Safe Motherhood. It seems like such a simple request. Around the world women and babies still die during pregnancy and childbirth – despite medical advances that could save many of them.
Five years ago, when I began my journey to fight maternal and neonatal mortality, I thought the problem was simple. Today, I see that the health of mothers is affected by more things than the availability of a skilled birth attendant. Like an onion, layers of cultural, socioeconomic and political problems continue to cause problems for women. While we are finding some solutions, we are not there yet.
Layer One: Family
It may be hard to imagine if you are reading this, but there are places in the world where a woman does not have the right to make decisions about her own health. The decision of whether or not she seeks care during pregnancy or birth may lie with her husband, her father, the family as a whole or even the community at large. The decision is based on the cost of care, the perceived need for care and the value of the woman to the society.
Layer Two: Poverty
Being poor in a developed country disadvantages a mother, but being poor in a developing country leaves many women with no options. If the closest health care is hours away, she may feel herself lucky to attend one antenatal clinic, and may simply accept that if something is not right in labor she will have no way to seek help in a timely manner. This is the risk many women take to achieve motherhood.
Layer Three: Cultural Norms
When accessing health care is expensive, accessing health care is the exception rather than the rule. This leads to cultural norms where normal healthy women give birth at home without assistance or with minimal family or community assistance. For many women in the world, this is a sister, mother or another mother from the community who has no training.
This becomes even more difficult in places where women have very little or no value. For example, if her only value is as a worker in the field she may not have the ability to take a day off to attend a local clinic without being considered lazy. Or if a woman is valued most for her ability to bear children, she may not be considered valuable enough for health care until she has proven herself by successfully giving birth the first time.
So women are caught in a cultural trap where the desire for high quality care is weighed against the belief that seeking even basic antenatal care means something is wrong with her.
Layer Four: Social Status
It seems the wealthy and educated look down on the poor and uneducated throughout the globe. This is so ingrained in cultures that we don’t even see it in our own as people laugh at jokes making fun of “country folks” and insult those who have different political ideas from our own because we cannot see why they might feel differently.
In the birth world, I see this through the poor treatment of mother’s within existing medical systems. Doctors and nurses are always educated. The poor women they work with will almost always have less education than them. In societies where status matters (which is basically all of them) there is a feeling that it is OK to treat poor women differently because the poor women deserve to be treated badly.
- You have to yell at them because otherwise they are so proud they won’t do what you say.
- You cannot be nice to them or they will be weak and not labor well.
- She needs to learn how to be tough because she needs to be a good mother.
- She doesn’t know anything and she won’t do what she is supposed to unless I tell her.
Layer Four: Community Resources
Even if her family desires care for her, if the community has no way to provide that care the woman may still have no options. Rural women living in communities without transport to the closest health post may lack antenatal care only because there is no realistic way to get the mother there and back safely. How should the family manage the upcoming birth – send the mother to an area with care before labor begins (paying for her stay of unknown length), or try to create a system that allows for her to access needed care when labor begins (risking not making it to a health post with emergency care in time if it is needed)?
I still wish safe motherhood for all the women of our world, but I no longer think the solutions to these problems are simple. If the solutions were simple, we would have the problems solved already. The truth is, families face difficult decisions when it comes to motherhood. My goal is to help them have more options.