analysisBy Mary Mwanyika-Sando
Underfunded facilities and cultural taboos mean that giving birth can be a deadly game of Russian roulette for women in sub-Saharan Africa.
One midnight, in the department of Obstetrics and Gynaecology at Muhimbili National Hospital in Dar es Salaam, Tanzania, 26-year-old Anna was brought into the labour ward on a stretcher. Her eyes were half open and she was too weak. Just a few hours earlier, Anna had been a typical mother-to-be, looking forward to her first child. But now, despite doing everything possible to try to save her life, it was simply too late.
Anna's death was the result of missed opportunities far before that tragic night. Anna should have been diagnosed with anaemia in prenatal appointments and received treatment.
And once she was at the local clinic, she could have been given a blood transfusion. With these simple steps, Anna and her baby could have survived. But instead, she died within 25 minutes of being admitted. Her baby died at the local clinic.
As the medical intern at the ward, I had to explain what had happened to Anna's husband. Even before I could speak the word death, tears began to stream down his cheeks. They had been married just one year.
Unacceptable and preventable
The Anna of story is deeply sad, but even more tragic is the fact that in this part of the world, there are so many Annas and so many grieving husbands. In the developed world, only 1 in every 3,800 mothers die in childbirth.
It is practically a thing of the past. But in sub-Saharan Africa, that figure stands at 1 in every 39 - a rate nearly 100 times higher. According to the World Health Organization, every day 800 women - the vast majority in the developing world - die from causes related to pregnancy and childbirth.
This is both hugely unacceptable and would be preventable with increased funding for local clinics where the majority of pregnant women give birth. So as the UN discusses priorities on the development agenda following the expiration of the 2015 Millennium Development Goals, it is crucial that there is a focus on improving basic healthcare for pregnant women.
Three deadly delays
Africa's expectant mothers face three main risks, what experts refer to as the "three delays": delays in leaving the house initially; delays in reaching health facilities; and delays in receiving care after reaching health facilities, many of which are understaffed with limited or even no supplies.
The first delay is more complicated than it might sound. Often, there is nobody available to take the pregnant woman to the hospital. Many women also wait for their husbands' permission in order to leave.
In many cultures, the husband is considered the head of the household, and the wife is limited in her ability to make independent decisions, even about her own health.
The second delay - in reaching health facilities - is often an issue of infrastructure as well as financial constraints. Many women lack reliable transport to get to the hospital. And when transport is available, women often don't have the money to pay for it.
Even if a woman is lucky enough to overcome the first two delays, the third can still prove fatal. I have often walked into a district hospital in Dar es Salaam to find the lobby crowded with patients in need.
Many, even those close to active labour, sit on the floors because the benches are too full, quietly waiting to be seen. Many such women have been socially conditioned not to speak up even when in pain. This means that many birthing mothers do not advocate on their own behalf, sometimes until it's too late.
Asides from these three delays, healthcare is often of poor quality and medical resources lacking. There are limited numbers of skilled healthcare personnel in the likes of Tanzania, the organisation of services can be poor, and there are often shortages of blood and equipment necessary for emergency procedures such as caesarean sections and other treatments.
Tanzania has 65% fewer skilled health workers than the government deems necessary - a shortfall similar to those seen in many other sub-Saharan African countries.
Making birth a celebration not a risk
The question of how to address these problems is urgent.
One aspect of the challenge is cultural. And while cultural change may be slow, it is possible. Furthermore, as a Tanzanian woman married to a man that considers me his equal, I know such gender relations can happen in my country.
One way in which we can begin to change how and when women vocalise their needs is by using women as champions and ambassadors in their communities.
These women can educate others on the importance of seeking healthcare at a health facility before, during and after pregnancy. We should also motivate health staff to provide better interpersonal care by providing information that empowers women to take control of their health, and plan, with their husbands, issues around birth preparedness and facility delivery.
But culture is not the only issue and we don't have to wait for a cultural shift before we act. The most immediate impact can be achieved by strengthening the healthcare systems at local clinics - by providing better funding and hiring, and training more staff to improve skilled delivery.
More funding for maternal and child health services could allow district planners to incorporate the expansion of health facilities, and provide the necessary equipment and supplies for them to care for more mothers, while also providing the best quality of care.
These and other steps might have been enough to save the lives of Anna and her baby, as well as those of so many others like them. They would certainly allow me to be a more effective physician.
I am a doctor and a wife, but I am also a mother, and I have been fortunate enough to have had the best care available in Tanzania during both of my pregnancies and deliveries.
And as a public health expert, I envision a day that every woman in sub-Saharan Africa, and every woman throughout the world for that matter, can experience pregnancy as a celebration rather than as dire risk. This is not an impossible dream. This is a hope, and one that is within our power to turn into a reality.
Mary Mwanyika-Sando, MD, is the Maternal and Child Health Coordinator at Management and Development for Health (MDH) in Dar es Salaam, Tanzania, and a 2013 New Voices Fellow with the Aspen Institute.