Global maternal health primer

Yesterday, I presented to two groups of high school students about what pregnancy and birth look like in three different countries: the United States, Honduras, and The Gambia. As I have witnessed and attended births in these three areas, my goal was to compare and contrast birth in those countries, with a lens into the global experience. I hoped these conversations would not be too far from their reach of personal understanding, as attendees were an all-woman crowd, despite the age range of 9^th through 12^th grade. As a friend so eloquently put, however, working with adolescents in such a short period of time, with them not knowing me, and with me trying to accomplish something so broad, the task was a difficult one. And thus, a maternal global health primer was my best bet. A few friends have asked to know the content of the presentation, and thus I have tried to outline it for you below.I started the conversation with an easy enough question. Answers? Pain, drugs, “anything can go wrong,” joy, and babies. In no particular order, that list is quite an insight into some general opinions about what birth can look like. I then showed one of Amanda Greavette’s images of a powerful and beautiful birth, and the conversation shifted. (Remember this week's giveaway, check out the post from Saturday!)I explained as best I could the differences between doctors and midwives, focusing on which providers are experts in normal and which are experts in surgical. As I was also focusing on the international sphere, I brought up the history of traditional birth attendants and the work they have done since the late 1970s, despite academics sitting in high towers speaking about their ineffectiveness.I had the goal of showing the universal impact of birth, and its ease as a comparator of the treatment of women in societies, and even further, an insight into broken healthcare systems. I then described women’s birth outcomes as a proxy for other issues.Breezing over “big” topics in international maternity care, we reviewed definitions of healthcare infrastructure, homebirths and birth centers, hemorrhage, obstructed labor, brain drain, and maternal and neonatal mortality. And the conversation shifted again.Worldmapper.org and Gapminder.com provided visuals and live-action statistical changes. The Worldmapper.org map of countries enlarged based on higher rates of maternal deaths puts the global impact into a sized perspective.

Hans Rosling’s "bubbles" on Gapminder.org showed that with lower fertility rates women are living longer, and how that has changed over the years.

And then to the real heart of the issues: how are pregnant women dying? The crux of statistics continue to be drawn from the 2009 Margaret C. Hogan, et al. article, “Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millenium development Goal #5.” Causes of maternal death center around hemorrhage, obstructed labor, infection, high blood pressure, and unsafe abortion. How many women are currently dying each day, each and every day, in childbirth, from preventable deaths? 800. Every day.I asked for volunteers to offer the safest countries to give birth. Answers? The United States, Sweden, and one girl quoted Ireland, having recently read Nicholas Kristof and Sheryl WuDunn's Half the Sky. Hogan quotes Italy as the most recent safest place of birth, with an impressive top ten below.

Maternal Mortality by Country
MMR Global Rank	Country	MMR 2008
1	Italy	3.9
2	Sweden	4.6
3	Luxembourg	4.8
4	Australia	5.1
5	Austria	5.5
6	Ireland	5.7
7	Israel	5.9
8	Malta	6.3
9	Canada	6.6
10	Spain	6.6
Source: IHME

And the United States? Top 20? Top 30? Nope. Shockingly we rank #39, preceded by Singapore and Lithuania, and followed by Macedonia and Latvia. Five times as many women die in the United States as they do in Italy. And with each group of students, the question was, “Why?”First we reviewed our other topic countries. Honduras sits at #111, with a maternal mortality ratio of 105.3, and with an MMR of 281.3 The Gambia ranks at #131.I then reviewed the main issues in birth in seemingly “developed” nations. I reviewed rates of cesarean delivery, beliefs about normal birth, affordability of and accessibility to contraception, and adolescent birth rates wrapped in issues of sexual health education. In the United States in particular, the issues that I am focusing on lately include the struggles between Midwives and Obstetricians, homebirth, surgical delivery and repetitive surgical delivery, interventions in starting and speeding labor, and higher risk pregnancies due to a declining societal health. [Other US-based midwives may have a different list, but this is my latest thought process.] I discussed the World Health Organizations recommendations of 5-10% surgical deliveries, and where those rates fall for the United States an other countries not in the top 10."Join the transformation" from Childbirth Connection also provided an overview of "big picture" issues:And what of seemingly “developing” nations? The main issues I personally experienced as a provider focused on abuse in maternity wards, reproductive expectations of women in societies with unequal gender role distributions, availability of skilled attendants at births, and understanding and maintenance of sterile technique. [Others also experienced in international maternal work may have a different list, but this is my own.]"Break the Silence:Respectful Maternity Care" from the White Ribbon Alliance showed current issues in international maternal health:And specifics to Honduras and The Gambia? It has been six years since my work in Honduras, so I extrapolated my experience then to what I read from my colleagues who continue to work there: nurses with medical training pinned against experienced lay midwives in the community, limited standard midwifery training, and a healthcare infrastructure with distant referral systems. My work in The Gambia last summer is much more tangible and emotional to me personally: brain drain, intermittent electricity, limited blood donation, high twin and triplet rates, difficult stretching from female genital cutting, and an overall high fertility rate averaging 5 births per woman.I emphasized that for me, now working in the United States, each fight is important. This work, the work toward good healthcare for women, is happening everywhere, each line of work in parallel with the other. Just as women laboring in hospitals in Chicago are doing so in the world where women are contracting in Morazan and where women are birthing in Brikama, these fights happen simultaneously. Each one is important. Birth is a global experience for women.I also discussed that as a midwife, I believe in midwifery care as a model, as an evidence base, and I am passionate about what midwifery care means for women. However, in the world of international maternal health, I am arguing overall for good healthcare for women. I am just lucky that midwives factor largely into that conversation, as frontline care providers in many parts of the world.Pictures from labor rooms in the United States, Honduras, and The Gambia showed examples of spaces where women are, where they labor, where they birth, and where they experience maternity care.Conclusions? I wanted to repeat my initial thought around Ina May’s wise words. (Did I get to this slide in either presentation? Nope. But it was a great group of attendees with lots of questions!). For other midwives who work or have worked internationally, what else would you have included in a global maternal health primer?Please note: I am more than happy to share my slides with anyone who would like them! This information is important to share. Please cite me when using any of the images above.