From midwives in flip-flops to motorcycle ambulances, saving pregnant mothers is global goal

Gains made, but many pregnant mothers still die

KATMANDU, Nepal — Astamaya Tami, 55, is part of a ragtag army of women who have turned Nepal into an against-all-odds success story when it comes to saving lives of expectant mothers, hundreds of thousands of whom die unnecessarily every year across the globe.

She and others pull on their flip-flops and head into the mountains by car or on foot to visit desperately poor villages, some connected only by a single, rocky footpath. They bring vaccines, vitamins and, equally important, advice.

“At first people were suspicious. They’d scold us, or wouldn’t talk to us at all,” said Tami, herself a mother of eight, adding that not long ago almost all women were giving birth at home or in filthy, frigid cowsheds. They were helped only by female relatives or untrained midwives cutting umbilical cords with unsterilized knives.

“But that’s all changed,” said Tami, smiling proudly and dressed in a red ceremonial sari.

Like many developing countries today — especially in South Asia and sub-Saharan Africa — this Himalayan nation of 28 million people, plagued by political instability following a decade-long communist insurgency, still faces massive challenges.

But it is seen by many as an example of just how much can be achieved through sheer will when it comes to fighting maternal mortality: In the last five years, it has slashed rates in half.

That is something 189 heads of state and development agencies well understood a decade ago when they set their Millennium Development Goals of tackling the world’s most serious humanitarian crises in the areas of poverty, disease and lack of education.

Where mothers were concerned, the goal was to bring down the number of deaths linked to pregnancy, childbirth and unsafe abortions by 75 percent by 2015 from where they stood in 1990.

As the U.N. hosts a summit in New York starting Monday to review progress, new figures point to gains in cutting maternal mortality worldwide, but not fast enough. “At the current rate of decline, we’re not going to make it… We’re not going to reach our targets,” warned Renee de Weerd of the U.N. Children’s Fund.

The number of deaths decreased by 34 percent from an estimated 540,000 two decades ago to 358,000 in 2008, according to a U.N. interagency report — an average annual decline of just 2.3 percent, half of what is needed.

In the U.S. and other rich, industrialized countries, 24 women die for every 100,000 live births, but that number soars to as high as 1,400 in Afghanistan and 1,000 in some of the other poorest corners of the globe.

Papua New Guinea has seen only small declines, and Somalia none. And Zimbabwe, where qualified midwives are attracted by better jobs and facilities abroad, is among two dozen nations where death rates are increasing.

Hemorrhaging and hypertension account for more than half the deaths, said Flavia Bustreo, a World Health Organization official.

AIDS and malaria play a growing role, as does the limited say some women have in decisions about their health.

And sometimes, the political will just isn’t there.

“I must tell you, I’m very angry about this,” said Graca Machel, a well-respected women and child rights activist married to South African President Nelson Mandela.

Not just governments are to blame, she said, but publics too. “I can’t understand why they think that women’s lives are cheap.”

Most maternal deaths can be prevented if births are attended by health workers with even rudimentary training. All they need is the right equipment and the knowledge to spot complications and refer patients to clinics.

Bustreo said many countries have shown that progress in difficult circumstances is possible.

Nepal’s answer is those 50,000 volunteers — recruited by the government and trained by U.S.-based World Vision and other aid organizations. India offers cash handouts to pregnant women getting prenatal care. So does Brazil, which also rewards families that send daughters to school.

Sierra Leone, which endured years of civil war and has one of the world’s highest maternal death rates, has launched a motorcycle service to rush mothers-to-be to hospitals, some of which only have one or two ambulances serving populations of 18,000.

This year, the West African country started offering free drugs and medical care to expectant mothers.

Nurses noticed an almost immediate U-turn.

Women used to show up too late, babies bloody or dead in their wombs, sometimes because of botched procedures. Now they check in at the first sign of complications.

“Before I almost never went… I was afraid of what the doctors and nurses would expect from me,” said Kadiatu Bangura, a pregnant woman. “But since they launched the program, I go regularly, as soon I experience symptoms of poor health.”

In Malawi, where non-physicians have recently started getting training to perform emergency Cesarean sections, Anne Phungwako wishes she had that option in her mountain village.

“I deliver right here in the village because the hospital is 40 kilometers (24 miles) away,” said the mother of two.

“I lost three babies because I lost a lot of blood and was too weak to breast-feed.”

Sometimes natural disasters compound the uncertainties of pregnancy.

Pakistan was lagging behind its millennium goal targets even before floods engulfed a fifth of the country.

The WHO estimates about a half million women affected by the disaster will give birth in the next six months, of whom about 32,000 will experience complications.

Women, some days away from delivering, were left stranded by the road or in flimsy canvas shelters. “This is a grave situation,” said WHO official Dr. Ahmed Shadoul. “Those affected are the poorest people and also living in remote areas that are not accessible.”

Numbers are always problematic when it comes tallying maternal mortality rates, in part because vital statistics do not exist in the countries hardest hit. Researchers going door to door may report impressive gains, but these may turn out to be unevenly spread.

Even in the U.S., disparities exist within the numbers.

In New York City, for instance, a Health Department study revealed that black women were seven times as likely to die as white women, said Dr. Lorraine Boyd, who heads the city’s Bureau of Maternal, Infant and Reproductive Health.

That really raised a “red flag,” she said, adding that health care providers, community partners and other government agencies have since been asked to work together more closely to address underlying risk factors.

“It bothers us tremendously.”

Online: www.who.int/reproductivehealth

Associated Press Writers Robin McDowell in Jakarta, Indonesia; Donna Bryson in Johannesburg; Margie Mason in Islamabad, Pakistan; Clarence Roy-Macaulay in Freetown, Sierra Leone; Angus Shaw in Harare, Zimbabwe; Raphael Tenthani in Blantyre, Malawi and Karen Matthews in New York City contributed to this report.