Health – Childbirth mortality
From South Africa to the US, the numbers of black women dying during pregnancy and childbirth continue to outstrip other groups. Why? And what can we do to help change this?
It was tennis ace Serena Williams’ frightening experience in childbirth that put the question of black women dying in pregnancy on centre court, as it were. Interviewed by Vogue, Serena told of having to self-diagnose a lifethreatening emergency and talk her doctors through saving her, after she gave birth to daughter Alexis last September. Serena had a history of blood clots, and when she began having breathing difficulties, “she told the nearest nurse, between gasps, that she needed a CT scan (a computer image of her chest) and intravenous heparin (a blood thinner) right away”, Vogue reported. The scan showed several clots in her lungs.
“We have a lot of work to do as a nation and I hope my story can inspire a conversation that gets us to close this gap,” Serena wrote on Facebook. “Every mother, regardless of race or background, deserves to have a healthy pregnancy and childbirth.”
Globally, the number of maternal deaths today is low and dropping in most high-income countries – but in the USA numbers have more than doubled since 1987, giving it what the World Health Organisation reports is one of the highest rates of maternal deaths in the developed world.
According to the Centers for Disease Control (CDC), black women in the US are dying at three to four times the rate of white women in pregnancy or from causes related to childbirth – and half those deaths may be preventable. In a study of five medical complications that commonly cause maternal death or injury, black women were nearly three times more likely to die than white women with the same complications.
When it comes to Africa, the picture is even bleaker. Women in sub-Saharan Africa have the highest maternal mortality ratio in the world, accounting for 66% of all deaths. Nearly 550 women die for every 100 000 babies born. This, against a global maternal mortality ratio that has dropped 44% from 1990 to 2015, according to a report by United Nations agencies and the World Bank Group – from 385 to 216 deaths for every 100 000 live births.
In that same 15-year period, South Africa’s maternal mortality rate actually rose – from 150 to 269 for every 100 000 live births. And most of the women dying are black.
WHY WOMEN ARE DYING
The reasons, it seems, are deeply rooted in the inequalities of our society. A 2016 study called Growing Inequities in Maternal Health in South Africa, compared access to maternal health services and health outcomes between 2008 and 2012, and found inequalities between socio-economic groups (and therefore race groups) had grown worse in key areas linked to maternal deaths:
Antenatal clinic attendance dropped from 97% to 90%, especially among the youngest and poorest women with the lowest education levels – “those living in rural and urban informal areas, and black African women”, the researchers said.
Skilled birth attendance stayed around 95%, but inequalities worsened and the gaps between race groups grew: 90% of white and Indian women had a doctor present in 2012, while for black African women, these levels only increased marginally (from 23.5% in 2008 to 28.4% in 2012) Planned pregnancies fell from 44.6% to 34.7%: just 22% of the poorest women had a planned pregnancy in 2012, and among women younger than 20, just 8.7% of pregnancies were planned, while schoolgirls and students accounted for 9.8% of all pregnancies – an increase from 7.7% in 2008.
HIV testing rose, but remained low in groups with high HIV prevalence, such as women in rural areas. The researchers (from the Human Sciences Research Unit, Wits Reproductive Health and HIV Institute (RHI), Evidence Based Solutions in Cape Town, and the Department of Psychiatry and Mental Health at UCT) found that “the wealthiest 10% of the population accounts for more than half the country’s income, and indices of health, and especially of maternal health, clearly reflect the inequalities in access and health outcomes.” They noted that
rise in maternal mortality from the late 1990s linked to the HIV/Aids epidemic had dropped dramatically, especially among pregnant women, maternal deaths from bleeding in pregnancy and childbirth (haemorrhage) had in fact gone up, especially in women having caesarian sections. They put this down to an increase in “deficiencies in the quality of maternal health services” – especially in emergency patient transport, availability of intensive care units, and provision of rapid care for critically ill women in pregnancy and childbirth.
SO WHAT’S THE SOLUTION?
The problem can seem overwhelming, but by pressuring government, by taking responsibility for our own health, and by spreading the word to other women in our circles, we can all help combat the main drivers of maternal mortality. The solution, it seems, lies in:
1. Antenatal clinic attendance: Women need to start this as early as possible (before five months of pregnancy) to pick up on conditions such as hypertension (high blood pressure), anaemia (low blood levels), HIV and complications associated with the abuse of alcohol and other substances which affect the growth of the foetus, and need repeated and careful investigations in pregnancy, says Prof Jack Moodley, chairperson of the National Committee on Confidential Enquiries into Maternal Deaths. Women can also get dietary advice and folic acid supplements vital in the first trimester to prevent spina bifida in their babies, and get ART if they have HIV, to prevent transmitting infection to their babies. “Many women in South Africa drink during pregnancy and the country has the highest rates of foetal alcohol syndrome in the world,” says Matthew Chersich, Associate Professor in the Wits RHI.
“They can get counseling about drinking during pregnancy and support to stop harming their child.” Moodley adds: “Women must plan their pregnancies and ideally visit a doctor experienced in the care of pregnant women to rule out chronic conditions like kidney disease and diabetes, or so these conditions can be controlled before pregnancy.” 2. Access to contraception/family planning: Women need easy, non-judgmental access from an early age to prevent unplanned pregnancies, which they may only discover when already many months pregnant, Moodley says. They not only miss out on the benefits of early antenatal care, but may continue consuming alcohol, using drugs, smoking and doing other things that put them and their growing baby at risk of complications. It’s for these reasons that in the USA, the disproportionately high incidence of maternal deaths among black women has been linked largely to 50% of pregnancies being unplanned, according to the CDC. “During pregnancy women must be informed about future pregnancies and contraception, and be offered immediate post-partum contraception before hospital discharge or six weeks after pregnancy,” Moodley adds. 3. Extended child-support grants: The researchers of the Growing Inequities study recommended that existing child support grants begin during pregnancy, so as to “alleviate the indirect costs of accessing services, such as transport”. They note that grants given during pregnancy have increased the use of services in Latin American and Asian countries, and led to “marked improvements in maternal and health outcomes”.
4. Better access to HIV testing in at-risk groups: Government needs to focus on women with relatively low-testing but high-HIV prevalence, the researchers advise – like older women or those in traditional households, who may not realise they are at risk.
5. Better nutrition: In her study, Social Factors Determining Maternal and Neonatal Mortality in SA, Rose Mmusi-Phetoe notes that “lack of adequate nutrition emerged as a major theme contributing to increased morbidity (illness) and mortality… Although starchy foodstuffs were available, protein-rich foodstuffs were reported as being scarce and unaffordable.” She quotes a woman in her study telling her: “The health professionals advise us that we should eat healthy; they don’t have any idea if we have the food that they tell us to eat… Right now I am pregnant and I can’t feed myself… I am not working… We eat only in the evening when everyone is home, mostly porridge and sour milk or pap and chicken livers or pap and achaar… the food is not good for a pregnant woman.”
6. Better overall health: In the USA, black women have a higher rate of chronic conditions such as obesity, diabetes and hypertension that make having a baby more risky, and the situation is the same here, Moodley continues. The leading direct causes of maternal death are haemorrhage, high blood pressure and embolism, and black women are at higher risk of these than white, notes another USA study. Black women have nearly three-times the risk of death from haemorrhage than white. This has been linked to poor diet, obesity and stress, but “more public health surveillance and prevention research is needed”.
7. Better support by partners: Mmusi-Phetoe reports “neglect and abandonment by male partners” to be the second most important social factor in poor health outcomes for women in pregnancy and childbirth: “Abandonment by a partner, especially when pregnant, was narrated as a deeply degrading and humiliating experience, causing serious ill health.” She quotes a 21-year-old interviewee: “All they want is to sleep with us; when we fall pregnant, they run away. One becomes a lughing stock in the community.” Stress has been linked to one of the most common pregnancy complications: preterm birth. In the USA, black women are 49% more likely than white women to deliver prematurely (March of Dimes Prematurity Campaign 2016 Report Card). The situation is thought to be similar in SA, Moodley explains.
Resilience comes with taking care of yourself – taking time to reflect and build on your experiences, so you can counteract some of the trauma, begin to heal
8. Rejection of abusive partners: All the participants in MmusiPhetoe’s study also reported being either physically, emotionally or financially abused. One 20-year-old interviewee said: “Throughout pregnancy he beat me, forcing me to sleep at his place so that he can have sex with me, when he knew that he didn’t love me. He was just using me.” Mmusi-Phetoe says: “We need to ask why men impregnate women and then disappear. Moreover, why is the apparent absence of responsible fatherhood so easily tolerated by the women? A possible explanation is that in a patriarchal society, women’s sexuality is shaped in service of men’s needs and defined according to male norms.”
9. Better education: This seems the surest way out of the poverty that underlies so much maternal ill-health and death – and out of some of the unequal relationships that underlie abuse. “In addition, schools should begin education about sexuality and reproductive health matters as early as possible,” Moodley says.
10. Safe otherhood goals: The Safe
Motherhood Initiatives are the USA’s vision for achieving social and policy changes to ensure safe motherhood, and would make a difference in SA too, if implemented. They include:
Women and men are equal partners in society
Women and men assume responsibility for making motherhood safe
Women are educated and empowered to make informed decisions for childbirth choices.
Motherhood takes place in a physical environment and social system that promotes well-being for all women
Women receive proper care based on need, and there is no discrimination based on ability to pay, place of residence, culture, religion or ethnic background.
The use of technology and interventions in childbirth is individualised to the health needs of each woman.
(Safe Motherhood USA’, Journal of Obstetric,
Gynaecologic and Neonatal Nursing.)
PLAN YOUR PREGNANCY
To protect yourself and your baby’s health, you need to plan your pregnancy. “The ideal time is between ages 22 and 26 – this is when the fewest complications in pregnancy occur”, says Prof Moodley. “Increase your space between pregnancies to more than two years, and get advice about family size. Appropriate nutrition and moderate exercise for 30 minutes a day lead to healthy, successful pregnancies.”
You need a balanced diet with fruit and vegetables, whole grains, calcium-rich foods and protein, says Durban dietitian Dudu Mthuli. “Kick bad habits and lay down stores, especially of folic acid, which the foetus will need even before you are aware you are pregnant. You must also watch your weight!”
Iron deficiency is common in women of reproductive age because of blood loss from menstruation and poor diet, says Cape Town obstetrician/gynaecologist and fertility specialist Dr Sascha Edelstein. So before conception and during pregnancy, eat iron-rich foods like lean meat, poultry and iron-fortified cereals.
In light of the listeriosis scare, remember to wash fruit and vegetables. Avoid unpasturised milk and soft cheeses, cook meat and eggs well, and heat processed meats until steaming hot to kill any bacteria, says Prof Elna Buys, head of Consumer and Food Sciences at the University of Pretoria. Wash your hands often.
If you struggle to quit alcohol or drugs, speak to your health professional, or contact the SA National Council on Alcoholism and Drug Dependence, 076 535 1701, www. sancanational.info.
To quit smoking, remind yourself it exposes you to about 7 000 chemicals, says Savera Kalideen, executive director of the National Council Against Smoking. Women who smoke produce fewer eggs of poorer quality, and their babies are more at risk of cot death, and of leukaemia and brain tumours. Her advice is to just ring a calendar date and quit on that day. Throw out your cigarettes and ashtrays, wash bedding and curtains to lose the smell. It takes about 10 days for the worst withdrawal symptoms to ease, Kalideen says. Keep reminding yourself of the reasons to quit (pin up a baby picture or scan), and ask for support: call the NCAS helpline, 011 720 3145, visit www.againstsmoking.co.za.