Christmas reminds us that the vocation of motherhood is a high one indeed. How is it, then, that more than half a million mothers every year die giving birth in the third world for want of simple medical care that has been available to first world women for over a century? And why is it so difficult for an organization dedicated to helping them, to raise funds for hospitals, training and research that would make a real difference to these mothers and their families?
Dr Robert Walley, founder and executive director of MaterCare International, talks about the human suffering behind the scandalous statistics and how simple it really should be to make pregnancy and childbirth safe for all women.
MercatorNet: We in our comfortable Western homes hear very little about mothers dying as a result of pregnancy or childbirth. Just how big is this problem? How does it compare, for example, to AIDS?
Dr Walley: Mothers in the developing world are experiencing unimaginable suffering due to a scandalous lack of effective care during pregnancy and childbirth, with the consequence that many thousands are dying. The World Health Organisation estimates that there are over 500,000 maternal deaths annually, of which 99 per cent occur in developing countries. There is no accurate data to substantiate these numbers, the reason being that most developing countries do not report information on births, deaths, the sex of dead people or the cause of death. However, figures from my own experience at a mission hospital in Nigeria, where the in-hospital maternal mortality ratio was 1,700 per 100,000 live births, illustrates the enormity of the situation.
Some 200 million women are pregnant, world-wide, each year. Most mothers deliver in villages without access to safe, clean facilities and without a trained person to assist them. Most maternal deaths occur during the last trimester and in the first week following delivery. Practising in Canada prior to going to Nigeria in 1981 and since then, I have never had a mother die under my care from a direct obstetrical cause, or been present at such a death. Maternal deaths in Canada are at the level of what is called irreducible minimums, 1/100,000 live births.
However, at the mission hospital maternal deaths were almost a daily event. I recall one weekend during which there were four deaths of mothers who had arrived at the hospital, two in extremis from haemorrhage, one in agony from obstructed labour, and another with a ruptured uterus after days in labour because she was young and consequently her pelvis was too small. Others would arrive unconscious due to pregnancy-induced hypertension, or suffering from malaria or severe anaemia resulting from malnutrition. Most mothers die in Africa alone and in terror in villages, as they have no way of getting to the hospital. These deaths of mothers and babies are the greatest tragedies of our times especially since they are readily preventable and treatable.
The disparity in maternal mortality and morbidity rates, between developed and developing countries, is greater than any other commonly used measure of health status. Pregnancy related deaths are one of the major causes of death and disability occurring among women in the reproductive age group. This loss is twice that of any other diseases including AIDS, malaria, TB or sexually transmitted diseases. There is no single cause for male mortality in this age group that comes close to the magnitude of maternal mortality and morbidity. The tragedy is that the solutions to this suffering have been known for decades and cost very little.
MercatorNet: Not all complications result in death, of course.
Dr Walley: Sadly, deaths represent only the tip of the iceberg of maternal suffering. It is estimated that for every death, 30 more mothers suffer long-term damage to their health — from obstetric fistulae, for example, which happens to young mothers as a consequence of neglected obstructed labour (lack of Caesarean section) and also from cultural practices such as Gisiri cuts and female circumcision. As a result of damage to the bladder and rectum they become incontinent of urine and/or faeces. Consequently, they are complete outcasts and are treated as worse than lepers by husbands/partners, families and societies, simply because they are wet, filthy and offensive. They suffer pain, humiliation and lifelong debility if not treated. World-wide perhaps two million of these poor, young and forgotten mothers are living with the problem — mostly in Africa. Reliable hospital data in Ghana puts the incidence of obstetric fistula as two per cent of all births.
Obstetric fistulae can be treated surgically but at present there are insufficient trained doctors, nurses or specialised hospitals. We are all too familiar with the violence caused to women by commission — by sexual assault, genital mutilation and torture — but this neglect of mothers is violence by omission.
MercatorNet: The effect of maternal death or serious disability on families must be drastic. In fact, there must be a serious social impact as well.
Dr Walley: The death of mothers has a domino effect as it frequently leads to the deaths of their newborns and the chances of survival of their children under five decreases dramatically resulting in the disintegration of her family, which in turn has a disastrous effect on her extended family and village.
In my experience mothers in Africa are optimistic and want to have babies as they know they are the future of their families, communities and countries. Mothers in developing countries do not expect to die or to suffer birth injuries and those who die obviously have no voice, only ours, to plead their case for adequate care, care of the sort mothers have access to in the rich world of North America, Australia or Europe, which is second to none, but is frequently taken for granted.
MercatorNet: It is 21 years since the Safe Motherhood Initiative was launched in Nairobi to address this problem, and 8 years since it was made one the UN's Millennium goals, and yet the director general of the WHO said recently that "the world failed to make a dent" in it. What is your analysis of this failure?
Dr Walley: A report in the British Medical Journal in July 2007 said that at the present rate of progress the 5th Millennium Development Goal will not be met for 275 years — in 2282, not in 2015 as intended. The reasons are poverty, lack of compassion, lack of political and professional wills, a conspiracy of silence, and a lack of imagination. That any woman should die giving birth in the 21st century is an international disgrace.
The responsibility in my view lies partly with national governments but also very much with Western governments, the UN and other international agencies e.g. those of the European Union, DFID (UK), CIDA (Canada) and USAID and, of course, the radical feminist movement, which cares little for motherhood. These are compromised by their desire to control populations in developing countries. While billions of dollars have been and are being spent on reproductive health programmes (a euphemism for birth control) only a small fraction is focused on providing emergency obstetric services that ensures that women survive their pregnancies — services which are freely available to all mothers in rich countries.
We have known the causes of maternal deaths for over 100 years — haemorrhage, infection, hypertension, obstructed labour, septic abortion — and we eliminated them in the our rich world by providing essential obstetrical care to mothers one at a time. The former Director General of WHO, Dr. Halfdan Mahler, commented in Nairobi in 1987, “We know enough to act now, it could be done; it ought to be done; and in the name of social justice and human solidarity, it must be done.” It hasn’t been.
MercatorNet: What we do hear a lot about is "unsafe (illegal) abortion", along with some alarming statistics. Is this a major cause of maternal deaths and ill health? What's the real answer to this problem?
Dr Walley: Abortion unfortunately has been around forever. In our times it has been promoted as choice, as a right; we are all familiar with the arguments which has brought us to the devastating numbers found in developed countries. Septic abortion is said to account for 8 per cent of maternal deaths in developing countries but, again, nobody knows as statistics are not kept. Nevertheless, abortion is a sad fact of life resulting from poverty, lack of education, coercion and a lack of alternative help. In panic the woman goes to the open door of the abortionist who may be a traditional birth attendant in the village, but is frequently is a health provider who has limited skills and equipment, who procures the abortion for money. However, the numbers are exaggerated to promote an agenda which is to have abortion legalized as a human right.
MercatorNet: Aren't we confronting in this whole area of Third World motherhood a certain racism and First World prejudice against the cultures and values of the poorer regions, rather than a desire to make them healthy and strong? Are there, in fact, aspects of these cultures that make it more difficult to look after mothers?
Dr Walley: I think there is prejudice against the cultures and values of third world countries. There is a determination to impose the values of the first world but this is causing a fierce opposite reaction. The people I meet in west and east Africa see how we have killed our babies, destroyed marriage and the traditional family with the result that they see we have no future. They are resisting this imposition but are being coerced — they must accept abortion and birth control if they want development aid. It is the new imperialism imposed by rich nations and the United Nations and their agencies.
MercatorNet: When and how did MaterCare come into existence? What is its mission and way of operating?
Dr Walley: Motherhood has special significance for everyone but especially for Catholic obstetricians and midwives, who are privileged to serve the co-creators of new life. As a result of the situation I have described, it became clear that there was a need for an alternative professional organization to provide mothers and their babies with the best of care but whose ethics were based on the teaching of the Church and also a need for a structure which could support obstetricians and gynaecologists in training and in practice.
We had discussions about this in church circles from the early 1980s, but the real impetus to the establishment of an organisation to do something came with Pope John Paul’s encyclical, Evangelium Vitae (the Gospel of Life). In it John Paul issued an urgent appeal to all, in particular health care personnel, to do something extra for life. This challenge resulted in the establishment of MaterCare International (MCI) Canada in 1995, followed by registration as a charity in the province of Newfoundland, Canada in 1997. An international and national office was established in St. John’s, Newfoundland. Other national organisations were established in Ireland, the UK (the EU), Poland, Australia and the United States.
MaterCare’s mission is to improve the lives and health of mothers and babies, both born and unborn, through new initiatives in essential obstetrical services, training of health care professionals at all levels, research, and advocacy designed to reduce the levels of abortion world-wide and maternal and perinatal mortality, morbidity in developing countries.
An international board sets policy and agrees on projects, and each national group finds consultants to carry out projects and raises funds. We have no central bureaucracy or expensive buildings but only a small core agency linked to national groups through modern communications technology; the board meets quarterly by teleconference. We have a website and information resources for the general public, and want to develop web-based resources for professionals.
MercatorNet: Can you really offer hope to third world women and make a dent in the shameful statistics? Please give us some examples of your work.
Dr Walley: In 1998 we began a maternal health project in Ghana designed to improve the survival of mothers in rural areas and reduce the incidence of fistulae. We do this by training traditional birth attendants (TBAs), who are responsible for 70 per cent of all deliveries, to recognise and refer high risk mothers using a pictorial antenatal card; by improving the care given to mothers in rural maternity centres by nurse/midwives using a labour partograph; by introducing a safe and efficient means of transporting mothers with obstetrical emergencies to the district hospital; and by providing a maternal blood transfusion service. We believe that this model can be used in any developing country. We have also funded and built a fistula hospital in Ghana, near the capital, Accra.
We have a research programme evaluating the use of a drug to provide a simple, effective, safe and inexpensive means of preventing or treating post-partum haemorrhage, and that traditional birth attendants could use where necessary. This research could be a major breakthrough in preventing maternal deaths and it has received five peer reviewed awards for excellence.
Our advocacy programme includes professional conferences presentations to the UN, the European Parliament and several national governments, as well as numerous public lectures.
MercatorNet: Have you received encouragement from bodies like WHO and professional groups? Where do you get your funding and other support?
Dr Walley: No, we do not receive encouragement or funding from WHO or any other government development agency. The reason is that we do not provide reproductive health — abortion and birth control.
Most of our funding comes from Catholic organizations, but most of all from individual donors large and small who are most generous. MaterCare International responds to invitations for help from dioceses, bishops’ conferences or colleagues. We receive at least two requests per month. Our projects to provide essential obstetrics in rural areas of Sierra Leone and Kenya have been turned down by all government agencies.
We need financial help to make a difference to poor mothers’ lives and health.
MercatorNet: What is your take-home message for those organisations and individuals who want to make motherhood safe for all women?
Dr Walley: As we begin the 21st century, millions of mothers throughout the developing world are dying from childbirth complications frequent during the middle ages. In the developed world millions of unborn children are being destroyed by the medical profession with surgical procedures which were common in the dark ages of human ignorance. Obstetricians and midwives share a unique and privileged vocation in the service of life. We all need to work together to provide poor mothers with the best of obstetrical and midwifery care which is committed to the dignity of motherhood, the right to life, medical excellence, love and hope.
Robert Walley is the founder and executive director of MaterCare International and an emeritus Professor of Obstetrics and Gynaecology at Memorial University of Newfoundland, Canada.