Maternal Mortality—One Woman a Minute. The previous descriptions of violence were horrific, Kristof and WuDunn write, but an even more pernicious cause of oppression exists: “the cruelty of indifference.” Outside Congo, fistulas like Dina’s are caused less often by rape and more often by lack of medical attention during childbirth. Simply put, maternal health is seldom a priority.
The authors write that, “for every Dina, there are hundreds like Mahabouba Muhammad,” an Ethiopian woman who was sold as a girl to be a man’s second wife. Soon pregnant by her abusive sixty-year-old husband, no one – not the first wife or her village – would help her, until finally an uncle found her. She tried to have the baby alone, but her small pelvis obstructed the birth. After seven brutal days, a midwife came, but the baby had already died and Mahabouba couldn’t even stand up. People insisted she was cursed, and her uncle put her in a hut on the edge of the village with food and water. One night, still unable to walk, she had to fend off hyenas with a stick all night long. The next morning she crawled half a day to the house of a missionary, who took her to the Addis Abba Fistula Hospital. There, she joined other girls also being treated for fistulas, with urine leaking to the floor and causing leg sores from the acid.
Dina developed a fistula directly from a single incident of rape. Mahabouba’s situation, on the other hand, was more complicated: it involved abandonment by her family, being traded into marriage, abuse, neglect, and finally the consequence (obstructed labor) of pregnancy at too early an age. The roots of Mahabouba’s crisis are harder to trace than Dina’s, one of the reasons maternal health is so neglected: typically, no single event causes the problem, and no single fix solves or prevents it.
The Addis Abba Fistula Hospital is run by Catherine Hamlin, an Australian woman who denies any claim of sainthood, saying that she loves her work. Catherine says, “For lepers, or AIDS victims, there are organizations that help. But nobody knows about these women [with fistulas] or helps them.” In Western countries, medical developments eradicated fistulas, but they remain common in some developing countries. Catherine and her husband opened the hospital in 1975 and have administered over twenty-five thousand surgeries. Mahabouba’s fistula couldn’t be fully repaired, but she was given a colostomy, an outer pouch which stores feces. Now, Mahabouba works at the hospital as a senior nurse’s aide.
That fistula sufferers go mostly ignored compounds the tragedy of fistulas. This is an important reminder that the most visible aid projects in popular culture do not encompass all the world’s urgent aid crises. Happily, Mahabouba makes yet another example of women who, once victims of oppression, work on behalf of other women, after being given an opportunity to do so.
Fistulas are inexpensive and usually easy to repair, the authors explain. Yet, most of the tens of thousands of yearly sufferers never receive treatment. One hospital employee describes fistula patients as “the modern day leper.” Fistula sufferers are triply disadvantaged by being poor, rural, and female. Healthcare in developing countries is bad for men, the authors write, but, as Catherine says, “women are an expendable commodity.” Further, insufficient funding is a perennial obstacle for maternal health, the authors write, as is indifference from both liberal and conservative groups. The authors also cite journalists as part of the problem: fistulas are almost never covered in news media.
Historically, lepers were pariahs, pushed out of society. This reality stemmed from ignorance, intolerance, and fear. Likewise, the authors imply, today fistula sufferers are ostracized due to fear, prejudice, and indifference. Few people advocated for lepers, and few people advocate for fistula sufferers.
While other public health issues have improved, maternity health largely hasn’t. The maternal mortality ratio (MMR) of developing countries is disgracefully worse than in the first world, and since women in those countries have more pregnancies, their chance of dying in childbirth is even higher. As the authors put it, the “lifetime risk of maternal death is one thousand times higher in a poor country than in the West. That should be an international scandal.” Maternal morbidity—injuries of women caused by childbirth, such as fistulas—is even more common. But, the authors write, they hesitate to give the reader numbers, because people are far less likely to respond to statistics than to stories, even when statistics make a better logical argument.
By pointing out the human propensity toward favoring specific stories over statistics, Kristof and WuDunn justify their own methodology in Half the Sky. The book locates specific examples of widespread problems, and by garnering empathy for unique players, the authors hope this empathy will extend toward other situations and motivate readers’ action. Still, numbers reflect the urgency of addressing gender inequity, so applying logic based on statistics can also be useful to readers, the authors imply.
To accommodate the human preference for story, Kristof and WuDunn write about Simeesh Segaye, an Ethiopian woman they met at the Addis Abba Fistula Hospital. At nineteen, Simeesh was thrilled to be pregnant, but her obstructed labor, then a two-day bus ride to the hospital, left her baby dead. When she made her way back to her village, waste leaked from her and gave her a terrible odor. She tried to take a bus back to the hospital, but she was forced to get off, as passengers refused to tolerate the stench. Simeesh’s fate was to live in a hut alone, barely eating what her parents brought her, deep in depression and contemplating suicide while liquids ran down her legs. After two years, her parents paid the high cost for a private car to take Simeesh to the fistula hospital, where she was finally treated for the many ailments she had developed. After months of work and physiotherapy, she recovered her mobility and, importantly, her dignity and ability to take pleasure in life.
By describing in some detail the grueling experience of Simeesh developing a fistula—and the painful recovery—the authors make more vivid the reality of having a fistula. Strikingly, Simeesh meets no empathy from people who see her excruciating condition but cannot tolerate the smell, which underscores again that cultural intolerance is an obstacle on the road to gender equality.
A Doctor Who Treats Countries, Not Patients. The authors introduce Allan Rosenfield, an American obstetrician who was influenced by witnessing women enduring childbirth injuries during the Korean-American War. In 1966, he moved to Nigeria for a job and saw that healthcare in Nigeria desperately needed more focus on disease prevention, and so launched his lifelong commitment to public health. Public health includes vaccinations but also campaigns to urge seatbelt-use and other non-medical solutions, such as providing school uniforms to keep girls in school longer, therefore reducing early pregnancies. He later moved his efforts to Thailand, where he enacted the revolutionary, unorthodox idea to permit midwives to prescribe birth control and insert IUDs. Eventually, after tireless advocacy for practical maternal health, Allan founded the organization Averting Maternal Death and Disability (AMDD) with funding from the Bill & Melinda Gates Foundation. He also “began approaching maternal death not just as a public health concern but also as a human rights issue,” the authors write, and stressed that governments needed to be held accountable for human rights obligations.
Allan Rosenfield’s revolutionary tactics to prevent health problems indicate the power of indirect, unexpected solutions. This is part of Half the Sky’s hopeful message, that innovation of new models can effect major global change in the future. That he was a major, lionized player in the field of public health also indicates the power of one person to improve solutions for women’s rights issues—he is an example of the charismatic leaders that the authors argue would help the current women’s emancipation movement.
Kristof and WuDunn write that Allan fundamentally influenced the field of global public health, which is popular today. As an aged man confined to a wheelchair, he continued to attend conferences and advocate for women until his death in 2008. His legacy includes the presence of AMDD in fifty countries. To describe his legacy in action, the authors introduce Obene Kayode, the only doctor in a Nigerian clinic, and Ramatou Issoufou, a pregnant woman in dire need of a caesarean section. Dr. Kayode explained to Kristof and WuDunn that he was waiting on her husband to provide the $42 for the operation materials. The AMDD made the materials available, but families still needed to pay for them in order to receive treatment. Because Kristof and WuDunn were present, the staff was shamed into performing Ramatou’s surgery even without payment. Both Ramatou and the baby appeared unconscious y the time the surgery was performed, but it went smoothly, demonstrating the miracle-like effects possible when women’s health is a priority.
The story of Ramatou Issoufou isn’t a purely happy one, since even though she and her baby were saved, they were saved by the fortuitous presence of Western journalists. Put another way, while Allan Rosenfield’s legacy did make safe childbirth more likely, it didn’t guarantee that Nigerian women would receive good health care. Financial obstacles—modest in American dollars—can easily lead to maternal death, even with Allan’s positive influence. The authors of Half the Sky are constantly trying to be realistic, to show both triumphs and that those triumphs aren’t complete, and much remains complicated and still be to accomplished.