Safe Motherhood: The difficult battle to reduce maternal deaths by Ruth Ayisi Montepuez, Cabo Delgado province - For two long days, fifteen-year-old Arminda Mário tried to push her baby out of her slight body. Eventually, the child’s decaying dead body emerged at sun set with the help of a traditional midwife. But Arminda went into a coma. In desperation, Arminda’s family rounded up their neighbours to carry her on a make-shift reed stretcher to the nearest rural hospital, a four-hour walk, mostly in the dark of the night across rough terrain. When they finally arrive at the rural hospital in the district of Montepuez in the northern province of Cabo Delgado, Arminda was still in a coma. Elsa Jacinta, one of the only two obstetricians in Cabo Delgado province at the time, met her. “At first it looked like the baby’s head was hanging out of her, then I saw that it was her internal organs,” said the doctor. Arminda had suffered a fistula, rupturing her uterus, which made her urine and faeces come out of the same opening. She was feverish and was in desperate need of surgery, which could only be performed in Pemba, the provincial capital, another two and a half-hour journey by road. Although Mozambique’s maternal mortality ratio has dropped from an estimated 1,000 women dying out of 100,000 live births to 408 per 100,000 live births, it is still one of the world’s highest ratios. Cabo Delgado, the northern most province with 1.4 million people, where Arminda lives, has some of the worst maternal health indicators in the country. According to the Cabo Delgado health directorate, in 2003 health professionals only attended 31.4 per cent of all deliveries, and only 29.4 per cent of all deliveries took place in health facilities. These rates are the lowest in the country. The national averages for attended and institutional deliveries are 48 and 49 per cent respectively. UNICEF is supporting the provincial health authorities to improve the quality of maternal healthcare. One of the key activities is to educate the community, including traditional birth attendants (TBAs), to refer pregnant women directly to a health facility. “Lack of education and myths about childbirths is one of the major problems we’re up against,” says Carolina Siu, UNICEF project officer. Siu points out that Cabo Delgado’s high maternal and child mortality rates go hand in hand with a very high women illiteracy rate of 83 per cent compared to 22 per cent in Maputo city. Under normal circumstances, Arminda should have been hospitalized as soon as the complications were apparent, and a caesarian section would have prevented the rupture of her uterus. But all too often the families delay making the long, arduous journey to the hospital due to misguided beliefs. Complications in pregnancy, such as sepsis (infections), hemorrhage and uterine rupture, are in some areas believed to be the woman’s fault. Elena Feta, an elderly traditional birth attendant in Linde, in Montepuez district says in the local Mocua language, “If a woman has bad habits during her pregnancy, then she will have a complicated birth.” Asked for examples of bad habits, she mentions “sex with another man.” Even if families bring a pregnant girl or woman to the hospital in time, traditional values in Cabo Delgado province can still prevent her life from being saved. Mothers can die because family members refuse to donate blood. A doctor working in the district says that some men refuse to give blood to their dying wife because they think if they divorce, their wife will take their blood away. Another problem is that childbearing begins especially early in the province. According to the local health directorate, in 2003 almost 54 per cent of women under the age of 20 were already mothers. The use of a contraceptives reported for the province in 1997 was less than one per cent, but has increased since to 10 per cent. UNICEF supported maternal health activities include a major communication campaign about safe motherhood, and the strengthening of the technical capacity of staff to provide quality obstetric care. So far, staff from 20 maternity facilities and 4 hospitals have been trained. Because much of the population is spread out in remote rural homesteads, and both public transport and communication are weak, UNICEF has provided ambulances, and short wave radios with solar panels which have been installed all over the districts. UNICEF has also provided ambulance-bicycles for rural areas where there is no public transport. “Community leaders select a person to be in charge of the management of the ambulance-bicycle: responsibilities of this person include bringing women from their house to the health unit and ensuring that the bicycle is properly maintained,” says Siu. For women living in remote areas with high-risk pregnancies, “waiting houses” were built with UNICEF support in Mocímboa da Praia Rural Hospital, Nangade and Muidumbe Health centres. Pregnant women together with their mother in law, sister or aunt can stay there in safe conditions during the last days of the pregnancy. The expectant mothers and their relatives can also receive more information about care of the newborn baby, breast feeding, family planning and nutrition. Over the past years, there has been some impact. From 2000 to 2003 the institutional deliveries increased from 25.5 per cent in 2000 to 29.4 per cent in 2003. The number of maternal deaths in the community decreased from 19 to 10 deaths. This could be the result of TBAs being better able to recognise high-risk pregnancies and promote safe delivery methods. Arminda also survived. She was luckier than many other young women, and underwent a successful operation in the Pemba Hospital, in the capital of Cabo Delgado province.
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