Childbirth crisis: From the cradle to the grave

Each year in South Asia, 188,000 women die needlessly during pregnancy and childbirth. But as these powerful stories reveal, if the problem seems obvious, the solution is far from simple. Words by Andrew Buncombe. Photographs by Anita Khemka
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The Independent Online

In one sense we do not need these remarkable pictures. The sheer numbers alone almost tell the story. Every year in South Asia an estimated 188,000 women die from complications during pregnancy and childbirth. That something so natural, something so basic, should carry such a lethal risk ought to shock and upset.

Perhaps the reason why Westerners accept or tolerate such numbers is because they do not, usually, relate to us. While every minute of every day a woman dies needlessly during pregnancy or childbirth, 99 per cent of these 536,000 deaths each year happen in the developing world.

Experts say the deadliest place to give birth is sub-Saharan Africa. Niger, where one woman in seven dies during childbirth, may be the single most risky location.

But parts of South Asia are not far behind. Afghanistan, whose people have long been the victims of hunger, poverty, extremism, war and an absence of the most basic facilities, is almost as deadly as anywhere in world. Any pregnant woman there faces a one-in-eight chance of dying as a result either of complications during pregnancy or else while trying to deliver their child.

India's latest unwanted honour as a footnote in the history books is again based on pure numbers. In this vast, mesmerising country, where so many recent headlines have focused on the remarkable economic growth that has helped create a small but newly consumerist middle-class and a tiny, wealthy élite, more women die during childbirth than anywhere else on the planet – around 117,000 every year.

While poverty is a huge factor behind these numbers, so are social attitudes. Campaigners and health officials point out that women are treated as second-class citizens within many areas of Indian society. As a result they often receive less food and less education and are valued less in a myriad of ways, great and small. The separate, but connected, issue of female foeticide – the selective abortion of foetuses known to be females – remains a huge issue in many parts of the country.

And yet progress is being made, even if it appears painfully slow. Between 1990 and 2005, the maternal mortality rate (MMR) in India fell by 1.6 per cent. This was not as good as the fall in East Asia (4.2 per cent) or South East Asia (2.4 per cent) but it was better than the global average of just 0.4 per cent.

"There is a lot of work that has already been done in India. Now we need to accelerate this," says Dr Marzio Babille, Unicef's Chief of Health in India. He says a crucial policy shift was to encourage women to give birth in facilities and clinics where expert help is available if things begin to go wrong during the birth. He says figures suggest that 15 per cent of all pregnancies will require special care and five per cent will need Caesarean section. The challenge in India, he says, is to ensure modern skills and standards are available – particularly in rural India where access to education and healthcare is so often non-existent.

This month, experts met in London for the Women Deliver conference. They were told that the challenge of meeting the UN's Millennium Development Goal 5 – that of reducing the MMR by 75 per cent of its 1990 level by 2015 – is unlikely to be met. These photographs go some way to explaining why.

Tales from the frontline

Mandy Cunningham reports from the Qatar Hospital, Karachi

It's just past midnight in the labour ward of Qatar Hospital in the port city of Karachi in southern Pakistan. The hospital serves the people of Orangi District, a sprawling urban slum of three-and-a-half million people.

Six young women in different stages of labour share the four beds in the ward. They sit, they stand and they squat, changing positions often in an effort to find momentary relief from the pain. Two women lie end to end in one bed. Its mattress is covered by a soiled sheet; a piece of plastic covers the middle section of the bed.

Between cries of pain, a woman vomits into a bowl on the floor. At the end of the bed next to hers stands a stained bin containing the bloody waste from previous deliveries.

The women are attached to IV drips which trail behind them if they attempt to walk.

These women are too far into labour to be given painkillers. Their cries can be heard by family members waiting outside. Occasionally a concerned sister or mother-in-law risks a stern ticking-off from staff by attempting to enter the ward to comfort her distraught relative.

In the centre of events lies a silent woman. She should have delivered her baby by now but her labour has apparently stopped. She's not connected to any monitors but the doctors know that her baby is in distress. She needs a Caesarean section but there is no blood available. The doctors start making phone calls. It is their job to contact the blood bank, and even to go and collect the blood themselves. The anaesthetist is also not in the hospital. He says he'll come when blood arrives. For the time being, all that the doctors can do is wait.

Lying on the scales at the side of the room is a baby delivered a few minutes earlier. Traces of blood remain on the tray of the scales, possibly left from a stillborn baby delivered earlier in the day. The unfortunate infant's partially covered body lay for some time on the scales before being disposed of.

One young woman emerges from the connecting delivery room; she's had to give up her bed to someone whose labour has overtaken hers. She struggles back into the labour ward, using the bedsteads to steady herself. Her eyes appeal for help but she doesn't make a sound.

The women are fully dressed. The salwar kameez, the traditional clothing worn by Pakistani women, is extremely practical. When the doctors want to examine a woman she simply drops the salwar, or trousers. She keeps her long shirt on. The dupatta, or shawl, usually worn to cover the chest, now acts as a makeshift sheet but few give much thought to modesty in here. Each woman just wants her ordeal to be over.

Two women, one young and one old, sneak inside the door of the labour ward. They crane their necks to try to see the new baby. They're not counting the fingers and toes. They want to know one thing: is it a boy or a girl? It's a girl. They leave without comment. There are no smiles, no words of congratulation for the resting mother.

Sometimes it's hard to keep in mind that among government hospitals in Pakistan this is about as good as it gets. The doctors are well-trained, the hospital is open 24 hours a day and drugs are available. All the women in this ward tonight deliver live babies.

But in a neighbouring ward others are less fortunate. One young woman lies in the corner, painfully thin and looking years older than her actual age. According to her sister she's given birth to 11 babies but none has survived. Another woman, Hameeda (pictured on previous page), has recently given birth to a stillborn baby. It was her eighth pregnancy; only four of her children have survived.

Hameeda's story is not uncommon. She believed she was in the eighth month of pregnancy so when pains began she thought it was too soon for her baby to be born. The local dai, a traditional birth attendant, told her that her labour had started and since she was bleeding heavily she should leave for the hospital immediately. But Hameeda's family is poor, they don't have a car and for a couple of hours they couldn't find a vehicle to take her.

When she finally arrived at the hospital, with only her mother-in-law and a young stepson, there was no one to sign a consent form for an emergency Caesarean section and no one to give blood for her. According to the doctors, she refused to call her husband to ask him to come to the hospital; a doctor took the number and made the call herself. The operation finally took place.

As she lay in her bed less than 24 hours later, Hameeda had pains in her back, legs and stomach. The bag of blood attached to her arm was empty and she was desperately worried about how her family would pay the hospital bill which she thought might amount to around £60.

What she didn't understand was that she was lucky just to be alive. It turned out that she was severely anaemic, her blood count was way below normal, her blood pressure was low and she was diagnosed with hepatitis C. She could easily have become one of the four women who are estimated to die every night in Karachi due to complications in pregnancy. The doctors call hers a "near miss" – a woman they are able to save, but only just.

For further information about Unicef's work, see