Does Birth Have to Lead to Death?

We visited the young pregnant woman as she was going into labor. She was pacing outside her home, a small mud hut surrounded by rows of corn, a pig, mangy dogs, and dirt roads. Pretty and petite, she tried to smile through obvious pain. She barely looked old enough to be pregnant, but this was not her first child. One of our field workers, a traditional birth attendant, was explaining in Spanish what would happen next. The expectant mother would not be brought to a hospital or seen by a doctor. She would deliver the baby on a dirt floor, and hope for the best.

I was part of a public health research team in the rural Guatemalan highlands, but we were not there to deliver babies. We were collecting data on indoor air pollution, a major contributor to morbidity and mortality in developing countries. But as we hiked through the steep mountains, populated by poor, indigenous Mayan farmers, it was impossible not to see other causes of illness and death: malnutrition, lack of clean water, and risky births. When two of our researchers, an OB/GYN and a nurse practitioner, saw the young mother-to-be, they decided to stay and help. They had little in the way of supplies—headlamps, alcohol hand wipes, a fortuitous pair of latex gloves—but their expertise could be crucial. Miles of unpaved, bumpy roads separated us from a medical center, and a serious complication could prove fatal.

Even though I was aware of the many challenges facing poor women in rural communities, it was still shocking to see the reality that lay before us. My mind immediately jumped to the cleanliness: Isn’t the floor dirty? What about infections? Are there any clean towels around? Hot water? This cannot be clean—she is standing next to a pig! In my alarm, I had not stopped to register that this is how the majority of the world’s women give birth—at home, either alone or with an untrained birth attendant.

Of the approximately half million women that die in childbirth every year, it is not surprising that ninety-nine percent of them are in developing countries. Death due to obstetrical hemorrhage (severe bleeding), infection, and obstructed labor is relatively uncommon in countries like the United States, where most women give birth in well-staffed and well-supplied hospitals. A trained midwife usually oversees home births, and access to emergency care and medicine is rarely more than an ambulance ride away.

Although solutions to birthing complications often have a straightforward, medical answer, poverty and gender inequality pose significant roadblocks for women in low-resource settings. Suellen Miller, PhD, CNM, director of the Safe Motherhood Program at the Women’s Global Health Imperative, notes four main obstacles.