On June 25-27, 2001, world leaders met in New York for the United Nations Special Session on HIV/AIDS, at which the U.N. General Assembly adopted the Declaration of Commitment on HIV/AIDS: "Global Crisis-Global Action." Alexander Sanger reflects on the effects similar declarations in the past have had on the lives of mothers around the world.

The world's literature is filled with images of women dying in childbirth. Catherine in "Wuthering Heights." Lolita in the novel of the same name. And even the first feminist herself in real life, Mary Wollstonecraft, died in childbirth of septicemia.

Women die in childbirth; "always have, always will" seems to be the world's attitude to this phenomenon. In a week when the world's attention was drawn to new U.N. resolutions to eliminate or reduce deaths from AIDS, I recall that, not so long ago, similar U.N. meetings in Cairo and Beijing resolved to eliminate or reduce maternal deaths. What progress have we made since then?

The World Health Organization (WHO) recently provided the answer in a sobering report on maternal mortality worldwide. Their answer: not much.

According to the WHO, more than 500,000 women die annually from pregnancy-related complications. This figure has remained stubbornly high throughout the 1990s and shows no signs of decreasing. The actual figure is probably much higher, according to the WHO, due to frequent official misclassifications of the causes of women's pregnancy-related deaths, including deaths from abortion, early pregnancy deaths (from ectopic pregnancies), and deaths from diseases that pregnancy aggravates, such as heart conditions, malaria or TB. Studies in Mexico and Argentina indicate that officially reported levels of maternal mortality may be underreported by as much as 50 percent.

At the Cairo Conference in 1994, reduction in maternal mortality was reiterated to be a high health priority, and the United Nations set a goal that 80 percent of births be attended by a skilled health care worker by the year 2005. The WHO report last week states that this goal is not going to be reached except in Latin America and the Caribbean, where IPPF/WHR has been working for the last 50 years. Currently, 83 percent of births in Latin America and the Caribbean are attended by a skilled attendant. In addition, well over half of births in this hemisphere take place in health care facilities, the biggest exceptions being Haiti and Guatemala. In Chile, Costa Rica, Argentina and the Dominican Republic more than 90 percent of births are in health care facilities. Panama, Jamaica and Brazil are not far behind.

The sobering part of the WHO report is that most of the reduction in maternal mortality in Latin America, and the rest of the world, occurred in the 1970s and 1980s and that little reduction occurred in the 1990s. Only Argentina, Chile and Costa Rica showed sustained reductions in maternal mortality in the 1990s. Elsewhere in the hemisphere and the world there were stagnant maternal mortality ratios in the 1990s.

Reduction in maternal mortality depends on two things: prevention and medical care. Prevention includes enabling women to plan and space their pregnancies through family planning consultations, which IPPF/WHR affiliates provide to more than four million clients throughout the hemisphere each year. Women have healthier children and preserve their own health better when their births are intended and properly spaced. Contraception reduces the overall number of pregnancies and hence childbirths. Contraception delays pregnancies until teens reach their twenties and are stronger. Contraception reduces the instances of unsafe abortion and helps prevent STI and HIV transmission, which in turn can lead to ectopic pregnancies and other complications. For all these reasons, family planning services are a necessary component in reducing the death toll from childbirth.

In addition, quality obstetrical care to manage complications is also a necessary component. It is harder to provide, but it is feasible. It is not necessary to have university-trained physicians in attendance at every birth, as is the case almost universally in the United States. There are lower levels of training that can be provided to skilled birth attendants, midwives and nurses that, along with some proper equipment and supplies, can go a long way toward managing obstetrical complications. This is not expensive and it does not require a huge infrastructure. Most deaths in childbirth are from hemorrhage, pre-existing health conditions that are aggravated by the pregnancy and sepsis. Most can be managed by a skilled attendant.

The WHO report cautions that it is not possible to establish clear and unequivocal links between the increased percentage of deliveries assisted by skilled attendants and reduced maternal mortality, but the linkage is intuitively clear. Maternal mortality, though, is a complicated phenomenon, perhaps not unlike the provision of family planning. There are many individual, cultural, geographical and medical factors that are involved. Women may be malnourished and anemic. Sexually transmitted infections and HIV may complicate a pregnancy. Being a victim of violence may cause medical complications during pregnancy and delivery--the most common time for a woman to be assaulted is during pregnancy. Unsafe abortion is all too common. Poverty and distance of travel for health care are serious factors.

Even though we cannot yet pinpoint all the factors leading to maternal mortality, we know some of the results: at least 500,000 women dying each year, and probably twice that number; another 20 million suffering from acute complications; and eight million infants dying annually, two-thirds in their first, and last, month of life. A third to half of pregnancies worldwide are unintended, as in the United States.

These challenges may seem daunting. But as has been shown by Latin America's progress in deliveries being attended by skilled attendants, they can be addressed and overcome. The provision of voluntary family planning must expand. Prenatal care and other preventive health care must be integrated with family planning. Skilled birth attendants must be trained and provided with equipment. Medical facilities must be upgraded.

The world demonstrated a few weeks ago the willpower to tackle AIDS. Can we do the same for women dying in childbirth?

Alex Sanger
7/19/01