By Nicole Itano
Sunday, November 2, 2003
A Kenyan woman bleeding from a botched abortion is denied medical help by disapproving hospital nurses. It is the kind of incident that translates into high maternal mortality rates in Africa, where reproductive-health clinics are losing U.S. funding.
NAIROBI, Kenya (WOMENSENEWS)--Dr. Linus Ettyang was at home in his Nairobi suburb last year when he saw a woman lying under a tree near his house, bleeding profusely from an incomplete abortion or miscarriage. He quickly put the woman in the car and drove her to the nearest hospital, run by missionaries.
But the nursing sisters turned the patient away, saying they didn't treat women sufferingfrom abortion complications. Shocked, Ettyangwas forced to take her to another hospital even though she had lost a great deal of blood and needed emergency care.
Ettyang, the program manager of the Nairobi-based Family Planning Association of Kenya, the country's oldest and largest private family planning organization, says the nursing sisters refused to even let him take her out of the car.
The incident haunts Ettyang. It also represents the kind of reality reflected by the latest dire statistics about women and mortality in Africa.
According to a report released earlier this month by the World Health Organization, the United Nations Population Fund and UNICEF, women in Africa have the highest maternal mortality rate in the world, with women having a staggering 1-in-16 lifetime chance of dying while pregnant.
In all, they estimate that 529,000 women die each year while pregnant, 99 percent in the developing world, particularly Africa and Asia. India has more maternal deaths than any other country, an estimated 136,000 each year, followed by Nigeria and Pakistan. Kenya has the dubious distinction of joining a three-way tie for ninth place with China and civil-war-torn Angola. Although African and Asian women have almost equal numbers of maternal deaths, since the population of Africa is much smaller than that of Asia, statistically African women have a much higher chance of dying while pregnant.
In Kenya, unsafe abortion is one of biggest causes of maternal deaths, accounting for an estimated 30 percent of maternal deaths and at least half of hospitalizations in public gynecology wards. It is, say family planning organizations, an epidemic that is being largely ignored, in Kenya and elsewhere on the continent.
The precise causes of maternal mortality vary from country to country, but across Africa, women's access to contraception, prenatal care, skilled birth physicians and abortion are hampered by poverty and overstretched health systems, say family planning groups. With little control over their own reproductive health, many African women are destined to have repeated pregnancies at great risk to their lives and health.
HIV/AIDS has also proven to be a double curse, raising maternal mortality and pulling attention away from family planning and reproductive health issues.
"Family planning and reproductive health is really on a back burner," says Ettyang, whose organization recently lost USAID funding because they refused to abide by the restrictions of the Mexico City Policy, also known as the Global Gag Rule, which bars U.S. funding to organizations that perform abortions or inform their patients about abortion or advocate for changing their nation's abortion policies and laws.
"Everything now is about HIV/AIDS," Ettyang says.
Although abortion is illegal in Kenya--as it is everywhere in Africa except South Africa--and the Family Planning Association of Kenya does not perform abortions, they provide post-abortion care and advocate revising the country's restrictive abortion laws.
When the rule was imposed in January 2001, the organization was forced to close three of its 15 clinics due to lack of funding. Two more that have been limping along will shut their doors in December. The British family-planning organization Marie Stopes has also closed two Kenya clinics.
Most of the closures have been in Nairobi slums and poor rural areas, where family planning had been heavily subsidized. USAID was one of the few donors providing large amounts of aid for family planning and Ettyang and his colleagues have been unable to replace the lost funds.
There are plenty of grants for AIDS education, but few for non-condom contraception programs such as Norplant, a long-term hormonal implant, and the Pill--popular options among Kenyan women who use birth control--despite evidence that family planning reduces maternal mortality and generally raises the standard of living for a family.
In comparison to other African nations, South Africa has a low maternal mortality rate, only an estimated 230 deaths per 100,000 live births compared with an average of 830 per 100,000 for the continent as a whole, according to the new report. Yet proportionately more mothers die in South Africa than in Asian and Latin American countries of equal wealth.
University of Natal Professor Jack Moodley, who chaired a South African government report on maternal mortality released earlier this year, says one reason for the poor maternal health is that, despite free prenatal care, many South African women fail to seek medical attention early enough in their pregnancies. Programs are now underway to improve prenatal education, but only began a few years ago.
"We need improvement in education in general, improved literacy rates, health education in schools," he says. "All that is being done, but I think we're only going to see the effects in a few years."
Research in South Africa, which has more HIV-positive people than any other country in the world, also indicates the number of pregnant women dying of AIDS is on the rise and is now one of the highest causes of death for pregnant women in the country.
According to the report prepared by Moodley's team, AIDS-related deaths now account for at least 17 percent of maternal fatalities and that percentage is likely to rise in coming years as the epidemic reaches maturity. In addition to simply improving and making more accessible general prenatal care, HIV-positive pregnant women will likely be a target group for South Africa's new national antiretroviral drug program which is currently being designed the government. Antiretroviral drugs can prolong the life of HIV-positive people and reduce the chance that they pass on the disease.
Africa's richest country has the luxury of looking at expensive remedies like antiretrovirals. Most African nations, however, are struggling to provide such basic care as skilled birth attendants and access to family planning services.
Even in Kenya, where family planning programs have helped to cut the birth rate from an average of eight children per woman to 4.5, only about 31.5 percent of women use modern birth-control methods and only 44 percent of women are aided in labor by trained assistants.
Efforts to reduce maternal mortality are hampered not only by lack of funds, but also by strong opposition to family planning by conservative forces such as the Catholic Church--which continues to oppose any contraception even when it is intended to prevent the spread of HIV/AIDS--and the U.S. administration which puts enormous pressure on countries and organizations to oppose abortion.
"There are people here who don't even want to hear the words 'reproductive health,'" says Dr. Solomon Orero, one of Kenya's strongest advocates of the right to abortion and head of an organization that trains rural health care providers in post-abortion care. "And that is emanating largely from your country, from the Bush administration."
Nicole Itano is a free-lance writer based in Johannesburg.
United Nations Population Fund:
Family Care International: