efforts to slander both health care providers and the people who seek out such services are tantamount to dooming born people to poor reproductive and sexual health outcomes and hence to higher rates of death and illness.  Can you explain to me how exactly this is “pro-life?”

    Thank you.

     

     

  • saltyc

    maternal mortality rate has indeed declined since 1980 from 442 globally to 320 in 1990 and down further to 251 in 1908.

    Is 1908 supposed to be 2008?

     

    I am shocked that maternal mortality in the US has increased in the last 20 years, how shameful.

  • marshamarshamarsha

    I’d like to address something you said about clinic locations.

    I often hear people say that locations of clinics somehow prove there’s a conspiracy to limit births of minorities.

     

    But if you look realistically at cost of real estate, it’s more affordable in the poorer neighborhoods. PLUS, don’t forget the high probability that people in the posher neighborhoods would not welcome – or allow – the building of a clinic that offers services to poor people on a sliding scale…that would bring poor people into their neighborhoods. Gated-community people don’t want businesses like that anywhere near their homes.

     

    Businesses choose locations that are accessible to the people that will frequent their businesses. It’s really simple and isn’t a plot.

     

  • marshamarshamarsha

    My comment was in reply to mjm9352.  I was replying to her comment about clinic locations.

     

    Thanks.

  • mjm9352

    What do you think would happen if an individual from a posher neighborhoold came to one of these clinics was referred to an abortion clinic unbeknowst to her parents and died as a result of an abortion. An economically challenged teenager does not have the resources that someone with money does. Shame on you. If you really CARE about disadvantaged youth ask yourself is what I’m providing for someone elses children With tax payers money what I would want for my own children? How would you feel if someone you knew personally and loved died because there parents were kept in the dark about a highly invasive medical procedure that not only robbed them of their grandchild but also took their daughter. I’m very proud to be pro-life and think it is way past time that Planned Parenthood asked itself some very difficult questions and came up with answers that everyone can live with. I’m not sure if your affiliated with planned parenthood but if you are ask them to look for the good in themselves and be so proud of that. Then ask them to honestly take a look at what they know in their own soul to be wrong. I think as an agency with the resources available there is an opportunity to do a world of real good. Young mothers and their unborn dying has very little to do with good and is at it’s root very evil. When infants are being burned in their own mothers’ womb and having their skulls crushed the threat of slander just doesn’t have the same effect. When planned parenthood administers services it does so I’m thinking with the tax payers money. How would you feel if your tax dollars were being used to provide services that resulted in the death of your family member. When the lifes of babies no longer have value the world becomes a much sadder place.

  • mjm9352

    If you would like references and citations go to a pro-life site and you can find these. A film has been done about a young woman who went to an abortion clinic had the procedure done and aborted her baby while in the bathroom. The baby was born alive she asked clinic helpers for help with her baby and was denied help. Her friend called 911 the medics came the medics were lied to and that baby boy died.  I became pro-life when I heard about a baby boy he wasn’t aborted he was delivered in a hospital setting. All he needed was  a simple surgery performed so he could eat. He had Downs’. His parents and the doctor decided that they weren’t going to give him that opportunity. He died in a hospital. What’s wrong with that picture. If you requested cites and references to intimidate me it’s too late when babies are being burned and there schools crushed it’s past time to speak up. If you were really surprised about this information go to Jill Stanek blog and you can find out what some of these helpful agencies are really doing.

  • saltyc

    mjm, it’s not intimidation to ask for some more information to find out what those cases are that you refer to. I asked you before, I don’t have time to slog through all the anti-choice websites to find what you are talking about. Being able to cite names, dates, etc. for your cases is an expected part of debating.

  • marshamarshamarsha

    mjm9352,

    Please feel free to live your life as you wish. When you respond to my thoughts that wealthy neighborhoods don’t want health clinics with “shame on you,” you are using age-old tactics to try to SILENCE me. Shame makes people afraid to talk. It’s better to say you believe abortion is wrong. I understand that much better than “shame on you.” Then I can tell you I do NOT believe abortion is “wrong” and that I know there is nothing in the Bible about it.

     

    If you get your information from anti-choice sites, you don’t know the truth about clinics, the services provided or the workers. And yes, I would and have wanted my own children to go to PP. I not only support PP with my tax dollars, but with my donations AND my volunteer efforts.

     

    However, not to worry - my tax dollars DO support things I disapprove of, such as “faith-based initiatives” which allow churches to use tax money for proselytizing and spreading MISinformation through fake pregnancy clinics.

     

    If women are to remain FULL citizens, they must have 100% control over their reproduction. To say otherwise is to say women should be slaves.

     

     

  • mjm9352

    I felt a little guilty even as I typed shame on you. Give me time to think and I’ll type something more appropriate. The response though had nothing to do with your comment on wealthier neighborhoods. I was trying to get you to understand  the injustice in referring minors in the first place to get abortions without parental knowledge or consent and then I was trying to appeal to your sense of fairplay or justice when I pointed out that some of these teenagers were dying after having had an abortion. O.K. instead of saying shame on you I will say look inside your own heart without shame and ask yourself is it fair in the name of better reproductive health, for young mothers to lose there lives and the lives of there babies? I don’t give as often as I should to churches but I should because it was a church that gave me back my life at very little cost to the tax payer. I think life is just about value if you really want to put value on women advocate for laws that protect them from real injustices. A baby is not an injustice a baby is a blessing.

  • prochoiceferret

    I was trying to get you to understand  the injustice in referring minors in the first place to get abortions without parental knowledge or consent

    …when they have abusive parents who would disown them or do them harm if they found out? No, we don’t see the injustice in that.

     

    We think it’s great when a pregnant minor consults with loving, supportive parents to decide what to do. We just know better than to believe that a law can make this happen where it wouldn’t have otherwise. Seriously—parental-consent laws apply to all pregnant teens, including the ones that really and truly are better off not having their parents know.

    and then I was trying to appeal to your sense of fairplay or justice when I pointed out that some of these teenagers were dying after having had an abortion.

    Some teenagers die when they go through with the pregnancy, too. Medicine isn’t perfect, advanced as it is. It’s not like abortion (or childbirth) is necessarily any safer when the parents know about it.

    O.K. instead of saying shame on you I will say look inside your own heart without shame and ask yourself is it fair in the name of better reproductive health, for young mothers to lose there lives and the lives of there babies?

    We support legal abortion because it’s safer for women than illegal abortion. As for “the lives of there [sic] babies,” that has to be the woman’s call, because it’s her body that’s doing the job of building it.

     

    Yes, that’s what we feel in the deepest corners of our hearts. We don’t understand why someone else would want to butt in and say to this woman that no, she has to remain pregnant even if she doesn’t want to be, because the fetus inside of her is more important than her body, her health, her life and her own autonomy.

    I think life is just about value if you really want to put value on women advocate for laws that protect them from real injustices.

    Forcing a pregnant woman to remain pregnant against her will seems like a very real injustice to me.

    A baby is not an injustice a baby is a blessing.

    Tell that to rape victims.