Making a difference in maternal mortality

It isn't that childbirth is more inherently dangerous in countries where many women die in childbirth than in those where relatively few die. The women who survive, statistically speaking, are getting appropriate help from trained attendants.

"...The main complications that lead to death during pregnancy or childbirth are fairly common among all women, regardless of where they live," write the authors of an article titled "Are We Making Progress in Maternal Mortality?" in the May 26 issue of the New England Journal of Medicine.Pregnant Graffiti

Hemorrhage, which most often occurs right after birth, is the leading cause of pregnancy-related deaths globally, accounting for 35 percent of all deaths in childbirth, according to the World Health Organization. And in fact, hemorrhage was the second most common complication seen in pregnancies in the United States in 2000.

However, most U.S. women who suffered hemorrhage were treated quickly, and survived, say the article's authors, Anne Paxton and Tessa Wardlaw.

WHO identified the second most common cause of maternal death as hypertensive disorders — pre-eclampsia/eclampsia, for example. Again, these disorders are a common problem all over the world, but women with access to good medical care have a good chance of surviving them.

The countries that are most dangerous for pregnant women are those suffering through wars, or burdened with a large population with HIV/AIDS, the authors write.

In general, poor women die in childbirth more often than affluent ones, rural women more often than urban ones. These populations are more vulnerable because they often deliver their babies without the benefit of skilled birth attendants, and lack access to obstetrical services like surgery by Cesarean section.

Sub-Saharan Africa, with widespread political unrest and HIV/AIDS infection, "has the greatest burden of maternal mortality," even though most countries there are seeing "small but promising" decreases in pregnancy-related deaths.

Worldwide, there is considerable cause for hope, Paxton and Wardlaw write. Maternal mortality has decreased globally by more than one-third since 1990, according to United Nations estimates.

"Dramatic improvements in China and other Asian countries...are associated with economic improvement, decreasing fertility rates and strengthening of health systems...," the authors write.

"The overall rate of decline in global maternal mortality, 2.3 percent, is lower than the 5.5 percent MDG target but is heartening nonetheless," they write.

Image: "Pregnant Graffiti" by Petteri Sulonen


Priority medicines for mothers and children

The World Health Organization has published a list of 30 medicines that can make the difference between life and death for mothers and children younger than 5 years of age.

This list of "priority medicines" was developed by the WHO, the United Nations Population Fund and UNICEF. It is the first such list, the sine qua non for mothers and children regardless of where they are , according to an editorial in the Lancet. (This list should not be confused with WHO's Model List of Essential Medicines.)

"An estimated 8.1 million children under the age of five die every year and an estimated 1,000 women — most of them in developing countries — die every day due to complications during pregnancy or childbirth," states the introduction to the list.

The new publication is something of a "wish list," the Lancet notes, in that five of the medicines to protect young children have not yet been developed.

These are the generic treatments on the list that address conditions that threaten the lives of mothers:

* For post-partum hemorrhage — oxytocin and sodium chloride

* For pre-eclampsia and eclampsia — calcium gluconate injection (for treatment of magnesium toxicity), magnesium sulfate

* For puerperal infection —  ampicillin, metronidasole, gentamicin, misoprostol

* For sexually transmitted diseases — azithromycin for chlamydia, cefixime and, for syphillis, benzathine benzylpenicillin

A Midwife’s Tale

Only one American midwife of the Revolutionary War era left a diary that has been recovered, Martha Ballard of Hallowell, Maine. It is a fairly basic document. Some entries are just a few words. Still, between 1785 and 1812, a time of incredible change in New England, Martha tended her diary regularly.

A Midwife's Tale

A Midwife's Tale

In 1990, the historian Laurel Thatcher Ulrich used her own considerable knowledge of the period to connect the dots in Ballard's diary. The result was A Midwife's Tale, which won the Pulitzer Prize and other awards. It is a terrific book, and it was made into a film for PBS's "American Experience."

One of the best things about A Midwife's Tale is the fact that Ulrich has given us a fully fleshed-out picture of Martha Ballard, and has at the same time retained her distinctive voice. Ballard was a religious, hard-working wife and mother who trained her daughters and other young women to assist her, understood the medicinal uses of the plants she grew in her kitchen garden, and in her prime delivered two-thirds of the children in Hallowell.

The town had more than one doctor, but in 816 births over the course of 27 years, Martha called a doctor in to help her with a birth just twice. In all those years, Martha saw 19 babies and five mothers die just before, during or just after birth.

While childbirth rested on a community of women when Ballard began her career, one of the tensions of the book comes out of the inroads male doctors were already making into midwifery by the time Martha died in 1812.