"Labour" – the act of giving birth – is the most dangerous labour in the world. Outside of a small number of privileged and/or conscientious countries that have succeeded in reducing maternal mortality to close to zero, each pregnancy and birth is a risky and potentially fatal experience for hundreds of millions of women worldwide.
The term maternal mortality is used to refer to all deaths of women ascribed to childbirth and puerperium, the few weeks immediately after birth. Postpartum haemorrhage, often with anaemia as an underlying or associated cause, sepsis and toxaemia are the most frequent causes of maternal deaths and are directly related to the absence or inadequacy of prenatal and delivery care. Pregnancies that happen before a woman is biologically ready for childbearing; pregnancies which occur towards the end of her reproductive span and pregnancies which follow many previous birth carry additional biological and behavioural risks independently of a woman's setting or life circumstances.
Because childbearing is spread over more years in developing than in developed countries, women in developing countries not only undergo a higher risk per pregnancy but they are at risk over a longer period of their lives. Maternal deaths may severely affect infants and young children, who often die soon after the passing of their mothers. Some children suffer impaired health or development prospects.
For every woman who dies from causes related to pregnancy or birth, approximately 30 more incur injuries, infections and disabilities which are usually untreated and unspoken of, and which are often humiliating and painful, debilitating and lifelong.
The increase of availability of such services accounted for a dramatic decline of maternal mortality in Sweden in the 18th and 19th centuries. Maternal mortality rates dropped in the UK, the Netherlands and other European countries with the advent of antibiotics, blood transfusions and improved surgical techniques in the 1930s.
Nearly 600,000 women a year die as the result of pregnancy or pregnancy related causes. 99% of these deaths occur in the developing world. An estimated 7 million peri-natal deaths (deaths of babies) are associated with maternal health problems. Maternal mortality rates represent the greatest disparity between developing and developed countries of any human development indicator. The risk of a woman dying in childbirth is 150 times greater in a developing country than in the industrialized world. A woman in Ethiopia has a one-in-ten chance of dying of childbearing-related problems, while a Spanish woman has one chance in 9,000; a woman in the USA has one chance in 3,500 because a greater number are teenagers than in other developed countries. In a number of developing countries, maternal mortality rates in excess of 500 per 100,000 live births are by no means exceptional, and rates of over 1000 per 100,000 have been reported in parts of Africa. It has been estimated that, in the areas with the highest maternal mortality (such as most of Africa and west, south, and east Asia) about half a million women die from maternal causes every year, leaving behind at least one million motherless children. In Latin America, the maternal mortality rates are much lower, but several studies have shown serious underreporting of maternal causes of death; in some countries up to half of such deaths were not reported accurately.
The high mortality of women in developing countries in their middle years is a cause for grave concern. Age-specific death rates for women rise sharply between the ages of 20-30 in many countries, where women often have less chance than men of surviving the years between 15 and 45. In a number of countries in Asia, life expectancy at birth is actually lower for women than for men. Despite the known underrecording, maternal causes are still among the leading causes of death for women in the child-bearing ages. In almost all developing countries, deaths from maternal causes are among the five leading causes of death for women aged 15-44; in one-third of these countries they come first or second.
A 1993 World Bank estimate shows that in some African countries, less than 10% of women needing family planning and maternity care services actually receive it. In a survey in rural areas in Bangladesh, maternal mortality was found to be 570 per 100,000 live births, the mortality rate for the youngest group of mothers being as high as 1,770 per 100,000. Maternal mortality accounted for 57% of deaths of women aged 15-19 years in the area and 43% of deaths of women aged 20-29. In Afghanistan, maternal mortality has been estimated to be around 700 per 100,000 live births. Variations within countries are considerable. In Afghanistan, for example, the urban rate was almost half the figure quoted above, and in Malaysia the highest rate for a district was 18 times the lowest rate.
Why is it that a woman dies every minute? The answer is that people don't care. We assume that women are there. We have never taken enough concern about the rights of women. (World Bank President James Wolfensohn).
Patriarchal cultural values that deny women adequate nutrition, education and health care translate directly into maternal death. Pregnant women in Benin would rather suffer days of obstructed labour than ask for help during childbirth and risk being seen as weak. In parts of Ghana, troubled labour is seen as a sign of infidelity, so women stall in calling for emergency care while they try to appease the gods to help with their delivery. In southern Papua New Guinea, women are expected to give birth by themselves, a tradition stemming from a belief that female blood is contaminated and could sicken or even kill a birth attendant.
It is no exaggeration to say that the issue of maternal mortality and morbidity, fast in its conspiracy of silence, is in scale and severity the most neglected tragedy of our times. These are not deaths like other deaths. They die, these hundreds of thousands of women whose lives come to an end in their teens and twenties and thirties, in ways that set them apart from the normal run of human experience. Over 200,000 die of haemorrhaging, violently pumping blood onto the floor of bus or bullock cart or blood-soaked stretcher as their families and friends search in vain for help. About 75,000 more die from attempting to abort their pregnancy themselves. Some will take drugs or submit to violent massage. Alone or assisted, many choose to insert a sharp object – a straightened coat-hanger, a knitting-needle, or a sharpened stick – through the vagina into the uterus. Some 50,000 women and girls attempt such procedures every day. Most survive, though often with crippling discomfort, pelvic inflammatory disease and a continuing foul discharge. And some do not survive: with punctured uterus and infected wound, they die in pain and alone, bleeding and frightened and ashamed. Perhaps 75,000 more die with brain and kidney damage in the convulsions of eclampsia, a dangerous condition that can arise in late pregnancy and has been described by a survivor as "the worst feeling in the world that can possibly be imagined." Another 100,000 die of sepsis, the bloodstream poisoned by a rising infection from an unhealed uterus or from retained pieces of placenta, bringing fever and hallucinations and appalling pain. Smaller but still significant numbers die of an anaemia so severe that the muscles of the heart fail. And as many as 40,000 a year die of obstructed labour – days of futile contractions repeatedly grinding down the skull of an already asphyxiated baby onto the soft tissues of a pelvis that is just too small. In the 1990s so far, three million young women have died in one or more of these ways. And they continue to die at the rate of 1,600 every day, yesterday and today and tomorrow. For the most part, these are the deaths not of the ill or of the very old or of the very young, but of healthy women in the prime of their lives upon whom both young and old may depend (United Nations Children's Fund (UNICEF).