The Perfect vs. the Good: Tackling Maternal Mortality in Mozambique

NPR's Melissa Block traveled to Mozambique, where poverty and a shortage of both healthcare providers and facilities contribute to a high maternal mortality rate, for the first segment of the "Beginnings" series that will air throughout the summer on All Things Considered. She starts off with some grim statistics:

In Mozambique in southeastern Africa, the rates of maternal and infant mortality are among the highest in the world.

In her lifetime, a Mozambican woman has a 1 in 37 chance of dying during pregnancy or within a short time after a pregnancy has ended. One in 10 children won't live past the first year. One in 7 dies before reaching the age of 5.

... Mozambique has one of the worst doctor-patient ratios in the world: just 1 doctor for every 25,000 people, according to the Ministry of Health.

Mozambique is hardly alone in its alarming maternal mortality rate; according to the World Health Organization, approximately 1,000 women worldwide die every day from pregnancy- or childbirth-related complications. The WHO lists the complications that account for 80% of of maternal deaths:

• severe bleeding (mostly bleeding after childbirth)
• infections (usually after childbirth)
• high blood pressure during pregnancy (pre-eclampsia and eclampsia)
• obstructed labour
• unsafe abortion.

Ideally, all women would get adequate prenatal care and would have easy access to both a skilled birth attendant and to any emergency medical care they or their babies might need. But many rural women give birth at home with the help of friends or relatives with little or no medical training, and live miles away from clinics. And even if a woman in labor can make it to a clinic, there's no guarantee it'll have what she needs. Block reports from one Mozambique clinic that had no fetal heart monitor nor doctors ready to perform emergency C-sections.

And then there's another factor that made me cringe when Block brought it up: after a Mozambican girl has had her first period and gone through an initiation ritual, she's considered eligible to marry, even if she's as young as 10. Adolescents (and, presumably, girls who aren't even adolescents yet) face a higher risk of pregnancy-related complications and death than older women do, so increasing the average age at which girls marry could go a long way toward reducing maternal mortality. It might also help girls stay in school longer.

Cultural norms like the average marrying age don't tend to change quickly, nor do challenges like inadequate infrastructure and physician shortages. But Block reports on one step that Mozambique's government is taking and another it is considering in order to address maternal mortality more immediately.

In her first Mozambique story, Block reports that maternal-child health nurses are being trained to perform emergency C-section surgery and operate to treat ectopic pregnancies and sepsis, all procedures usually reserved for doctors. So far, the Ministry of Health has trained 60 of these nurses around the country. It sounds like a drop in the bucket, but since these specially trained nurses can complete their education more quickly than doctors can, the number has the potential to grow relatively quickly.

More controversial is the widespread use of misoprostol, a drug that can prevent excessive bleeding after childbirth. A year-long trial of msoprostol administered by traditional birth attendants assisting with home births was evidently successful - attendants told Block that women were bleeding far less than they would have without the drug. When given to induce labor, excessive doses can cause fatal uterine ruptures, so it's not without risks. The fact that it's available as a pill that doesn't require refrigeration also makes misoprostol attractive.

WHO pharmacologist Suzanne Hill expressed reservations to Block about misoprostol; she says oxytocin is a more effective drug. Since oxytocin requires refrigeration and is given by injection, it'll probably be harder to distribute and administer to all the women who need it. Block explains that Hill "worries that seeing misoprostol as a panacea might obscure the real long-term need."

Some of the drug's opponents have a different rationale: they're afraid the drug makes it too easy for women to get abortions, which are technically illegal in Mozambique. Block speaks to one doctor who reports that misoprostol has reduced maternal deaths due to unsafe abortions - which counts as a benefit in my book. This doctor, Aida Limbombo, advises Mozambique's minister of health and will promote a nationwide rollout of misprostol to prevent post-partum hermorrhage.

I hope specially trained nurses and widely available misoprostol reduce Mozambique's awful maternal mortality rate. And I hope that the reduction will increase, rather than reduce, the intensity of efforts to achieve the culture, staffing, and infrastructure that allow Mozambican women to have healthy births and babies at healthy ages.