Summary: Maternal Mortality—One Woman a Minute, Why Do Women Die in Childbirth?, Family Planning and the “God Gulf”: Chapters 6-8

Chapter 6: Maternal Mortality—One Woman a Minute

Chapters 6 and 7 cover another aspect of gender inequality: reproductive health care. During a difficult delivery, a pregnant woman may have an obstructed birth canal and develop a fistula, or tears in her bladder and colon. Fistulas leave the woman incontinent, and if surgical care is not widely available, she may be shunned as a result.

This condition affected Mahabouba Muhammad, a 14-year-old Ethiopian girl pregnant by the 60-year-old man who bought her as a second wife. Mahabouba was incessantly beaten, so when she was seven months pregnant, she ran away. Her uncle housed her in a small hut. Mahabouba was so young that her pelvis was not fully developed, and during labor, her baby became stuck in her small birth canal. She suffered in this condition for seven days, by which time her baby was dead and part of her pelvis had rotted away. She had also developed a fistula that left her incontinent and unable to walk or stand. To save her life, Mahabouba crawled to a nearby missionary, who took her to a specialist hospital in the capital. There she had an operation that partially repaired her fistula, restoring her ability to walk. While at the hospital, she learned to read and write, eventually being hired as a nurse’s aide.

As dire as her situation may sound, Mahabouba was lucky. Impoverished women who develop a fistula often die from the condition for lack of medical attention. If they survive, the foul smell resulting from the condition often makes them outcasts. More than half a million women die of fistula in childbirth annually; 10 times as many are survivors who are ostracized by society because of their untreated incontinence.

When Simeesh Segaye, a young Ethiopian woman, went into labor, her birth canal was likewise obstructed. She suffered for two days before her baby died inside her. Her husband left her, and she lived for two years in a hut in a suicidal state. She was so depressed that she nearly starved to death. Her distressed parents sold all they owned to pay for her treatment, and she was taken to the capital’s fistula hospital. After months of intensive physical therapy, Simeesh regained the use of her withered legs; she was able to stand and then to walk.

Allan Rosenfeld, MD, is introduced as an American doctor who “became a social entrepreneur in the world of maternal health.” He implemented programs that made contraception more available to poor women in developing countries. Rosenfeld also raised money to establish an international network of people who supported his cause to make childbearing safe for poor rural women. Today, his organization operates in 50 countries.

Chapter 7: Why Do Women Die in Childbirth?

Chapter 7 further discusses the reasons poor women in the developing world die in childbirth. Birth canal obstruction and fistula are common causes of mortality. Lack of prenatal care and inept care by untrained birth attendants may also be fatal. Sometimes, though, lack of money to pay for life-saving caesarean sections (C-sections) may cost the pregnant woman her life.

Prudence Lemokouno of Cameroon spent three days in labor with an obstructed birth canal. She was taken to a hospital for a C-section, but the surgeon, Dr. Pascal Pipi, wouldn’t operate until her family paid him $100—a sum they could not raise. Dr. Pipi was sure the family was lying about their poverty, an opinion arising from his “resentful contempt for local peasants.” After two days, Prudence’s baby died inside her, poisoning her as it rotted. Kristof, who was at the hospital at the time, paid for Prudence’s operation. Although Dr. Pipi believed Prudence would be dead within hours, he left the hospital and went home. He did not operate on her until the next day. By that point, Prudence was in a coma, and her abdomen had developed a severe infection that strong antibiotics were unavailable to treat. Three days after her surgery, Prudence died.

Kristof and WuDunn describe several reasons women die in childbirth. One reason is anatomical: the human pelvis is narrow to permit easy running but too narrow for easy childbirth. Another reason is that humans—and their fetuses—have exceptionally large heads around their large brains. These, too, make childbirth more difficult. The third reason is lack of education for midwives and birth attendants, who are sometimes ill-prepared to recognize or intervene in emergencies. Girls’ education also lowers family size, as educated women are able to work outside the home and more likely to use contraception. Importantly, the lack of rural health care facilities in developing countries makes it hard or impossible for pregnant women to access the care they need. This problem is exacerbated by the lack of physicians willing to work in rural areas. Finally, the devaluing of women makes maternal mortality a marginalized, unimportant issue in many developing countries: women are allowed to die because, ultimately, they’re seen as expendable.

Some countries, the authors note, have found creative ways to address these problems. Sri Lanka, for instance, has used monetary incentives to deliver health care to all its women. It pays pregnant women to deliver in hospitals, and rural health care workers get paid for each pregnant woman they bring to a hospital for delivery. In Ethiopia, relatively uneducated women are trained to do the work of obstetricians—with excellent results.

The final story in this chapter concerns Edna Adan of Somalia, who was a young girl when she earned a scholarship to study nursing in the United Kingdom. When she returned to Somalia, she raised money to open her own maternity hospital. Her hospital treats pregnant women, but it also trains them in useful, marketable skills. Some former patients are trained as midwives or nurses and continue to work in the hospital and expand health care for Somali women.

Chapter 8: Family Planning and the “God Gulf”

Chapter 8 addresses the conflicts between conservative and liberal Americans that prevent effective assistance from being provided to pregnant women in developing countries. Kristof and WuDunn call this the “God Gulf,” because it pits religious conservatives who oppose abortion against secular liberals who insist that abortion be included in US aid packages. Conservatives, especially Evangelical Christians, lobby to deny maternity aid if it even mentions abortion; liberals lobby for aid that includes all options for pregnant women. The dispute between pro-life and pro-choice Americans has sometimes made provision of maternity aid, including contraception, impossible.

During conservative US governments, the authors report, aid to promote family planning (such as the use of condoms) and sex education to limit the spread of AIDS is typically defunded. For example, during the administration of George W. Bush, the focus of aid programs was “abstinence only,” which was irrelevant to the young people it targeted. Teenagers had sex anyway, and the incidence of AIDS and unwanted pregnancies increased. Lack of funding also leaves developing countries without the resources for widespread testing for AIDS and other sexually transmitted diseases. American Jane Roberts was so outraged by this intransigence that she organized a fundraising effort called 34 Million Friends that, in cooperation with the United Nations, opened clinics to provide safe abortions to women in West Africa.

Kristof and WuDunn acknowledge that the Catholic Church and many Evangelical churches fund health clinics in Asia and Africa and that many of these clinics treat pregnant women and women experiencing difficult childbirth. They suggest that if these religious groups could find common ground with more secular liberal donors, real progress might be made in improving the life chances of pregnant women throughout the developing world. 

Analysis: Maternal Mortality—One Woman a Minute, Why Do Women Die in Childbirth?, Family Planning and the “God Gulf”: Chapters 6-8

Barriers to gender equality are central to these chapters. One of the primary barriers to gender equality is the devaluing of women, especially in societies where religious views or local customs treat women as not worth saving. Yet Kristof and WuDunn show that it’s not just these women’s families and local communities who ignore them; it’s also governments who think it a waste of money to provide potentially lifesaving reproductive health care. Another important barrier to gender equality in health care is the lack of doctors and nurses in developing countries, especially in rural areas. The few doctors who remain in their home nation also lack many of the basic supplies needed to provide adequate health care to women suffering problems during childbirth. Too often, medical supplies must be imported, and some governments fail to or cannot afford to purchase essential medical equipment.

Kristof and WuDunn explain that discord in developed countries such as the United States creates another barrier to gender equality in the developing world. The ongoing conflict between pro-life conservatives and pro-choice liberals in America often produces a stalemate that prevents any relevant action from being taken to fund women’s health care in developing nations. When aid is funded for women in poor countries, it’s too often limited or targeted to unrealistic goals, such as “abstinence only” sex education. Conservative policies, the authors argue, also deny women (and men) desperately needed forms of contraception that prevent pregnancy and sexually transmitted diseases. Kristof and WuDunn consider the lack of contraception to be a significant cause of gender inequality because women in developing countries are often powerless to refuse to have sex with a man who demands it.

Class prejudice is another form of oppression that prevents uneducated and impoverished peasant women from getting the help they need. Governments may build hospitals in their nation’s capital city but ignore the health needs of poor rural women. In Chapter 7, Kristof and WuDunn suggest that classist attitudes are the basis of Dr. Pascal Pipi’s open contempt for the poor peasant women who come to him for treatment. They also point out that Western media and international organizations inadvertently perpetuate this problem when they focus their reporting or their aid on large cities, neglecting the greater need in rural areas. Their blindness to the needs of peasant women leaves these women oppressed because they lack advocacy.

In showing how Westerners can meaningfully improve health care for women in poor nations, Kristof and WuDunn point to examples that empower the women themselves. They describe many women’s clinics and hospitals that also provide basic education and job skills training, which promotes independence and raises self-esteem. Western-backed programs that train women as health care professionals are having an especially positive effect on women’s lives, particularly in rural areas.