Illustration 1: Kinney MV, Lawn, JE, and Kerber KJ, eds. !ien!e in a!tion: a"in# the li"es o$ A$ri!

!a%s mothers, newborns, and !hildren.& 'e(ort $or the A$ri!an A!ademy !ien!e )e"elo(ment Initiati"e *+,,-.. /eb. +- January +,10.

The Right to Health Understanding the Significance of Maternal Mortality.

Life is not a privilege; life is woman's right. A mother sho ld not have to ris! death every time she "ears a child. A p "lic health article in The LA Times recently reported the death of a healthy mother. Her life was premat rely c t short the day after a cesarean section "y a s dden p lmonary em"olism #Roan$. Li% Logelin& at the age of thirty was yo ng and vi"rant; she wanted to travel the world& she had great e'pectations for a happy family life "efore the pregnancy(related complication nipped all her dreams in the " d #Logelin$. )n a nation as developed as o rs& s ch an event is shoc!ing; to the h s"and and child left "ehind& it is a tragic loss. )n the h s"and*s own words& it was +the saddest& most horrific moment of my life& and many other people*s lives, #Logelin$. -hile even one s ch occ rrence is rare for s in the -est& it is an everyday event in s "(Saharan Africa where ../ women die each day from pregnancy and child("irth #-H0$ ( that is one death every . min tes& 1 st the amo nt of time it ta!es for s to "rew a c p of morning coffee.

That s "(Saharan Africa with 1 st 223 of the world*s pop lation sho ld acco nt for over half of all maternal mortality #-H0$ is grossly naccepta"le. )nternational treaties recogni%e health as every women*s "asic h man right #H nt and Mes4 ita$& yet we have failed to deliver and neglected the pro"lem as it grows
Illustration +:Kinney MV, Lawn, JE, and Kerber KJ, eds. !ien!e in a!tion: a"in# the li"es o$ A$ri!a%s mothers, newborns, and !hildren.& 'e(ort $or the A$ri!an A!ademy !ien!e )e"elo(ment Initiati"e *+,,-.. /eb. +- January +,10.

and festers in the poorest co ntries that need o r help the most. A mother*s death is not a solitary event& it 1eopardi%es the very life and f t re well("eing of her yo ng children and tra mati%es her family and the whole comm nity. Maternal mortality in s "(Saharan Africa is not merely a clinical n m"er& it is a "reach in "asic h man rights that will re4 ire not only improved medical care& " t also a commitment to elevate the lives of all the women and girls thro gh social reform. )n order for this to s cceed in a s staina"le way& it will ta!e the cooperation and dedication of local African governments and the whole international comm nity. Among all the other co ntries of s "( Saharan Africa& nay& even of the world& So th S dan& a land(loc!ed co ntry of 2/.52 million& stands o t in having the highest maternal mortality rate #MMR$ ( an incredi"ly crippling n m"er of 6&/7. deaths for every 2//&/// live
Illustration 1: outh udan. htt(:22www.edu!ationandtransition.or#2w(3 !ontent2u(loads2+,112,42 udan3mother3and3!hild.5(#. 1, January+,10. 6uote: outh udan: The 7i##est Threat to a /oman8s Li$e.& I'I9. :9 ;$$i!e $or the <oordination o$ =uman A$$airs. /eb. 1, January +,10.

"irths #8)A$. 9ot persistent war " t pregnancy and child"irth has th s "ecome the leading

ca se of death in women and girls. How has it "ecome this way: The ca ses are manifold. So th S dan did not s ccessf lly secede from S dan as an independent nation ntil ; ly 6/22. <efore that& the nation was gripped for decades in a "loody civil war that destroyed the co ntry*s infrastr ct re and roads and left little reso rces for f nding medical facilities and social programs #Rai& Ahmed& and T lchins!y$. =isplaced "y conflict& m ch of the pop lation lived in ref gee camps witho t proper sanitation and n trition& and >/3 of "irths were at home witho t s!illed care #+So th S dan,$. )n addition& ed cation for girls is severely lac!ing and gender ine4 ality is deeply entrenched in the c lt re& forcing teenage girls into marriage and often preventing them from receiving timely medical care #+So th S dan,$. These com"inations of detrimental conditions mean that high rates of maternal mortality is a reflection& a res lt of m ch "roader social pro"lems. S ch social factors greatly increase ris! of maternal death& and repeated pregnancy and child( "irth p ts so m ch additional strain on a mother that it can res lt in chronic pro"lems and death. )n addition& teenage girls& as yo ng as 27& witho t f lly developed reprod ctive organs and wea!ened "y maln trition and anemia are not s ita"le for the long years of child("earing that is e'pected of them ntil menopa se #+So th S dan,$. Th s& "eyond 1 st medical care& the women and girls in these comm nities need sanitary living conditions o tside of ref gee camps& they need no rishing food and ed cation that gives them meaningf l opport nities o tside of child(rearing. < t in light of this& why have many organi%ations s ch as -H0 and U9?@A foc sed heavily on 1 st addressing the clinical ca ses of death at child"irth when so m ch can and needs m st "e done to raise the "asic standard of life of millions of women and girls in s "(Saharan Africa: )n order to "etter nderstand this c rrent clinical approach to maternal mortality and ltimately improve these health initiatives& it is helpf l to loo! at the historical and medical perspectives that have led s to where we are today. )f we t rn "ac! o r cloc!s and peer into the annals of -estern history& we will reali%e that maternal mortality is not a new and diffic lt illness to treat li!e cancer and H)ABA)=S. St dies "y medical historian )rvine Lo don show that rates have historically "een high& even at a pea! of nearly

>// deaths per 2//&/// "irths in the United States d ring the early 2>//s #Lo don& )ll stration .$& a rate that is compara"le to co ntries in Africa li!e 8had and Somalia " t not nearly as high as MMR in So th S dan. As the st dy f rther indicates& maternal mortality in the 2>//s decreased the most as a f nction of improvement in maternal care. Most cr cial of the changes were s!illed attendants to monitor the mother d ring delivery and the introd ction of anti"iotics that greatly decreased the chance of death thro gh pelvic infections. #Lo don 6.5S$. This st dy has given legislators a framewor! on which to " ild policies for o"stetric care and highlights the necessity of targeted medical action.

Illustration 0: Loudon, Ir"ine. Maternal Mortality in the >ast and its 'ele"an!e to )e"elo(in# <ountries Today.& The Ameri!an Journal o$ <lini!al 9utrition 4+*su((l. *+,,,.: +01 3? . /eb. 1@ January +,10.

As an e'ample& Lo don presented an important case st dy cond cted in Cent c!y d ring 2>67( 2>5D that followed the wor! of a pioneering gro p of midwives led "y Mary <ec!inridge. )n the poor farming comm nities of r ral Cent c!y& her midwives administered s!illed& sanitary care n s al for the time and e'perienced e'ceptionally good res lts E there was only an average mortality rate of F7 per 2//&/// "irths. )n comparison& medical practices that had remained less sanitary even in r"an hospitals had res lted in m ch higher rates of infection and mortality& sometimes even p to ten times higher #Lo don 6.5S$. Th s& as o r own compara"ly m ch lower rates will testify and modern st dies state& f lly >G3 to >>3 of maternal mortality is preventa"le #-H0$. )n fact as research shows& it does not even ta!e modern technology& 1 st s!ill& sanitation& and determination. = e to s ch findings&

organi%ations s ch as a"in# Mothers, Ai"in# Li$e, <loom"erg @hilanthropies& and other gro ps wor!ing in Africa have foc sed most attention on improving health facilities and training midwives to oversee home "irths. Also contri" ting to o r c rrent medical approach was the reality that maternal mortality had reached a pea! of 7.5&/// in 2>>/. Maternal mortality was neglected for many years d e to nder( reporting and a lac! of consens s on the definition of maternal mortality #A"o Hahr 6$. The -orld Health 0rgani%ation th s rapidly developed a wor!ing definition #see footnote2$& and together with the United 9ations 8hildren's ? nd #U9)8I?$ and the United 9ations @op lation ? nd #U9?@A$& developed acc rate methods to trac! maternal mortality& creating cr cial data for glo"al health organi%ations to draft and implement strategies to red ce maternal mortality. So far& the res lts have "een heartening; a comprehensive report from U9?@A& +Trends in maternal mortalityJ 2>>/ to 6/2/&, indicates that maternal deaths have decreased "y over .D3 from 7.5&/// to 6GD&/// over the past two decades& a remar!a"le change that demonstrates 1 st how m ch concerted glo"al s pport and comm nal dedication can achieve. < t as mentioned earlier& while mothers in -estern co ntries can now loo! forward to a safe pregnancy and a promising f t re with a MMR as low as . per 2//&/// "irths #8)A& -orld ?act"oo!$& merely delivery for a mother in Africa is still a "attle against death #see endnotei for leading direct ca ses of maternal mortality$. )n a telling video interview of @rofessor Ilwyn 8hom"a "y the 8enter for Strategic )nternational St dies& she reveals that +in Ham"ia& when women have delivered& we say '0h& yo have s rvived.',#9agel& ?leischman& and Letendre$. This alarming statement highlights the fact that while glo"al maternal mortality may have fallen& hot spots of maternal mortality and mor"idity have remained prevalent thro gho t many co ntries of Africa and a mother*s death is still m ch& m ch too common. Th s& improving maternal health was esta"lished as the fifth Millenni m =evelopment Koal at 2The death o$ a woman while (re#nant or within 0+ days o$ termination o$ (re#nan!y, irres(e!ti"e o$ the duration and site o$ the (re#nan!y, $rom any !ause related to or a##ra"ated by the (re#nan!y or its mana#ement but not $rom a!!idental or in!idental !auses.& 3 /=;

the United 9ations Millenni m S mmit in 6///& along with other cr cial targets s ch as eradicating e'treme poverty and h nger and com"ating H)ABA)=s. According to a -H0 report& the target is to red ce maternal mortality "y three 4 arters "y 6/27. Some co ntries s ch as Istonia have red ced their maternal mortality ratio "y >73 with many others ma!ing rapid progress; at the same time& S "( Saharan Africa acco nts for 7F3 of the 6G.&/// glo"al maternal deaths #-H0$. There is consens s then& that m ch more rapid implementation of health programs m st "e achieved in order for developing co ntries to stay on trac! and meet the goals of M=K 7.

Illustration B: /orld =ealth ;r#aniCation. /eb. 1, January +,10.

< t in o r r sh to red ce the n m"ers and reach the target D73 red ction& have we settled on second(rate sol tions that are cheaper to implement as some s ggest that we have: Sarah <oseley reporting for The Auardian8s Alobal =ealth 7lo# s ccinctly presents this pro"lem in the c rrent de"ate over one dr g ( misoprostol. Misoprostol is a small& white pill that red ces "leeding after delivery "y contracting the ter s& and nli!e the more widely tested and accepted anti(haemorrhage dr g& o'ytocin& it does not re4 ire refrigeration and can "e orally ingested. The f ror arose when the -orld Health 0rgani%ation placed misoprostol on their list of essential dr gs and developing nations s ch as 9igeria "egan to stoc! misoprostol over the "etter& " t less convenient& o'ytocin that m st "e refrigerated and administered intraveno sly #8h & <rhli!ova& and @olloc!$. The pro"lem is that the se of misoprostol incl des s ch negative side effects as vomiting and increased fever while tests have not

shown misprostol to "e especially effective& as 8hristina S. 8h and her fellow researchers report for the Journal o$ the 'oyal o!iety o$ Medi!ine. Advocates who deno nce misoprostol see it as an inferior& 4 ic! fi' sol tion that ta!es emphasis off developing relia"le health care networ!s #<oseley$. 0n the other hand& Anthony 8ostello& contri" tor to The Lan!et& contends that many poor nations do not have the reso rces to develop the infrastr ct re and technology necessary for health(center "ased care and sees dr gs s ch as misoprostol& that are heat sta"le and orally ingested& as a life saving meas re that front(line health wor!ers can 4 ic!ly implement #8ostello& A%ad& and <arnett$. < t there is growing fear that implementing s ch short term sol tions will diminish interest in developing the long term goal of a s staina"le health care system& as seen in red ced attempts to implement o'ytocin& a +s perior treatment, as 8h and her colleag es report. 8onse4 ently& it m st "e recogni%ed that short term sol tions s ch as misoprostol do not precl de the a"sol te necessity of improved health care& ta!en f rther& improved health care can only go so far if the society as a whole is not elevated and the women and their children are condemned to a marginal life of s4 alor and poverty. Ultimately& there m st "e ongoing acceleration and cooperation "etween short and long term medical and social sol tions in "ringing life(saving and li$e 3#i"in# care to millions of women. 0nly saving mothers from dying is not eno gh. -e m st sim ltaneo sly create the environment that will give them a meaningf l life to loo! forward to& free from h nger and oppression. )mproved medical care co ld ma!e s ch great leaps in the -est d ring the 2>5/s "eca se it was fo nded on a standard of living that had already "een improving for the past half cent ry. These two go hand in hand. As an I'I9 article has s pported& we m st not lose sight that even the most "asic standard of health care is not "eing met in Africa& things as essential as electricity at night to power lights at hospitals& clean sheets and eno gh "eds for patients #+So th S dan,$. At times li!e these& it may seem that o r hands are already overflowing with medical needs that m st "e addressed. < t as researchers H nt and Mes4 ita state in their seminal st dy of h man rights& it is e4 ally important to recogni%e that maternal

health and mortality is not only a medical pro"lem to "e fi'ed thro gh more doctors and more dr gs& " t a grave social and h man rights tragedy #H nt and Mes4 ita$. The naccepta"ly high rates of maternal mortality in developing co ntries is d e to a comple' we" of not only poorly maintained and
Illustration ?: =unt, >aul and Judith 7ueno )e MesDuita. 'edu!in# Maternal Mortality2 The !ontribution o$ the ri#ht to the hi#hest attainable standard o$ health.& =uman 'i#hts <enter. :ni"ersity o$ EsseE. /eb. +- January +,10.

ins fficient hospitals " t perhaps even more

significantly& dire poverty& oppressive gender ine4 alities& and a society(wide lac! of ed cation and opport nities for girls #H nt and Mes4 ita$. -e m st rise p to address "oth the social and medical ca ses of maternal mortality "eca se a woman*s right to health is as "asic a h man need as clean water and no rishing food& as f ndamental a right as access to ed cation and treatment against infectio s diseases li!e malaria and polio. @rofessor 8hom"a from the a"in# Mothers, Ai"in# Li$e initiative ma!es a powerf l statement that +if a woman dies& the nation dies with that woman& "eca se a nation starts with a family,#9agel& ?leischman& and Letendre$. )f women tr ly are the fo ndations of a strong family& a strong nation& then it is the time for nations aro nd the world to deliver on the essential h manitarian promise of health and well("eing to all o r sisters& da ghters and mothers.

-or!s 8ited 2. A"o Hahr& 8arla. +Klo"al < rden of Maternal =eath and =isa"ility., 7ritish Medi!al 7ulletin FD #6//5$J 2(22. -e". 2> ;an ary& 6/2.. 6. <oseley& Sarah. +Misoprostol E a pill that saves women's lives or an e'c se not to give them care:, The Auardian. K ardian 9ews and Media Limited& 65 A g st 6/26. -e". 2G ;an ary 6/2.. 5.8h & 8hristina S.& @etra <rhli!ova& and Allyson M @olloc!. +Rethin!ing -H0 K idanceJ review of evidence for misprostol se in the prevention of postpart m haemorrhage., Journal o$ the 'oyal o!iety o$ Medi!ine 2/7 #6/26$. -e". 5/ ;an ary 6/2.. .. 8ostello& Anthony& Cishwar A%ad& and Sarah <arnett. +An Alternative Strategy to Red ce Maternal Mortality., The Lan!et 5FG #6//F$J 2.DD(2.D>. -e". 2G ;an ary 6/2.. Anthony 8ostello& Cishwar A%ad& and Sarah <arnett& respected mem"ers of international health organi%ations& presents a series of evidence("ased sol tions in +An Alternative Strategy to Red ce Maternal Mortality., The Lan!et is a world(renowned 1o rnal of peer(reviewed general and speciali%ed medical articles& and the a thors of the article cited here se specific case st dies of alternatives sol tions s ch as training traditional health wor!ers in <angladesh and Malawi that showed promising res lts. Additionally& they eval ate how ma!ing life(saving anti"iotics and o'ytocins more readily availa"le to "oth health wor!ers and mothers wo ld help to red ce maternal mortality in r ral villages. The perspective here shifts attention from health centers to "etter e4 ipping the traditional health wor!ers that often assist mothers d ring la"or in r ral and inaccessi"le villages. The approach presented wo ld "e an important aspect of my research in eval ating the most via"le and s staina"le sol tions to maternal mortality in co ntries witho t developed infrastr ct res and limited reso rces. 7.H nt& @a l and ; dith < eno =e Mes4 ita. +Red cing Maternal MortalityB The contri" tion of the right to the highest attaina"le standard of health., =uman 'i#hts <enter. University of Isse'. -e". 6> ;an ary 6/2..

@a l H nt& a @rofessor of Law at the University of Isse'& UC& and a United 9ations Special Rapporte r colla"orates with ; dith < eno =e Mes4 ita& a Senior Research 0fficer at the H man Rights 8entre& University of Isse'& to "ring a highly detailed st dy that ill minates maternal mortality in light of the niversal h man right to health and draws from relia"le case st dies and reports from U9?@A and -H0. They arg e that health(care and the other social factors contri" ting to health m st "e attaina"le and afforda"le to 4 alify as meeting the standards of international h man rights. Social factors can range from contraception to ed cation& " t each of these ltimately play a cr cial role in delivering woman from poverty& illness& and mortality. This st dy incorporates a more holistic approach to maternal mortality in Africa and its stress on the need for international s pport and acco nta"ility to local African comm nities is a perspective that will inform m ch of my research for the "est sol tions. F.Cinney MA& Lawn& ;I& and Cer"er C;& eds. +Science in actionJ Saving the lives of Africa*s mothers& new"orns& and children., A$ri!an A!ademy !ien!e )e"elo(ment Initiati"e, 6//>. -e". 6> ;an ary 6/2.. D. Logelin& Matt. +-hat Happened:, Matt& Li% and Madeline #6//G$. -e". 52 ;an ary 6/2.. G. Lo don& )rvine. +Maternal Mortality in the @ast and its Relevance to =eveloping 8o ntries Today., The Ameri!an Journal o$ <lini!al 9utrition D6#s ppl$ #6///$J 6.2S(FS. -e". 2G ;an ary 6/2.. )rvine Lo don& a -ellcome Research ?ellow and acclaimed historian of medicine& presents compelling data in +Maternal Mortality in the @ast and its Relevance to =eveloping 8o ntries Today, to s pport his arg ment that the "est approach to red cing maternal mortality in developing nations today is to improve the standard in health(centers and train a new generation of s!illed midwives and "irth attendants. Utili%ing caref lly researched statistics and graphs of historic trends in maternal mortality& he " ilds a convincing case pointing to the efficacy of improved medical standards. This so rce provides val a"le historic data to develop the relevancy of this social iss e in my research and also gives detailed s pport that ) can incorporate as to why health(care "ased sol tions to maternal mortality is an effective approach to com"at maternal mortality.

>. +Maternal Mortality ?act Sheet, /orld =ealth ;r#aniCation.-e". 5/ ;an ary 6/2.. 2/. 9agel& ; lia& ;anet ?leischman& and 8hristopher Letendre. +Saving MothersJ A 9ew )nitiative to Address Maternal Mortality., mart Alobal =ealth.or#. 8enter for Strategic and )nternational St dies& 5 March 6/25. -e". 52 ;an ary 6/2.. 22. Rai& Ra1esh C mar& Ally Ahmed& and Theodore Her%yl T lchins!y. +@rioriti%ing Maternal and 8hild Health in )ndependent So th S dan., Maternal and <hild =ealth Journal 2F #6/26$J 225>(22.6. -e". 2G ;an ary 6/2.. 26. Roan& Shari and Kirion& Lisa. +Rising Maternal Mortality Rate 8a ses Alarm& 8alls for Action., Los An#eles Times. 65 May 6/2/. -e". 6> ;an ary 6/2.. 25. +So th S danJ The <iggest Threat to a -oman's Life., I'I9. U9 0ffice for the 8oordination of H man Affairs. -e". 5/ ;an ary 6/2..

i 9ote i -H0 has identified the +five ma1or direct pregnancy(related conditions asJ post(part m haemorrhage& p erperal sepsis& pre(eclampsia and eclampsia& o"str cted la"or and a"ortion, #A"o Hahr 7$. The s mmaries "elow are meant to provide a clearer pict re of the many complications that health providers& wor!ing in clinics and r ral villages& m st "e a"le to detect and properly treat. 2. Haemorrhage Haemorrhage can occ r d ring pregnancy& " t "y far the most deadly is severe "lood loss after delivery. 8omplications arise when "leeding from a raw ter s and genital tract cannot "e controlled& especially in villages that are far from health centers. Alternative sol tions s ch as dr gs and physical prohi"itors to stop "lood flow have "een implemented together with "lood transf sions to save many lives. 6. Sepsis Historically !nown as p erperal sepsis& infections from child"irth reached epidemic levels thro gho t the world ntil sanitary practices and anti"iotics were introd ced in developed nations. Today& infections remain as a deadly pro"lem to mothers in developing co ntries; meas res are "eing made to allow easier access to anti"iotics and train frontline health wor!ers in practicing good hygiene d ring delivery. 5. @re(eclampsia and eclampsia ?or many years& eclampsia ca sed "y pregnancy was not a well nderstood condition " t is now reali%ed to ca se sei% res of the nervo s system and lesions in internal organs. )t is deadly "eca se it can go ndetected "y pregnant mothers; recent programs have distri" ted "lood press re c ffs with red mar!ings that even illiterate health wor!ers can se to detect early warning signs of eclampsia s ch as elevated "lood press re. .. 0"str cted La"or 0"str cted la"or often occ rs when a "a"y*s head is not correctly aligned with the shape of the mother*s pelvis& and can also "e a res lt of constricted pelvises ca sed "y maternal maln trition. 0"str cted la"or can res lt in the death of "oth the "a"y and mother& and when not fatal& can ca se severe "lood loss and "rea! holes in the mother*s ter s. The only sol tions are mechanical manip lations of the "a"y and cesarean section; th s& there has "een an increased p sh to train "irth attendants in this life(saving proced re. 7. A"ortion A"ortions may "e either spontaneo s or ind ced& the most concerning "eing ns!illed and illegal operations in places with low access to health clinics in case of "leeding and infections. This iss e is "eing addressed thro gh a "roader social approach of ma!ing safe a"ortions accessi"le to mothers and ed cating comm nities in contraception and family planning so that +every pregnancy is a wanted pregnancy, #?amily @lanning =elivers$. The information presented a"ove has primarily "een gathered from +Klo"al < rden of Maternal =eath, "y 8arla A"o Hahr& +@rioriti%ing Maternal and 8hild Health in )ndependent So th S dan, "y Rai& Ramadhan& and T lchins!y& and research into vario s health initiatives and approaches in Africa.