If Jeannette Mukamparirwa had become pregnant a few years ago, she would probably be dead now.
Pregnancy and childbirth is a high-risk business in sub-Saharan Africa. Estimates of the number of women who die worldwide while pregnant or in labour every year range from 350 000 to over 500 000. The majority of these deaths occur in developing countries.
A third of these deaths are in Southern Asia, but half are in sub-Saharan Africa, where the chances of a woman dying as a result of pregnancy or giving birth is one in 22. But in Rwanda, where Mukamparirwa lives, gradually things are changing.
Her baby is sleeping in the peaceful darkness of the parents’ bedroom, in an elaborately-decorated cot that testifies to how glad they are to have her. At only two weeks old, she has no official name yet, but is known as Teta, which means “the spoiled one”. Her mother won’t wake her, but smiles and smiles. She knows she is lucky they are both alive.
Mukamparirwa (25) became pregnant not long after her marriage to Theogene in July 2009. She says the signs of trouble to come appeared in the first three months — she experienced bleeding as well as the vomiting and lack of appetite that are not uncommon in early pregnancy. Morning sickness eventually disappeared, but at five months, the bleeding started again.
Mukamparirwa had a complication of pregnancy, placenta previa, which would have been of serious concern even if she had been living in Europe or the United States, where obstetricians abound and maternity units are brimming with high-tech scanning and monitoring equipment. In sub-Saharan Africa, it is often a death sentence. The placenta had implanted across the mouth of the uterus, blocking the way for the baby’s descent down the birth canal.
Mukamparirwa was lucky enough to live close to Rwamagana hospital and health centre in the east of the country, where she also works. The hospital is an expanding regional centre serving more than 265 000 people, with 11 doctors. Five years ago it had four — although it has no specialist obstetrician. Mukamparirwa was told to go to the capital, Kigali, for an ultrasound scan to confirm what the local doctor suspected. Then she was advised to stay at home and rest.
She was told that she would need to give birth by caesarean section. In much of rural Africa, women have to travel long distances to reach hospital-based doctors who can carry out the operation. Usually it is an emergency, because problems such as placenta previa are not been diagnosed or could not have been anticipated. Obstructed labour can cause the uterus to rupture and lead to haemorrhage and sepsis (blood poisoning) — the leading causes of childbirth deaths.
When Mukamparirwa went into labour, her doctor was not around, she says. In Rwamagana, that was not the disaster it could have been elsewhere — another doctor was found to operate instead. Today, both mother and baby are doing well.
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Rwanda, which has been working closely with the UN Population Fund (UNFPA), is working hard on reducing its maternal death rates. Between 2000 and 2005, the indicator fell from 1 071 to 750 per 100 000. UNFPA has encouraged auditing, so that the ministry of health and local hospitals and health clinics know how many women are dying, where and why.
Rwanda is piloting the use of SMSes. Community health workers have been given cellphones and trained to send in details of women who are pregnant, including their state of health and likely date of delivery. Getting a woman to hospital in a hurry in an emergency is key to saving her life and that of her baby. The health workers call ambulances, again provided by UNFPA, when labour begins. Last year, almost all women went for at least one ante-natal check-up and 63% of deliveries were attended by a skilled health worker.
Rwanda is doing well, but there is so much further to go in most of sub-Saharan Africa. MDG5, to reduce maternal mortality deaths by three-quarters and achieve universal access to reproductive healthcare, is proving harder to reach than most of the goals, not least because there are no quick fixes. Entire health systems need to improve.
The first step is prevention of unwanted pregnancy — which sometimes leads to deaths as a result of backstreet abortion in countries that have no legal provision for termination. But only 17% of married women in sub-Saharan Africa use a modern contraceptive, according to UNFPA. More than half of all pregnancies in Southern Africa are unintended. Early pregnancies, between the age of 15 and 19, which can be more dangerous, are common.
All pregnant women should go for four antenatal check-ups, says the World Health Organisation, where trained midwives will hopefully spot most of those with potential complications, such as high blood pressure, anaemia or a baby too big for the size of the woman’s pelvis. But more than half of all pregnant women do not make four visits. All women should deliver their child in a health facility, where staff have skills and equipment to help in an emergency — but in sub-Saharan Africa more than half of all births take place at home, unattended or with only an untrained traditional birth attendant, who does not have even basic drugs to stop a haemorrhage. By the time transport has been begged or borrowed to get the woman to hospital, it is too late. – guardian.co.uk