Yemeni women are dyingWhat is a mother’s life worth? [Archives:2005/830/Health]
By Nadia al-Sakkaf
Yemen Times Editor-in-Chief
“She had been suffering from labor pain for two days before her husband thought of taking her to the hospital. It took more than two hours to reach the main road, and when she reached the hospital five hours later, both mother and baby were dead.”
This is a common scene in the rural areas of Yemen, where the maternal mortality ratio is 570 maternal deaths for every 100,000 live births and infant mortality is 84 infant deaths for each 1,000 live births.
Dr Jean Chamberlain Froese who is a specialist in obstetrics and gynecology has devoted herself to helping improve Yemeni women's health for the last five years. She describes these facts as depressing; “The fact is that most of these deaths are preventable. But it seems that not enough attention has been given to this issue so far” she says.
Coming from Canada as an assistant professor at McMaster University in Hamiltion, Ontario, her primary focus is international women's health. Chamberlain- Froese decided to do her best in helping Yemeni woman directly through providing medical support in the cities and villages and also through training medical staff, especially midwives in order to achieve sustainable impact in reproductive health.
Dr. Chamberlain-Froese is working for an NGO called International Community Services as a consultant with a focus on women's health education. She spends a day and half every week at Kuwait hospital teaching medical students, in addition to seeing patients at other times.
She has also helps to coordinate Yemeni physicians to receive additional medical training at McMaster University in Canada. She is also involved in a 3-day training course called ALARM (Advances in Labor and Reducing Mortality), an emergency obstetrical course where doctors and midwives are given training in obstetrical complications and treatments.
At the present time, the course is sponsored by Catalyst (a reproductive health project of USAID) in coordination with the Association of Obstetricians and Midwives of Yemen. She has also helped in the Yemeni Family Care Association by coordinating donations from Canada and offering her expertise in research.
The Canadian doctor dropped by The Yemen Times after coming from a field visit to one of the rural areas outside Sana'a where she provides medical treatment for women on regular basis. She has kindly agreed to talk about her work in Yemen.
The facts are astonishing. I landed up with mixed feelings whether to feel hope knowing that so much could easily be done to improve reproductive health in Yemen or feeling frustrated knowing that although it is not that difficult not enough is being done. So I leave it for you to decide, and perhaps see where you can play a role in this issue.
Q: You recently talked about women's health in the Majority World. What does that term mean?
A: Majority World is a term used to describe the developing world where 90% of the world's population now lives. This means that the majority of women live in the developing world and that is where the improvement of women's health should be. There are many challenges facing women's health in Yemen since many of them suffer from poor general health and reproductive system complications.
Q: How severe is the situation regarding reproductive health complications?
A: When the tsunami tragedy hit, there were approximately one quarter of a million death cases. If one had known beforehand that this tragedy would happen, they surely would have rushed along the beach and warned the people to get off the shoreline. Compare this with the than 585,000 mothers who die every year from preventable pregnancy complications.
That's the equivalent of three jumbo jets crashing daily)loaded with pregnant mothers. Why isn't more attention paid toward these women who die from preventable causes? The Tsunami caught worldwide attention but these mothers die silently with very little notice.
In Yemen, women are very vulnerable to reproductive health complications, obviously because of a shortage of medical treatment coupled with lack of awareness. Numbers say that one in nineteen Yemeni women face death during her life from maternity related complications. One important reason that leads to this high rate is that the average woman in Yemen has 6.7 children.
So every single time a mother is pregnant, she has a chance in dying. Compare this to Canada for example, where 1 in 4000 women die from pregnancy complications. It's not that Yemeni women are physically different, but in most cases, the problem is due to a lack of proper medical treatment.
For example, a medicine called Oxytocin (costing approximately 60 Yemeni Riyals) stops bleeding during delivery. It is very cheap and yet can save a woman's life. We know that at least 5 % of all pregnant women need a caesarian section, if the actual number is lower than that it is not because women don't need it, but rather the service is not available. In Canada where I come from the percentage is 20% .
Q: How many mothers are dying in Yemen?
A: According to the UNFPA, the Maternal Mortality Ratio in Yemen is 570 maternal deaths for every 100,000 live births. That means one in 19 Yemeni women will die of pregnancy complications. Compare Yemen's ratio to the ratio in North America which is has one out of 10,000 women dying from pregnancy complications. The ratio in Yemen is not just double, it's hundreds of times more. The fact is that most of these deaths take place during delivery.
A lot of people think that prenatal or antenatal care is the solution to maternity death, but it isn't the most important part of the mother's care. Most women die during delivery or just after delivery. Prenatal care is important but it is not the final answer. You can only identify 33% of pregnant women with complications ahead of time. It means that over 50% of the deaths can't be predicted and will happen during or just after delivery.
There are several cause for deaths during delivery but at least 25% of them die due to bleeding (see chart). A similar percentage die due to infection. Other significant causes include high blood pressure and unsafe abortion.
All of these complications are preventable. Mothers lives can be saved.
Q: How can mothers' lives be saved?
A: There are three reasons or delays which lead to mothers dying. The first is that decision to seek care, the next delay is reaching the facility and the third is receiving the care. I recently heard of two cases of women in Sana'a who were just two kilometers away from the hospital yet they died at home during delivery. The reason is that nobody made the decision to take these women to the hospital. The women herself may not be the one to make this decision. She might not have the money or the transportation tc.
The next delay is reaching the facility especially in the rural areas. There is often a combination of factors where the husband waits until the situation deteriorates and the women is really ill. By the time he organizes a ride, thirty kilometers across the mountains to reach the facility, the mother reaches the hospital either dead or barely alive. And whether this facility is in Yemen or in the best hospital in the world, it's very difficult to save a nearly dead person.
The finally delay is receiving the care at the hospital. Sometimes there are no medications, or there is no doctor or midwife. The person in charge may make a bad decision. That is why part of my purpose here in Yemen is to give modern and up to date training to medical and reproductive health staff in Yemen.
Q: If a mother lives, what are risks after the delivery?
A: A condition called 'fistula' is one of the possible complications of an obstructed delivery especially for young girls. It is common in Ethiopia where because of the baby pushing for a long time against the mother's pelvis, a hole is created in the bladder or in the rectum. One million women worldwide suffer from fistulas caused by pregnancy complications. There are a lot of women here in Yemen who suffer from this and the consequences are tragic. These women are outcasts, unemployable, their husbands leave them and they can't have children again because in most cases their uterus or womb is destroyed. All of this could be prevented if more value was given to a woman's life.
Q: Is it is about value then?
A: Women here in Yemen are like women in most of the developing world. It's about women's social situation and how much are they valued. I can't forget what a Yemeni women told me once in Sa'ada when I was trying to explain to her how to use the medication she said: “Oh don't explain it to me I am a cow, explain it to my husband!”. That's what that woman thinks of herself, that she is a cow. Many women think very low of themselves.
If they don't value themselves, they don't felt they are worthy of help. Women's value in society needs to improve. Husbands need to prioritize their wives' health over other issues (including qat!). Education also plays an important role. Statistics convincingly show that if the level of women's education goes up, then maternal mortality goes down.
Many international agreements include the protection and improvement of women's lives yet many women continue to die from preventable pregnancy complications. This is clearly a violation of these women's human rights which were guaranteed in so many of these agreements.
Q: Is maternal mortality a cause of other problems in the society?
A: When a mother dies, many times she leaves children behind who are more vulnerable to illness and death. So it is not only do women die, but the babies also die. Children under five years of age who have lost their mothers are five times more likely to die than children who have their mothers.
In addition, due to poor care during pregnancy and delivery, many women in Yemen have lost at least one or two babies. I can't get over it when they talk about it as a natural thing. I would have to work a year in Canada to come across a case where a mother has lost two babies.
Q: What about other health indicators?
A: If you look at the statistics around the world, maternal mortality is still the worst health indicator between developed and developing countries. What I mean is that the infant death rate is 5 times higher in developing countries (as compared to developed countries) while the maternal mortality ratio is 17 times higher. It really hasn't changed much during the last few years. Infant mortality has improved because antibiotics are becoming more commonly used and this prevents many children from dying of infection. In contrast, the case is different for saving mothers' lives. Ineffective interventions such as promotion of antenatal care with little provision of labour and delivery care and the training of traditional birth attendant have had little impact on globally reducing the rate of mothers dying.
Q: What about professional health care?
A: I think that this is a basic issue in saving mother's lives. Doctors or skilled midwives or birth attendants are the solution to improving pregnancy care. The greater the access to skilled professionals and adequate health facilities, the fewer the number of mothers who die. This is a basic problem in Yemen. I ask pregnant women where they plan to deliver and their answer is usually “at home”. I ask them: do you have medicines in your house? Do you have oxygen in your house? Do you have a skilled attendant in your house? And the obvious answer is no. I want them to start thinking about it seriously and to realize that they need to deliver in a place with adequate facilities under the care of someone who can treat any complication they may have.
Q: What about other reproductive health problems in Yemen?
A: Female gentile mutilation (FGM) causes significant reproductive health problems. Consequences of FGM range from pregnancy complications eg obstructed labor, recurrent abscesses, infertility, sexual problems and bleeding and death.
In addition to the problem of female gentile mutilation there is the HIV/AIDS. Although accurate numbers are not easily obtained, the disease does exist in Yemen and there are many cases reported especially in the coastal areas. Cervical cancer is also a preventable cause for women's death claiming 200,000 lives per year 80%. Most of these deaths are in developing countries such as Yemen. In developed countries there is a regular screening test, which is not routinely found in Yemen.
Q: With these alarming numbers, isn't anything being done?
A: Yemen is one of the countries that ratified most international conventions that protect human rights, of which is the right to life, and the right to health. There are specific convention for women such as the Convention for the Elimination of All Forms of Discrimination against Women (CEDAW). The goal was to reduce maternal mortality by 75% by year 2015. In Yemen, this is far from happening. There are a number of traditions and policies in Yemen that hinder women's health.
For instance, a women need her husband's approval for any surgery and there is often restriction in access to birth control methods. Early marriage is a good example of a tradition which places a girl's life at risk. She is more likely to experience obstructed labor (and death) because her body hasn't fully developed.
As such, no government opposes safe motherhood, but until there is real action with legal ramifications, little will change. Isn't a man responsible for his wife's un-necessarily death? The government should be responsible to ensure safe motherhood.
There is a lot that could and must be done to help women in Yemen. Financial support must be given to programs related to women's health and this must be made a priority. Advocacy and lobbying for basic human right for mothers are essential. Influential individuals must champion the cause of safe motherhood.
Q: Are there examples of initiatives that should be supported in Yemen?
A: There are several programs and projects that aim at improving maternity health in Yemen, for example the activities of the Association of Obstetricians and Midwives of Yemen. This Association is to be headed by Dr Arwa M. El-Rabee who is deputy minister of health for population and women's health. I think it is important that there is such a governmental department that focuses on women's health and doesn't just brush the topic aside. I think that leaders such as Dr. Arwa can help to give women's health the priority that it needs. The Association is providing training as well as establishing guidelines for safe and proper maternal care. The Association is trying to be a voice for women's health.
It is going to take a long time to change the situation, because it requires an infrastructural change. I mentioned those three delays and I would like to think of them as links in a chain. If one of the links breaks, the woman's life is threatened. The fact is that 15% of pregnant women are bound to have some complications naturally, but the vulnerability increases in countries like Yemen because of the three delays: the decision to seek care, no transportation and inadequate medical treatment. An infrastructural change is required and people have to take a social responsibility to make it happen.
Q: As you are leaving Yemen, after 5 years of giving, is there anything you would want to leave behind?
A: As I leave Yemen, my desire is that the Yemeni people bear their social responsibility. It is not just the government – although it has a vital role. Care is available but so many women do not get to it. Often, somebody in their family did not take the responsibility for taking this woman to the hospital. Also the government in cooperation with health NGOs and health care workers, must continue to help the situation.
There are a lot of professional health workers who don't have a job and there are many places that are in dire need for those workers, but obviously no one works for free. This is the responsibility of the government to support these workers for women's health. In Canada if a mother dies there is a huge inquiry and people come together questioning, why did it happen? In Yemen, nobody outside the family may even know that she died!
Change takes time. The commencement of a women's health department at the ministry of health is a good step, through leadership of Dr. Arwa El Rabee. However, in the big picture, the society needs to take responsibility for mothers' health. The situation can be different. It will require individuals from many disciplines and expertise to creatively develop a more effective health care system for all Yemeni mothers. But each mother and baby are worth saving.