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From London to Aleppo, pregnancy and childbirth are part of the normal cycle of life. Delivery is by far the most dangerous time for both a woman and her baby and the vast majority of maternal deaths occur just before, during or after delivery, often from complications that cannot be predicted.
The pre-existing risk of complications that all women face can quickly become a death sentence if skilled medical care is unavailable.
During a conflict or a time of crisis, women and their babies are at their most vulnerable. The five main causes of maternal death include haemorrhage, sepsis (infection), complications resulting from unsafe abortion, hypertensive disorders and obstructed labour.
Maternal mortality rates worldwide dropped by over 40 per cent between 1990 and 2015 but challenges clearly remain. In many countries where MSF works, obstetric care is in a constant state of emergency. National health systems are disrupted, there is a lack of qualified medical personnel and the necessary medicines and equipment are not available. Many women in these places are unable to access medical care due to insecurity or conflict, some are not permitted to go to hospital alone, or at all, while others cannot afford to seek out professional medical care.
Even before the 2010 earthquake struck Haiti, which severely damaged or destroyed 60 per cent of its health facilities, the country had extremely high maternal mortality rates. In the aftermath of the disaster, women arrived with pre-eclampsia or eclampsia — serious conditions characterised by high blood pressure, exacerbated by stress. With the construction of its Centre de Référence en Urgences Obstétricales in the capital, Port-au-Prince, MSF is responding to the city’s ongoing emergency obstetric care needs.
This has included caring for pregnant women with cholera. Obstetric cholera treatment units, supervised by specialised staff, handle the ensuing serious and sometimes life-threatening obstetric complications or premature labour. Offering 148 beds, these units assisted over 6,000 births in 2015.
The risks faced by women during pregnancy and childbirth are compounded when they are forced to flee their homes due to violence or instability. By the time they reach safety, these women are in a weakened state and the living conditions that greet them are precarious, further endangering the survival of both mother and baby.
When the Ebola epidemic ravaged West Africa, newborns entered a world where hospitals were shut, health staff were scarce and people were frightened. Fever and bleeding — both common during pregnancy — are also symptoms of Ebola, so health staff were often reluctant to admit pregnant women to hospitals or let them deliver in health facilities, fearing contamination.
When I was in Liberia in 2014, four pregnant women showed up at MSF’s Ebola treatment centre, having spent the whole day searching for a place to deliver. By the time they reached MSF, they had all lost their babies. Their plight underlined how vital the provision of emergency care is, even in times of great uncertainty. To address this, MSF set up a centre in Hastings, Sierra Leone, with specific obstetric services for Ebola-positive pregnant women in need of tailored care. Medical staff focused on trying to minimise the mother’s bleeding while in labour and after delivery, to prevent her dying from haemorrhage.
Approximately 830 women die every day from causes related to pregnancy and childbirth, according to the World Health Organisation. It is estimated that 99 per cent of maternal deaths happen in the developing world. These deaths are preventable. If complications are identified and addressed quickly, and care is available, the chance of survival is high.
MSF provides skilled birth attendance and emergency obstetric care in one-third of all the organisation’s projects in 69 countries; over 200,000 deliveries in 2015 were assisted by MSF teams, who additionally offer preventive action such as contraception, prevention of mother-to-child HIV transmission, prenatal care as well as cervical cancer screening, treatment and the repair of obstetric fistula.
We must continue to be present and to provide skilled care to the women and girls who need it.
Dr Joanne Liu is the international president of Médecins Sans Frontières