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Maternity's Thin LineNana Kofi Acquah

Maternity's Thin Line

What separates mothers who die from those who survive?

The handwritten notes in the hospital logbook are spare, but they tell the story of how a woman named Amina Seidu nearly died giving birth at one of the best hospitals in Kumasi, Ghana.

 Seidu (whose name has been changed to protect her privacy) lives in a dusty settlement of cinderblock family compounds clustered beside a green-roofed mosque on the periphery of Ghana’s second-largest city. In one of those compounds, she shares two rooms with her husband and their daughters, 8 and 4.
On a late summer afternoon, she serves visitors water from a hand-cranked well and tells how her fourth pregnancy nearly killed her.

Labor pains woke her before dawn one morning last May, says Seidu, a 29-year-old woman with broad cheekbones and a turquoise floral headscarf. For this baby, she and her husband had decided that she would go straight to a referral hospital in Kumasi. The long taxi ride would be expensive for a couple that makes a living selling machetes and groundnut paste in open-air markets. But their third child had been born dead after a 15-hour labor in a local clinic, and this time they wanted expert care. Amina Seidu had gone to seven prenatal checkups and expected no problems.

When she and her mother-in-law arrived at the hospital at 6 a.m., the nurses told Seidu that her baby would take some time to arrive. By noon she had begun to gush so much blood that it pooled on the floor beside the bed. The nurse-midwives brought her pads. She soaked pad after pad. “I can’t count how many,” says Seidu, who remembers calling for the nurses many times. “They thought I was a complainer.” Seidu was hemorrhaging.

"Maternal mortality is ‘the tip of the iceberg.”—Michelle Hindin

Eventually, she says, a doctor passed by, saw the blood and rushed her to the ultrasound room. She remembers nothing further until she woke to find that her baby had been delivered by cesarean section and that the baby was dead. Her husband and his father buried the child, a boy. She never got to see him.
“God gives and God takes away,”  she says.

If Seidu had followed her son to the grave—and she came close—she would have been among the hundreds of thousands of women whose deaths cut a red swath across the world map in a recent Lancet assessment of maternal mortality. UN Millennium Development Goal 5 calls for a 75 percent reduction in maternal deaths between 1990 and 2015. The red on the Lancet map indicates countries that, at current rates, won’t reach that goal by 2015, or by 2025, but rather after 2040. Red covers most of Latin America and the Arabian Peninsula, much of Central and Southeast Asia, and nearly everywhere in Africa south of the Sahara. More than half the women who die from pregnancy-related complications worldwide are Africans, according to WHO.

In narrowly avoiding death, Seidu became what researchers call a “near miss”—a woman who nearly dies because of complications of pregnancy or birth. While the study of maternal death has long been a public health priority, researchers are increasingly studying near misses. They hope this research will help forestall severe complications, improve care when complications do occur and increase their understanding of what leads to deaths.

“Maternal mortality is ‘the tip of the iceberg,’” says Michelle Hindin, PhD ’98, MHS ’90, an associate professor in Population, Family and Reproductive Health (PFRH) at the Bloomberg School. “Women who nearly die but survive are much more common, and their needs are not being addressed.”

Near misses almost always occur in clinics and hospitals; medical interventions are what prevent crises from becoming deaths. However, the health care facility is a “black box,” says Özge Tunçalp, MD, PhD ’12, who studied near-miss cases globally and in Ghana for her doctoral work with Hindin.

Near-miss researchers look inside that box both to suggest improvements as well as learn about maternal mortality. The circumstances and events that lead to a near miss resemble those that end in a death, says Tunçalp, who now works for WHO in Switzerland. A woman in a life-threatening condition will become either a maternal near miss or a maternal death; the distance between the two is “a thin line,” says Tunçalp.

Numbers for near-miss cases also can serve as “proxy indicators” for maternal mortality, which is likely underestimated because one in three women in developing countries gives birth without medically trained attendants, and deaths at home often go unreported. Because near misses occur in clinics and hospitals, however, researchers capture them all.



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