MATERCARE INTERNATIONAL

House Committee on Foreign Affairs, Subcommittee on Africa and Global Health

March 13^th 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 21^st 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.