Deaf to the Screams
by Peter Adamson
New Internationalist magazine, January / February
This is a story of unimaginable suffering. And it is a story
that will be inadequately told. For no one who has not experienced
what is meant by maternal mortality and morbidity can know the
suffering implied. And those who do know are usually silenced
- by their early deaths, by their poverty, by their gender, and
by the insulating layers of censorship and embarrassment that
still surround the issues of sex, blood and birth in most societies
of the world.
For a decade the figure of 500,00 maternal deaths a year has
been part of the statistical liturgy. In 1996 new estimates are
showing that the number of women who die each year in pregnancy
and child birth is probably closer to 600,00.
But before the new estimates replace the old as a way of packaging
up the problem, it should be said that a mistake has been made
in allowing statistics such as these to slip into easy usage.
For these are not deaths like other deaths, and death is only
a part of the story they have to tell.
They die, these hundreds of thousands of women whose lives
come to an end in their teens and twenties and thirties, in ways
that set them apart from the normal run of human experience.
Over 200,000 die of hemorrhaging, violently pumping blood
onto the floor stretcher as their families and friends search
in vain for help.
About 75,000 more die from attempting to abort their pregnancy
themselves. Some will take drugs or submit to violent massage.
Alone or assisted, many choose to insert a sharp object - a straightened
coat-hanger, a knitting-needle, or a sharpened stick through the
vagina into the uterus. Some 50,000 women and girls attempt such
procedures every day. Most survive, though often with crippling
discomfort, pelvic inflammatory disease, and a continuing foul
discharge. And some do not survive: with punctured uterus and
infected wound, they die in pain and alone, bleeding and frightened
Perhaps 75,000 more die with brain and kidney damage in the
convulsions of eclampsia, a dangerous condition that can arise
in late pregnancy and has been described by a survivor as 'the
worst feeling in the world that can possibly be imagined'. Another
100,000 die of sepsis, the bloodstream poisoned by a rising infection
from an unhealed uterus or from retained pieces of placenta, bringing
fever and hallucinations and appalling pain.
Smaller but still significant numbers die of an anemia so
severe that the muscles of the heart fail. And as many as 40,000
a year die of obstructed labor - days of futile contractions repeatedly
grinding down the skull of an already asphyxiated baby onto the
soft tissues of a pelvis that is just too small.
In the 1990s so far, three million young women have died in
one or more of these ways. And they continue to die at the rate
of 1,600 every day, yesterday and today and tomorrow.
For the most part, these are the deaths not of the ill or
of the very old or of the very young, but of healthy women in
the prime of their lives upon whom both young and old may depend.
But the numbers of the dead alone do not reveal the full scale
of this tragedy. For every woman who dies, approximately 30 more
incur injuries, infections, and disabilities which are usually
untreated and unspoken of, and which are often humiliating and
painful, debilitating and lifelong.
It is part of the silence that has for so long surrounded
the issue of maternal morbidity that there is so little research
into its prevalence. But based on a few studies and many assumptions,
the best estimate that can be made puts the ratio of injuries
to deaths at about 30 to 1.
This means that at least 12 million women a year sustain the
kind of damage in pregnancy and childbirth that will have a profound
effect on their lives. And even allowing for the fact that some
women will suffer such injuries more than once during their child-bearing
years, the cumulative total of those affected can be conservatively
estimated at some 300 million, or more than a quarter of the adult
women now alive in the developing world.
It is therefore no exaggeration to say that the issue of maternal
mortality and morbidity, locked fast in its conspiracy of silence,
is in scale and severity the most neglected tragedy of our times.
Excluded from the home
Many of the injuries sustained during pregnancy and childbirth
are distressingly obvious. Rupture of the uterus, prolapse, pelvic
inflammatory disease and lower genital tract injuries, make life
miserable for millions.
Most obvious and distressing of all is fistula. Fistula occurs
when the tissues of the birth canal are deadened by prolonged
labor and days of pressure from the baby's skull. In the days
and weeks after the birth, the dead tissue falls away, leaving
holes which allow leakage from the bladder and rectum, or both,
into the vagina. Urine and feces now bypass the muscles that normally
control the flow. She is incontinent. And without an operation
to repair the fistula, she will remain so all her life. Special
clothing is not available. She must make do with cloths and rags
which quickly become soaked and soiled. The constant leaking abrades
the skin of the genital area and produces a permanent and painful
rash. Washing is difficult. Frequent bathing is impossible.
Soon, the woman is excluded from her husband's bed, and then
from his home. Living in an outhouse or animal shed, she cannot
visit anyone or travel anywhere except by walking. Each year,
unknown numbers decide that suicide is preferable to such a life.
The best available estimates suggest that perhaps 80,000 women
develop fistula every year. Most cases go untreated, and somewhere
between 500,000 and a million women are now living with the problem.
Other conditions can be more successfully hidden, at least at
first. Most hidden of all are the long-term effects of the hemorrhages
that are suffered by an estimated 14 million women every year.
Half of those women, it may be assumed, were already anemic. But
a hemorrhage in childbirth, or in repeated childbirths, can push
women further and further down the anemia road, slowly lowering
the quality of life for uncounted millions, making every task
an unwelcome effort, every day a day of drudgery, leaving no energy
even for the common enjoyments of life.
For a smaller percentage of women, the trauma of hemorrhage
brings something worse than anemia. Those who experience hypopituitarism,
or Sheehan's syndrome, almost always assume that they are suffering
only from temporary tiredness. But as the months pass, the tiredness
becomes a chronic weakness, a listlessness stirred by alarm as
other symptoms begin to appear -- the cessation of monthly periods.
the loss of pubic hair, an increasing confusion and forgetfulness.
Without knowing what is wrong, such women grow old while still
young. And eventually their alarm will give way to the cruelest
symptom -- the deepening apathy which makes it unlikely that treatment
will ever be sought.
To the extent that Sheehan's syndrome is known at all, it
is assumed to be a rare condition. For obvious reasons, definitions
are shadowy and figures vague, but recent estimates suggest that
Sheehan's overtakes the lives of 100,000 women a year, and may
currently affect a total of over three million.
Further still into the realms of the unreported lies dyspareunia
- the pain that some women suffer during sexual intercourse.
After childbirth, a woman is bruised and battered and needs
time to recuperate. Many will also have suffered specific injuries,
often including the tearing or the surgical cutting of the vagina.
But in many societies, and in many millions of individual cases,
women have no choice but to resume sexual relations within two
or three days, regardless of the pain it causes. Pain during intercourse
may last for up to a year after a birth. It may also be so severe
that a woman lives in dread of having sex. Few can count on sympathy
or support and many endure anger, rejection and violence.
Once again, this problem of unknown extent is made worse by
the silence that surrounds it. Yet the truth is that it is just
one more abuse in a lifetime of abuses that are linked, in one
way or another, to the different ways in which different societies
make a woman suffer for her reproductive role.
As a child, she may endure genital mutilation in order to
contain sexuality and protect marriageability. As a menstruating
girl she may be set aside as unclean, polluting and made to feel
dirty and ashamed. As a teenager she may be married to someone
she does not know, and made pregnant before her own body is fully
grown. As a woman unable to bear children she may be abused and
abandoned, even though it may be the husband who is infertile,
or even if her infertility is caused by a sexually-transmitted
disease originally contracted by her partner. As a pregnant woman
she may be denied the basic consideration, the rest and the food
and the antenatal care, to which she is entitled. As a woman in
labor she will run the risk of dying from the lack of obstetric
care, and of sustaining injuries and disabilities for which she
will not receive treatment.
As a woman enduring a prolonged childbirth she may be left
to die alone and in agony, the baby asphyxiated inside her, in
societies where men interpret obstructed labor as a sign of unfaithfulness.
As a woman suffering from a childbirth injury, from a still-open
artery or a ruptured uterus, she may die because her husband will
not allow her to be seen by a male doctor. As the mother of a
baby girl she may be blamed and beaten despite the fact that is
the chromosomes of the male that determine the sex of the baby.
As a wife he may be forced to submit to sex within I few days
of giving birth, or subjected to violence if she refuses. As a
new mother he may be expected to become pregnant gain before her
body has recovered. And finally, even if she has sustained an
injury or infection that is serious and treatable, and even in
those rare cases when health workers seek her out knowing that
she will not come to them, she may still not be allowed to go
into hospital because there will be no-one to cook the meals.
How can such a heavy burden of death, disease and disability
have continued for so long with so little outcry?
In part, the conspiracy of silence surrounding this issue
is a reflection of the fact that women are conditioned not to
complain but to cope. No matter the injuries or disabilities they
labor under, they will usually continue to look after children,
fetch and carry wood and water, go to market, and work long hours
in the fields, while hoping that the pain will go away, that the
wound will heal, that the discharge will stop, that they will
soon be able to have sex with out pain, and that they will one
day recover their vitality. And for the most part they cope in
silence. They neither ask nor receive a lesser workload, or medical
care, or consideration for what they have suffered or the condition
they are in. Ultimately, therefore, little is either said or done
about this problem because it is a "woman's problem",
a problem that, by long tradition, most men and most governments
do not wish to know about. As one midwife with 25 years' experience
of developing countries has put it: 'If hundreds of thousands
of men were suffering and dying every year, alone and in fear
and in agony, or if millions upon millions of men were being injured
and disabled and humiliated, sustaining massive and untreated
injuries and wounds to their genitalia, leaving them in constant
pain, infertile and incontinent, and in dread of having sex, then
we would all have heard about this issue long ago, and some thing
would have been done.'
But there is another, more surprising reason for the failure
to break the silence. It might have been expected that the voice
of the women's movement would have been raised on behalf of the
millions of women who suffer for reasons that are related solely
to the fact of being a woman. But with honorable exceptions, this
is an issue on which the women's movement in the industrialized
nations has raised scarcely more than a murmur. When asked, many
of the women who work with maternal death and injuries in the
developing world will offer the same explanation: for most Western
women feminism is in large part a fight against the circumscribing
of a woman's opportunities of her reproductive role; many who
are engaged in that struggle have therefore been reluctant to
take on an issue which seems to center on women as mothers rather
than women as women.
The first and most obvious step towards reducing the toll
of maternal mortality and morbidity is to make high-quality family
planning services available to all who need them. With today's
knowledge, it is possible to do this in ways that are acceptable
to all countries and cultures. Meeting only the existing demand
for family planning would reduce pregnancies in the developing
world by up to a fifth, bringing at least an equivalent reduction
in maternal deaths and injuries. Add in the many other benefits
of family planning for all - fewer abortions, better health and
nutrition of women and children, faster progress towards gender
equality, slower population growth, reduced environmental pressures
- and the costs are almost derisory. Yet family planning receives
less than two per cent of all government health spending in the
developing world, and less than two per cent of all international
The greater challenge is to reduce deaths and injuries in
the great majority of cases where the pregnancy is wanted. Some
will always fall back on the idea that this must await economic
development, and that only when women are healthier, better educated
and better nourished will maternal risk be lowered.
But the historical record gives scant support to such complacency.
In Britain, for example, there was almost no fall in maternal
mortality rates during the century before 1930 when standards
of health, nutrition, education and hygiene were advancing rapidly.
Only when skilled midwifery made deliveries cleaner and safer
- and modern obstetric care began to cope with obstructed labor,
hemorrhage, infection and hypertensive disorders - did maternal
deaths begin their sharp fall to today's levels. On a smaller
scale, these same conclusions have been demonstrated by a study
of a sect in the US whose members were relatively prosperous,
well nourished, and well educated, but who would not accept modern
medical care. The study found that the maternal-mortality rate
was approximately 100 times higher than the US average and approximately
the same as in rural India.
Faced with this and other evidence that obstetric care is
the key, many have argued that the costs of such services are
simply too high for the developing world to contemplate. But no
developing country is starting from scratch. Even in the largest
and poorest nations, there are usually health units and district
hospitals with the doctors, midwives, nurses, drugs, and equipment
that can provide obstetric care when needed. If they cannot, then
this usually reflects a lack of priority, or a lack of relatively
small amounts of funds for basic training and equipment, rather
than the inherent impossibility of the task. Few figures are available
on how many women have access to obstetric care, but in a country
like India, informed estimates suggest that perhaps three-quarters
of the 125,000 women who die each year in child birth live within
a few kilometers of a health unit or district hospital where emergency
care is or should be available. And there is usually enough time
for a woman to be transferred to such a facility if danger signs
are recognized in time.
Action on this issue has been paralyzed for too long by the
idea that only the building of hundreds more hospitals and the
training of thousands more expensive obstetricians can make the
right kind of care available to the 15 per cent who need it. But
the fact is that properly trained health workers and midwives,
working in modern health units with inexpensive equipment and
reliable supplies of relatively cheap drugs, can usually cope
- and know when to call in obstetricians if a cesarean section
A great deal of confusion has arisen because the terms 'midwife',
'traditional birth attendant' and 'trained birth attendant' are
frequently used interchangeably. In particular, much of the argument
about what midwives can and cannot be expected to do is born of
the failure to distinguish between a formally trained midwife,
working with the support of modern health services, and a traditional
birth attendant unconnected to obstetric services. Properly qualified
midwives and health workers who are used to dealing with such
problems will usually cope better than doctors who may encounter
such problems only a few times a year.
The opportunity must be there for every woman who becomes
pregnant to be brought in to a health unit or hospital if and
when complications occur. Making modern obstetric care more available
is no insignificant task. But the financial cost would be only
a very small proportion of the $85 billion a year that the governments
of the developing world currently spend on their health services,
or of the $5 billion a year in international aid that is allocated
to those services.
Reducing maternal deaths and injuries is therefore not a matter
of possibilities but of priorities. The strategies that work have
been identified. And the resources will follow if priority lights
the way. What is needed now is a much wider and noisier demand
for action in order to force this issue into public consciousness
and onto the political agenda. The first task is to break the
mold of silence. And there is scarcely a politician, or health
professional, or researcher, or journalist, or non-governmental
organization, or women's group, or member of the public, that
could not play some part in such a movement. In particular, the
professional organizations of obstetricians and gynecologists
that exist in almost all countries could say more and do more
about the issue. All of these voices are needed to press for government
health budgets and international aid programs that specifically
confront the taboo tragedy of maternal deaths and injuries.
Failure to do so, in the face of an issue that has affected
so many so severely and for so long, amounts to a tacit complicity
with the forces of silence, an acquiescence in the long reign
of the idea that these issues should not be spoken about too loudly
because they are faintly embarrassingand because, after all, they
affect mainly women and mainly the poor.
The statistics alone would be enough to justify the claim
to priority of a problem that has affected perhaps 25 per cent
of the women now alive and which causes some 585,000 deaths a
But there is also a dimension that statistics cannot capture.
It is perhaps not possible to give a weighting to the pain and
the fear, the undermining of confidence and self-esteem, or the
nagging injuries and humiliations and anxieties that are the constant
companions of so many women's lives. But the world at the close
of the twentieth century is guilty of a colossal failure of imagination
if it remains deaf to the cries of so many women who daily live
with the sadnesses and sufferings that travel under the name of
Aldous Huxley wrote of human suffering: "Screams of pain
and fear go pulsing through the air at the rate of eleven hundred
feet per second. After traveling for three seconds they are perfectly
inaudible." It is time to amplify the screams.
Peter Adamson was the founding editor of New Internationalist.
and death in Third World