MATERCARE
INTERNATIONAL
House Committee on Foreign Affairs,
Subcommittee on Africa and Global Health
March 13th 2008
Dr. R. L. Walley, FRCSC, FRCOG,
MPH (Harvard)
Executive Director, Honorary
Research Professor of Obstetrics and Gynaecology
Mothers, in the developing world, are experiencing
“unimaginable suffering” due to scandalous lack of effective care during
pregnancy and childbirth with the consequence that many thousands are
dying. The World Health Organization claims
that there are 600,000 maternal deaths annually of which ninety-nine per cent
occur in developing countries. However, 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
for death. However, figures from my own
experience at a mission hospital in Nigeria where the in-hospital maternal
mortality ratio was 1,700/100,000 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 in which to
deliver and without a trained person to assist them. Most maternal deaths occur during the last
trimester and in the first week following delivery. Prior to going to Nigeria in 1981, I had
never been present or had a mother die under my care
from a direct obstetrical cause.
Maternal deaths in Canada are at the level of what is called irreducible
minimums, 1/100.000 live births. However,
in the mission hospital maternal deaths were almost a daily event and I recall one weekend during
which there were four deaths of mothers
who had arrived at the hospital in extremis from haemorrhage, one in agony from
obstructed labour, and another after days in labour with a ruptured uterus as
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.
Many more mothers die in Africa alone and in terror in the villages as
they have no way of getting to the hospital.
Not only are the lives of these mothers abruptly ended but also the
lives of their babies, and in the aftermath the chances of survival of their
young children decreases dramatically resulting in the disintegration of their
families.
Sadly, these deaths represent only
the tip of the iceberg. It is estimated
that for every death, 30 more suffer long-term damage to their health, e.g.
from obstetric fistulae. These arise in
young mothers, as a consequence of neglected obstructed labour (lack of
Caesarean section) and also from
cultural practices e.g. Gisiri cuts and female circumcision.
The result is because of damage to the bladder and rectum these
mother become incontinent of urine and/or faeces (obstetric fistulae). Consequently, they are complete outcasts and
are treated 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 2 million of these poor,
young and forgotten mothers are living with the problem mostly in Africa.
Reliable hospital data in Ghana gives the incidence of obstetric fistula as 2% of all births. These deaths of mothers and babies are the
greatest tragedies of our times especially since they are readily preventable
and treatable. Obstetric fistulae can be treated surgically but at present
there are insufficient trained doctors, nurses or specialised hospitals.
The problems of maternal health, and
the need for improved health care has been discussed by the international
community for years, most recently as Millennium Development Goal (MDG) No 5 to
improve maternal health by reducing maternal mortality and morbidity. It is admitted by the UN and the
international health community that this goal is the most neglected of all the
MDG’s. A report in the British Medical
Journal in July 2007 commented that at the present rate of progress the MDGs
will not be met for 275 years i.e. 2282 and 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.
The consensus of the obstetrical
community is that mothers need essential prenatal care, skilled attendants at
all deliveries and specialist care for life threatening complications. While
billions of dollars have been spent on reproductive health programmes and as
more is demanded only a small fraction is focused on providing the services
that ensures mothers survive their pregnancies.
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.
Mother 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
cases for adequate care, care of the sort which mothers have access to in the
United States of America and Canada which is second to none, but which is
frequently taken for granted. I have
found that mothers
in Africa are becoming aware of what has been done to unborn babies in the rich
world. They are becoming increasingly angry and resistant at attempts at
coercion by NGOs to make them accept the killing their babies which is totally
contrary to their faith and cultural and beliefs. It is egregious that any government or
international health agency should suggest that the lives and health of African
mothers should be improved
by the killing of their unborn babies. We are all too familiar with the violence
caused to women by commission e.g. by sexual assault, genital mutilation and
torture but this neglect of mothers is violence as the result of omission. The
root cause of all this suffering will not be solved by more death and despair.
MaterCare
International (MCI) was established in 1995 by obstetricians
particular concerned about the tragic state of maternal health in developing
countries. MCI has extensive experience
in West Africa, in particular Nigeria, Ghana, Sierra Leone, Rwanda and Kenya
working with local Churches that provide 30 - 40 % of the beds and with local
colleagues. In addition to providing
much of the healthcare in rural African countries, these faith based hospital while
for many years enjoyed the trust of mothers and their families, MCI’s approach has been to put into practice the old
obstetrical adage that
live healthy mothers produce live healthy babies. As a consequence, MCI has developed a model
of comprehensive, rural, maternal health care based on local causes of
mortality and the circumstances under which they occur. This model is a way of taking essential
obstetrical services found usually only in hospitals closer to the mother. It
provides, at a small 30 bed mission hospital; full prenatal care, with
treatment for common medical conditions e.g. malaria, HIV and severe anaemia,
with immunization against tetanus, and specialist management of life
threatening obstetrical complications with for example caesarean section, blood
transfusion, and manual removal of the placenta; and post-partum care including
family planning through fertility awareness.
The hospital is linked by radio to an emergency transport which can go
to the mother with life threatening complications with the equipment needed to
resuscitate her and then to transfer her to the hospital in a safe and timely
manner. The hospital is linked to rural
clinics, staffed by trained midwives also providing pre and post natal care,
safe delivery and early referral of complications. A training programme for doctors
and midwives in emergency obstetrics and training is provided and traditional birth attendants (TBAs) are taught to identify
and refer mothers at risk to the nearest clinic. It is known that at least 15%
of normal pregnancies and labours may run into complications, so the radio and
transport system is able to meet these emergency needs.
This model
was developed in Nigeria in the early 1990’s and refined in Ghana where it has
been functioning since 1997. Evaluation
has shown an increase in referrals to the hospital of mothers with
complications and thus an inference is that maternal deaths have been reduced.
The cost of running this sort of programme for 5 years we estimate to be $2.5
million, Canadian or US dollars, a mere pittance compared with the cost hospitals
in our
countries. Our funding proposals,
for projects in Sierra Leone, Rwanda and Kenya to government agencies, however
have been turned down.
That any mother in the 21st century
should die having her baby or sustain a birth injury is an international
disgrace. This tragedy will only be
solved one mother and her baby at a time with appropriate obstetrical care to
which she has a fundamental right.