Baby steps

Giving birth might be the most universal human act but the way it happens varies considerably around the world. How can it be made safer for both mother and child?

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Every day, 830 women die from complications in pregnancy and childbirth. This is despite a 44 per cent reduction in maternal death between 1990 and 2015.

For every woman who dies in childbirth, around 20 more suffer injury, infarction or disease. One million children are left motherless each year from birth, and are up to 10 times more likely to die themselves before their second birthday.

“The act of giving birth is still very much a lottery with the dice loaded according to who you are and where you live,” says Dr Mukesh Kapila, professor of global health and humanitarian affairs at Manchester University.

In 2015, 4.5 million infants died. In 1990, this figure was twice as high – but the World Health Organisation believes that maternal and infant death are under-reported.

Improvements are due in part to the fourth and fifth UN Millennium Development Goals (MDGs), which aimed to reduce global maternal deaths by three-quarters and infant mortality by two-thirds over 25 years. But neither goal was reached.

“If you are born in a rich country, you expect to live 82 years and to bear 1.7 children. But if you are poor, you will bear on average 4.3 children and be lucky to get past your 66th birthday,” says Kapila, who will join other experts on panel discussions that are part of the Birth festival of theatre and debate at Manchester’s Royal Exchange this month. The discussions will follow plays by seven female playwrights, exploring labour in their home countries. Each will highlight gross gender inequalities through the prism of birth.

Many forms of violence against women have a direct impact on the birth experience. Rape is used as a weapon of war, and Kapila adds that the forced impregnation of women is recognised as a form of genocide. Domestic abuse often escalates during pregnancy if the mother lives in an abusive household – and worldwide studies indicate that up to 30 per cent of pregnant women do. Violence in pregnancy increases risks of miscarriage, infection, premature birth, low birth weight and stillbirth.

“If men were pregnant, we would have a completely different world.”

“I have worked in over 120 countries and a lot in women’s health, and the fact that services for maternity and birth, and women’s health generally, have been under-resourced forever is gender political. I’m sure if men were pregnant, we would have a completely different world,” Kapila  says.

In Kenya, progress on maternal mortality has been slow but gradual since 2013, with the introduction of free maternity care. Just over 60 per cent of deliveries now take place in a public institution, and deaths have dropped.

But in rural parts of Kenya, where most women give birth at home without skilled attendants and far from emergency care, there is a high level of obstetric fistula – a subject explored by Nairobi-based playwright Mumbi Kaigwa for her verbatim play at the Birth festival.

Fistulas occur when a labour becomes obstructed, often the result of female genital mutilation, and the patient does not receive timely access to a Caesarean section. The foetus becomes stuck in the birth canal – sometimes for days –often leading to stillbirth. Contractions push the baby’s head against the patient’s pelvic bone, denying adequate blood flow to delicate tissue. This creates ruptures, leading to incontinence.

Fistula treatment is not free in Kenya and there are as few as five doctors and 10 trainees who can perform the simple operation to correct it. Many women who suffer are ostracised from their communities, partly because of the poor hygiene that follows, and partly because, in traditional communities, there is a stigma attached to giving birth in a hospital rather than at home.

Six thousand miles away, Brazil offers a very different picture of childbirth. The country has the highest rate of caesarean sections – addressed by Brazilian playwright Marcia Zanelatto in The Birth Machine.

Kapila notes that while there is no money in maternity, as it is a natural process – hence a dearth of research into making birth safer – there is money in C-sections. In Brazil, 66 per cent of births occur via C-section, the majority are not medically necessary. He says that they are a result of coercion by the medical profession.

“The culture in Brazil is that giving birth is for poor people,” says Ana*, a Brazilian mother of two living in Leeds. “I opted for a natural birth the first time and my family and friends in Brazil thought I was insane. I explained that in England you can’t just choose to have a C-section. They thought that was just barbaric.”

Following a complicated birth, Ana had her second child in Brazil, where she was guaranteed a caesarean.

“Even if you visit a doctor who says they don’t routinely do C-sections and they prefer natural birth, it’s not true. They will make up a problem to make you have the baby via C-section. I only know a few people who have managed to have natural births in Brazil. The doctors convince you there is something wrong and you need to get the baby out as soon as possible.”

Like the beauty industry, profit making has driven fashion. In Brazil, if you are posh, you don’t push.

“The national health system is really basic,” says Ana. “Women want to go to a nice hospital. Some of them have champagne for guests, and the mums go to the hospital with their hair done, their nails done, waxed. The women think that everything down there is going to get ripped and ruined for their husbands forever, which is not true. It’s very shallow but they have been manipulated into thinking that way because it’s an industry of money-making.”

Although Ana felt that flying to Brazil would allow her to take control of her birth process, the experience soon became disempowering when she was, she believes, coerced into an early C-section by a doctor keen to leave for a holiday.

Rules introduced in Brazil last year require doctors to inform patients about the risks of a C-section and to justify their position if they believe that it is necessary. But Ana says that conditions for the alternative are poor.

“They leave you alone and make you suffer because they get so annoyed that you’ve opted to have a natural birth – it’s not scheduled, they’re going to have to be there with you for ages. They make it as miserable an option as possible.”

Although the number of caesareans in the UK is a snip of Brazil’s at 25 per cent, critics believe that this figure is still too high. Kapila says that here, too, women are disempowered by the medicalisation of birth.

“Birth is inherently risky but it’s a balance of risks and we have become extremely risk averse – home births are frowned upon, while risk factors like eating soft cheese may be blown up by public health. Women can’t use their basic common sense and they can’t enjoy the experience [of pregnancy] – it’s nine months of terror, foreboding and every two minutes there’s scans, tests, screens and so on.”

While many patients may feel they have been denied their liberty in the birth process, for around 100 women in prisons each year, this is a reality long after their babies have been born. Dr. Rachel Dolan of the University of Manchester has been researching birth in prisons for nine years.

“Antenatal care is good and there is regular access to a midwife. When they go into labour, women may be handcuffed on the journey and will have two uniformed officers with them when they arrive at the hospital, which is embarrassing,” Dolan explains, adding that the officers are not necessarily female. “They stay in hospital for as long as you normally would and the baby will be removed usually within less than 48 hours. They are entitled to six weeks’ maternity leave from prison work.”

A lucky few of the 600-800 mothers of babies in prison each year will get one of the coveted 65 spaces in mother and baby units (MBUs) in eight of the 13 women’s prisons in the UK. But the units are rarely full. Dolan says that many women don’t apply because they feel that social services won’t support their application due to past their childcare history. Others feel that their children are better off outside prison walls with family.

Although patients’ physical needs are met in prisons, there is no formal emotional support. “Any woman who is pregnant or has recently had a child is much more likely to suffer from mental illness, and around 90 per cent of women in prison have some kind of mental illness or disorder anyway,” says Dolan. “The women I’ve spoken to who have had children removed are generally very depressed. It’s a completely devastating experience, but because many of them have faced so much adversity previously, this is just another dreadful experience on top of everything else, and they somehow manage to find a way to carry on.

“Most are not violent, most have mental health problems, many have substance use issues, and prison is not the place to resolve those problems. We need to stop sending these women to prison because the damage done to their children is horrendous, and it perpetuates a cycle of people living through very difficult circumstances.”

In other parts of the west, even women’s most basic physical needs are not being met. The US rates 61st globally for maternal health and has the highest maternal mortality rate in the first world – something that Kapila attributes to inequality and the absence of nationalised healthcare. The average cost of a natural birth in America is £20,000, and a Caesarean almost double.

“Many high risk mothers – those who are poor, possibly have poor health or other risk factors – delay seeking antenatal care because they are not part of an insurance scheme,” says Kapila. “It’s a very stupid system driven by the self-interest of the medical and insurance community. Americans spend record amounts of money on medical care and they get some of the worst health outcomes for a developed country.”

The UK and the US will be explored in the Birth festival by Stacey Gregg and Kirsten Greenidge, while Syrian playwright Liwaa Yazji will look at the effects of conflict on the birth process. This summer, Kapila visited the Calais migrant camp.

“The vast proportion of the camp’s population is women and children, and the reason for this is that the men got away,” he says. “Each mother, baby in tow or pregnant, had a unique story to tell – of fear, of violence, of separation. For them, birth means something very different.

“One woman asked me whether she should have her baby there in France or whether she should have a baby in the UK and come across illegally. The child would have no status and legally not exist – imagine the life chances for the future when actually you’re alive but you don’t exist.”

In China, many female babies have never been given the chance to exist. Xu Nuo reveals how gender supremacy still prevails in her nation in her play A Son Soon.

A historic preference for sons over daughters among many parents – sons are believed to be more of an economic asset and to preserve family lines – has led to sex-selective abortions and female infanticide at birth, often by drowning or abandonment. This has been exacerbated by the country’s one-child policy, which began in 1979 and ended last year. The result is an estimated 40-60 million girls fewer than there might have been.

“These are girls who have not been allowed to be born,” says Kapila. “This is genocide – or rather femicide – and an outrageous abuse of human rights.

“You would have thought that with women being rare they would be highly prized or respected as potential wives, but it hasn’t improved the treatment of women in society. If you kill them off because you think they’re not worth being born then you can see what that says about society’s treatment of women.”

As in FGM-affected countries, where many of the cutters are female, women in China have been implicated in this femicide, but Kapila believes that they cannot be blamed wholly as they themselves are victims of a society that has brainwashed them for centuries. But haven’t men been brainwashed equally?

“We can definitely blame men,” says Kapila. “If we blame society in general, that is a get out of jail sentence and no one is accountable. Men set the tone for society. They are more educated and richer so very definitely have to take some kind of historic responsibility for this.”

Kapila: giving birth 'still a lottery'
Kapila: giving birth “still a lottery”

Three years before China introduced its one child policy, India began trying to bring its population under control with a family planning programme made up of sterilisation camps, which Indian playwright Swati Simha* examines in Ouriboros. Last month, the Supreme Court ruled that the camps should be shut down within three years. The court heard that 363 women had died during or after surgery in the camps between 2010 and 2013 alone due to doctors using contaminated equipment and expired pharmaceuticals.

“Other forms of contraception have been neglected, and the way it was done on a mass scale created coercion,” says Kapila, pointing to the payments that doctors receive per operation and the financial incentives offered to women and men to undergo surgery. They were taken up largely by women. Only 1 per cent of Indian men undergo the procedure, but one in four Indian women are sterilised, according to the WHO.

Maternal health on the whole is improving in India, with the number of maternal deaths per year down since 1991. But even now, 120 women die of causes associated with pregnancy each day.

Of the eight MDGs set in 1990, which included universal primary education and combating malaria, improving maternal health was the worst-performing because of the social, economic and cultural issues that underpin it.

The MDGs have been replaced by the Sustainable Development Goals, which aim to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030.

“These goals are much better – they’re more broad based and include enabling factors,” says Kapila, former special adviser to the UN and resident representative in Sudan. “They concern wider society, which is necessary to hit this particular area. It’s more about prevention, investment, public health, education, social change, and it’s learning the lessons of the somewhat limited MDGs.”

As well as robust laws, Kapila insists that we also need men to champion these issues, saying that women talking to other women about women’s issues won’t change societies dominated by men.

“We have all the technical means we need. We have the all the science we need. We have all the knowledge we’ll know. We know what the problems are and we know how to tackle them. What’s lacking is some kind of leadership to make a determined assault on this problem.”

Birth is on 19-22 Oct, Royal Exchange, Manchester. Against a Tide of Evil by Mukesh Kapila is out now

“The anaesthetist jumped on my bed”

Ana is a Brazilian mother of two living in Leeds

“I had a natural birth with my son in Leeds and it was quite traumatic. He was a big baby, 9lb 13oz, and I was really poorly after giving birth, so I went to meet with a consultant when I fell pregnant with my daughter and they said they wouldn’t give me a C-section. It was a no-brainer to go to Brazil.

“When I met my doctor, we set on a date at 39 weeks. But I started having some contractions before that and they started panicking and saying that my baby was going to suffer. They sent me for a scan and said they needed to get her out. I was 35 weeks.

“I went for scans every two days to monitor the baby. Even though I had insurance, it didn’t cover much, and this was a very expensive scan where you could see the blood flow.

“When I was 37 weeks, I went to the doctor and she said we were going to the hospital tomorrow. She told me we needed to get her out because the placenta was mature, because the cord was around her neck, because she was already big – giving me all the reasons, and I know they were excuses. I have had a baby here and these things are not a problem. The doctor was lying to me but I was scared and emotionally drained so I went along with it. I later found out that two days after the section, she was on holiday – so she couldn’t have done it at 39 weeks.

“I had to pay for my doctor to do the C-section, otherwise I would have had to have it done by a student or someone I don’t know. I was so comfortable with my own doctor, I wanted her to do it. I paid 1,500 Brazilian real (£350) for the section. I had to pay for all the instruments they used – that was another 600 real (£140). I had to pay for all of my medicine and for my scans because they weren’t standard.

“I would not go to Brazil to have a baby again. Everything is very plastic. The actual section was very fast – they have so many, they have to do it as quickly as possible. She wasn’t coming out very easily so the anaesthetist jumped on my bed and started forcing my belly down for the baby to come out. I was screaming: ‘I feel sick.’ Baby came out and they showed her to me – she was black because she needed oxygen, she wasn’t expecting to be born.

“They whisked her away and put me in a recovery room. Nothing was said. I didn’t know what was going on. My baby wasn’t with me. It was really strange. I just lay there thinking: ‘Where’s my baby?’

“Over here, baby came out and went straight to my chest – nobody touched him, so he just stayed with me the whole time and I felt like I bonded with him. I didn’t feel like I could bond with my daughter – it took time.

“They brought her back to me four hours later, bathed, dressed, all ready. I was like: ‘No, I want my newborn – dirty, naked.’”

“I have to just smile and suck it up”

Mama Deux* talks about her experience of fistula, caused by an expensive Kenyan obstetrician

“When I was in hospital, there was a lady who had a daughter my age – so she could easily be in her late seventies or early eighties. The doctor told me she had a fistula, so she’d been living with it for about 40 years. But you know just the stigma associated with it – you just don’t talk about it.

“It’s a horrible feeling, I tell you. I had given birth to my daughter fine. I didn’t even have an episiotomy. Then I had my son. I am what the doctor’ call “two-para-six”, which means I have had two children live from six pregnancies. I have miscarried and my first daughter lived for 100 days. Then I had two mid-term losses.

“When I had my son in July, I was completely paranoid, but I was walking around the labour ward thinking: ‘Oh, good, this is going well.’ So I told my husband to go home and I stayed with the doula. But then my labour pains disappeared, so I rang the doctor. It was five in the morning, and he said: ‘Let’s watch how it goes.’ He came – I’ll never forget – at 12:30 in the afternoon and he ordered oxytocin to induce the labour.

I was happy the baby was out and healthy, but I was in so much pain

“I remember being horrified. I’ve never been induced, but I knew it was crazy. It was too much. My doula was telling me to breathe but I had no time to breathe. Contractions were coming left, right and centre. I couldn’t breathe, so they gave me Pethidine. I was frantic – I didn’t want painkillers because it is a natural process. The baby came in 45 minutes. He was okay – a fat little thing – but he had bruises on his face. My beloved doctor said: ‘Oops, torn cervix.’ And I thought, ‘But cervixes don’t tear. You can tear the perineum through pushing, but cervixes don’t tear – they’re supposed to soften to 10 centimetres.’

“I was happy the baby was out and healthy, but I was in so much pain. The Pethidine started kicking in and I was getting drowsy. My doctor said he was off to the next delivery. My husband was excited, saying: ‘I have a SON!’ I looked at my baby and he was really, really dark. I mean, babies usually come out light and darken with time. I kept saying: ‘Is this mine?’ I don’t tend to bond with my babies straight away because of my losses. I take time because I don’t know if they’re going to be here with me for long.

“After that, I kept getting fevers. The doctor said, ‘Oh, maybe you have mastitis.’ But I said, ‘I know the symptoms of mastitis and this was not it.’ Then he said, ‘Maybe you have cow fever.’ And my husband, who’s a farmer, said, ‘I know cows and this is not it.’ So we had a laugh and I went home. My husband’s birthday was coming up. Three days later, I was completely out of it with fever.

“In the middle of the night, I was sweating. My husband called the doctor who said maybe I had ulcers. I knew it wasn’t ulcers and something was very wrong. I was wheeled into casualty, examined and admitted immediately. I turned out I had peritonitis, an infection of the peritoneum, which causes multiple organ failure, and that’s what was happening to me. It was day nine now, but I was also leaking; I knew the discharge wasn’t normal. When I was positioned a certain way, I would leak, and I started suspecting it was pee. So the doctor said, ‘Maybe you had a vaginal prolapse, but first we need to keep you alive.’ I was hospitalised for about 10 days on high doses of antibiotics, then I was sent home.

“One day, I was in the mall buying diapers times three – for my baby, for my two year old and for myself. I felt a leak and I just stood there in the shop and started crying. My husband was confused. I said, ‘Do you understand? I have to just smile and suck it up.’

“One day, I had relatives around and I said, ‘I’ll be right back.’ I went to my doctor’s, walked into his office and said, ‘I don’t have an appointment, and I know you have people waiting, but we need to figure this out because I am not going to live like this. I can’t.’”

“Communities can be very cruel”

Mumbi Kaigwa’s research for her play, Orchid, led her to Gynocare Fistula Centre in Eldoret, a town in the North Rift, Kenya

Doctor Hillary Mabeya operates on around 500 women a year and another 500 in camps during outreach work. He has operated on over 6,000 fistulas, but says that there are between 3,000 and 7,000 new cases in Kenya per year, in addition to a huge backlog of women who have been living with the condition for years.

“The oldest patient that I operated on had suffered for 77 years,” he says. “She was 93 years of age and said she wanted to die clean without the wetness.”

Mabeya first encountered fistula in 1997 in Pokot, Kenya, where female genital mutilation and child marriage had led to a high rate of early labours that became obstructed during home births, subsequently leading to fistulas.

“We only had one surgeon who could come once a year to do the operations, so the ladies were desperate. I could not do anything about it,” he says.

After training as a gynaecologist, he opened the Gynocare Fistula Centre in a rundown house with only three beds. On its first day, he received four patients and had to bring his own bed from his home into the facility. It now has 25 beds, and Mabeya hopes to move into a larger facility soon.

“My hope was to create a place where I can give these women care despite the fact that we didn’t have enough money,” he says.

“Ninety-five per cent of the patients are women who have literally nothing.”

Fistula is not considered a maternity issue in Kenya, and Mabeya says that he has given up on trying to secure a commitment to treat it as such from the government. The majority of his funding comes from US-based non-governmental organisations, including the Fistula Foundation and Fistula Project. Much of his work is funded by performing caesarean sections in private hospitals.

“Ninety-five per cent of the patients are women who have literally nothing,” he says. “They walk into the clinic barefoot. Sometime we have to buy them slippers. They are marginalised, the poorest of the poor.”

Before maternity care became free in 2013, many of his patients would suffer from subsequent fistulas because they were forced to give birth naturally instead of having a caesarean section as recommended following fistula surgery. Many women who suffer from fistulas are ostracised from their communities because of the poor hygiene that follows leakage and recurring infection.

“Some have been divorced, some have been left by their relatives because of the smell that comes with the urine and the stool. They are desolate. They are on their own and they don’t have knowledge or the funds to reach the hospital in the first place. Some are even extremely malnourished because they don’t have the income to eat well, and many are depressed.”

Dr Khisa Weston Wakasiaka, a consultant fistula surgeon in Kenya who is researching and working in the rehabilitation and societal reintegration of post-operative fistula patients, says that the ostracisation of fistula sufferers goes beyond hygiene. In traditional communities, there is a stigma attached to giving birth in a hospital and an assumption that women who cannot give birth naturally are inadequate as mothers and as women.

“We found out that slightly over 90 per cent of the fistulas were due to neglect or prolonged labour,” says Wakasiaka. “[After surgery] it’s on us to come and tell them, ‘You are okay and you are clean enough to make a meal, clean enough to have sex with your husband, clean enough that your children in school are not rejected by fellow pupils and teachers.’ What we came to realise is that communities can be very cruel and [that these women] hold a mirror up to society.”

“Rape is happening by outsiders”

On a research trip for her play, Ouroboros, Indian playwright Swati Simha learnt about the plight of the Ho Adivisi women

Jharkhand, a state in eastern India, holds one of the worst records on maternal mortality – 208 deaths per 100,000 live births, compared to the national average of 167. This excludes the number of unreported deaths in remote or tribal communities. In rural Jharkhand, only 39 per cent of births are attended by a skilled health professional.

Noamundi, a small iron ore-mining village in Jharkland, is home to the Ho Adivasi tribal population. Until 2014, residents were largely invisible to the census, as land rights of the Ho people have rendered the village, and others like it, non-existent in the eyes of the government.

Swati Simha's research trip to India included a primary health centre in Noamundi
Swati Simha’s research trip to India included a primary health centre in Noamundi

In a conversation with healthcare professional Ajitha George, who works for the NGO Aumon Mahila Sanghatan, Simha found that while the status of Ho women is high, the infiltration of mainstream religion, colonialism, industrialisation and subsequent capitalist and patriarchal systems have led to a decline in the treatment of Ho women and poor maternal health.

“Anaemia is very common here and 70 per cent of women and children are malnourished,” George says, explaining that this has much to do with deforestation due to mining in the iron-rich Jharkhand jungle.

“The Ho are part-gatherers, part-agriculturist, and their food resource base has been eroded. A lot of mining companies came here in the last decade, so the amount of deforestation increased many-fold, which has affected the health of the people. There’s also been a lot of migration, as people are going to find work in other states and money has become more important than cultivation.

“The worst-affected are the women, because they have to do a lot of the work and don’t get enough to eat – and because of constant childbearing. Deaths among women are high and they are vulnerable to diseases like malaria, which is very common cause of death here, and TB, which is also prevalent.”

It’s not just deforestation that has affected the Ho women, however – the development of the mining industry has opened up new areas of exploitation. The mines have attracted a large influx of men since the 1960s, which has disrupted the sex ratio – there are only 84.4 females for every 100 males. Living outside of mainstream religion, the Ho were socially stigmatised and easy targets for sexual abuse by the male workers. Reports of trafficking of tribal girls and prostitution emerged, and the health of the mineworkers was poor, with many suffering from sexually transmitted diseases.

“There is very strict punishment for rape and incest in Adivasi ethic,” said George. “Among the Ho, men and women treat each other with respect. Rape is happening by outsiders – the Adivisi women are trusting and would socialise with men and it would be interpreted as them being sexually available.

“Workers would visit the village in the evening to drink rice beer and they assumed [that] because the women were selling rice beer, they were also selling their bodies. Contractors would exploit women and they would keep them as long as they worked here – they’d [impregnate them], then they would leave. Industrialisation brought lots of people in from outside and there was a clash of cultures.”

*Names changed to protect identity

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