In Developing World, Most Dangerous Day of Life Is Birth

World Health Organization Director General Margaret Chan
World Health Organization Director General Margaret Chan  said, “We should judge the progress in humanity and the progress of any society or country by the way they treat their women and children. They have been lagging behind in the last 20 to 30 years of development. We should give them special attention.” Photographer: Alain Grosclaude/AFP via Getty Images

The woman hung up her phone and delivered a baby into her yellow and orange skirt so quietly it almost escaped the nurses’ notice.

A muffled squawk from under her capulana, a piece of cloth traditionally worn sarong-style, signaled the arrival of the 5-pound boy last month in a flood-damaged hospital of rural Mozambique. The nurses casually lined up balls of cotton wool on a steel dish and drew up a shot of the hormone oxytocin for the mother before noticing the newborn wasn’t breathing.

He required a nail-biting 10 minutes of resuscitation to survive. In the next bed lay a woman who hemorrhaged after delivering a stillborn. Already one baby had died that day at the maternity ward in Chokwe, southern Mozambique.

Birth remains a stubbornly deadly affair in the former Portuguese colony and 74 other developing nations, eroding their human capital and keeping billions of people entrapped in a cycle of poverty that a new United Nations-backed plan says can be reversed with spending just over $1 a person more on health.

“We should judge the progress in humanity and the progress of any society or country by the way they treat their women and children,” Margaret Chan, the director general of the World Health Organization, said in an interview. “They have been lagging behind in the last 20 to 30 years of development. We should give them special attention.”

Girls and women are a pillar of population health, according to the Geneva-based WHO. Females undernourished during infancy, adolescence and especially pregnancy are more likely to deliver babies which are preterm or small at birth. Low-birthweight babies, in turn, are at higher risk later in life of type-2 diabetes, heart attack and other chronic diseases that kill breadwinners and are expensive to treat.

Haunting Legacy

“If we don’t take care of all these issues, it’s going to come back to haunt us,” Chan said. “Many countries’ health system will go into insolvency.”

Last year, 289,000 women died giving life and about 1 million newborns didn’t survive their first day amid a dearth of high-quality, skilled maternity care. Their plight is gaining attention with only 500 days to go before the world is scheduled to meet the eight Millennium Development Goals for improving the health and wellbeing of the world’s most vulnerable people. The targets least likely to be met include a two-thirds reduction in child mortality from 1990 levels and a 75 percent drop in the rate women die from childbirth.

‘Most Dangerous Day’

“The day of birth is the most dangerous day of your life,” said Joy Lawn, director of the Centre for Maternal, Adolescent, Reproductive & Child Health at the London School of Hygiene & Tropical Medicine. “Most of these deaths are preventable with simple approaches, but a sense of urgency is key.”

The delivery at the hospital in Chokwe last month caught by surprise the two nurses who were busy explaining the hemorrhage patient’s hospitalization. That woman almost bled to death after delivering an 8-pound boy, born dead in a village clinic about 50 kilometers away.

The woman in the bed beside her by the window had only minutes earlier ended a call on her mobile phone. Her cervix was less than 2 inches dilated when it was checked less than 20 minutes earlier, a nurse said later.

“Parto!” (or “delivery!”) one of the nurses yelled in Portuguese after a gushing sound and a brief wail signaled the birth. The mother had dropped her bent knees and laid motionless on her back. When the nurses extricated the baby from his mother’s capulana after having spent crucial minutes preparing a kidney dish with cotton and the oxytocin shot, it was obvious he wasn’t breathing.

Nearly Died

He was taken to the delivery room and laid on his back on a table draped with a green surgical sheet. One nurse ventilated him with a squeezable bottle attached to a facemask covering his nose and mouth, while another connected a fine nasal tube to a suction machine to vacuum fluid from his airway. Finally, 15 minutes after birth, the newborn started breathing.

Two baby deaths were recorded that day, including the stillbirth. The other occurred in the hospital as a consequence of its mother’s pregnancy-induced hypertension.

For every 1,000 babies born alive in Mozambique, 21 are dead within a week, according to a study published in The Lancet medical journal in May. That’s 50 percent more than the global neonatal mortality ratio of 14 deaths per 1,000 live births.

Investing an additional $1.15 a person in high-burden countries like this one on the eastern edge of southern Africa would save 3 million women, stillbirths and newborns by 2025, according to the Every Newborn Action Plan, a roadmap for faster progress on maternal and child health.

Triple Return

“Care at birth is one of the best buys in global health, with a triple return on investment: saving women, stillbirths and newborns,” said Lawn, a co-author of the 58-page document.

Lawn has a personal connection with birthing tragedies. Her mother had an obstructed labor while living in rural Uganda and was taken to a remote bush hospital where she had an emergency caesarean section by a medic who had never done the procedure before. Lawn’s mother developed sepsis as a result of the surgery, but lived.

Now a pediatrician and perinatal epidemiologist, Lawn works with governments and partners to integrate, scale up and evaluate newborn care, particularly in Africa.

She presses for such low-cost measures as immediate drying and stimulation of the baby at birth, immediate and exclusive breastfeeding, chlorhexidine umbilical cord care to prevent infection, and skin-to-skin contact between a mother and baby to promote breastfeeding and regulate the baby’s temperature, heart rate, and breathing.

Sunset Delivery

Women in Mozambique have an average of 5.3 babies and a 1-in-41 probability of dying in childbirth. That compares with a 1-in-180 risk globally and a 1-in-2,400 chance in the U.S.

The 27-year-old woman who had just delivered already has four children, the first at age 19, she said. She isn’t being identified because she has HIV. Usually kept confidential, her status was revealed when she and her baby were treated with antiretroviral drugs to prevent mother-to-child transmission.

She began therapy after she was diagnosed during her most recent pregnancy, she said. A quarter of people aged 15 to 49 have the AIDS-causing virus in the southern province of Gaza, where Chokwe is located -- the highest rate in Mozambique. Among women 28 to 37, prevalence is 46 percent.

The mother had come alone to the hospital by public transport from her home, about 10 kilometers away, a few hours before her sunset delivery. Had she given birth hours later, things would have been different.

Scant Resources

Between 7 p.m. and 7 a.m., the Chokwe hospital only has one doctor for emergencies and someone minding the blood bank. There is no obstetrician. The center has one functioning operating room after flooding from the nearby Limpopo River in January 2013 damaged equipment in a second theater. The only ultrasound machine has been broken for two months and there’s no incubator, just a crib, said nurse Ancha Ernesto Acuácua.

In 2012, per-capita health expenditure in Mozambique averaged $37.20, more than double the $14 a person spent a decade earlier, according to WHO data based on average currency exchange rates. The population expanded 30 percent to 25.2 million over the same period.

Most women deliver in wards like the six-bedded room, where plastic shower curtains are trussed along poles above each bed for use in case anyone insists on privacy.

“Some women were fearful of the obstetric bed and all the equipment,” said Inacio Chichango Jr., the doctor in charge of the hospital. “The idea is to make it as similar as possible to how they would deliver in their home.”

Birth Control

The mother who had just delivered hadn’t wanted more children, she said. She blamed falling pregnant on forgetting to take her birth-control pill. Across Mozambique, only 29 percent of women say their demand for family planning is met.

Satisfying that need worldwide could prevent 104,000 maternal deaths a year, a 2012 study funded by the Bill and Melinda Gates Foundation found. It could also lead to a 47 percent reduction in child deaths, according to research published in The Lancet in May.

“The most cost-effective, high-impact intervention for reducing newborn deaths is actually family planning,” said Mariam Claeson, director of maternal, newborn and child health at the Gates Foundation in Seattle.

Baby Season

Mozambique has three doctors for every 100,000 people, about an eighth of the African average of 25 per 100,000. It has 34 nurses and midwives compared with a regional average of 91. At least 230 doctors, midwives and nurses per 100,000 people are needed for basic care, according to the Newborn Action Plan.

Nurses, who typically earn 5,000 meticais to 7,000 meticais ($160-$228) a month, may look after as many as 50 patients in peak delivery season, Acuácua said.

The number of deliveries tends to surge in September and October in Gaza, a key supplier of labor for South Africa’s mines, nine months after migrant miners return home for their annual break in January. Births at the Chokwe hospital peak at about 290 a month, from 240 the rest of the year, according to Acuácua.

Maternity patients are discharged 24 hours after a normal delivery and kept in for as long as 10 days if they have had a caesarean section so their stitches can be removed.

The expediency isn’t ideal because complications such as sepsis typically occur one to two days after delivery, said Flavia Bustreo, the WHO’s assistant director-general for family, women’s and children’s Health.

“There are many times when we need to put mattresses on the floor for the women and the babies, or they share the beds,” Acuácua said. “There are never enough beds.”

---Jason Gale traveled to South Africa and Mozambique on a fellowship with the International Center for Journalists supported by the United Nations Foundation.

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