Half the Sky

Why Do Women Die in Childbirth? In posing the titular question, Kristof and WuDunn ask the reader to “consider the factors that converged to kill Prudence Lemokouno,” which are many. A young mother of three, Prudence was a patient in a Cameroon hospital when the authors met her. Before that, after three days of obstructed labor at home, a midwife jumped up and down on Prudence’s stomach, which ruptured her uterus. Her family paid for transport to the hospital, but said they could only pay $20 of the $100 Dr. Pascal Pipi required (which may have been untrue, since a family member had a cell phone).

The authors describe Dr. Pipi as having a “serious and intelligent manner, superb French—and a resentful contempt for local peasants.” Dr. Pipi complained of women’s disregard for preventative health measures, appearing spiteful and angry. By the time Kristof arrived, Prudence had been in the hospital for two days and her baby had died, now rotting inside the womb, poisoning her. Dr. Pipi resented Prudence’s husband’s objections to her treatment, and demanded $80 more for the urgently needed intervention. Kristof and his videographer donated blood and money at that moment for Prudence’s surgery. Her condition improved, but after some hours Dr. Pipi disappeared—he had gone home. Apparently the hospital staff was spiting Prudence’s family, and by the time Dr. Pipi bitterly operated on Prudence in the morning, she was in a coma, neglected by nurses, her catheter unchanged and overflowing with urine. Furious, her family took her back to her village so she could die at home, three days later. “That's what happens, somewhere in the world, once every minute,” the authors write.

The authors outline four reasons behind Prudence’s death. First, biology played a role: “Humans are the only mammals that need assistance in birth,” they write – more assistance than is typically provided in many developing countries. Second, a lack of education contributed to Prudence’s tragedy. With an education, Prudence would have been more likely to have fewer children, to give birth in a hospital, and to be a financial priority for her family. Also, a more educated midwife would not have sat on Prudence’s stomach. Third, the poor rural health systems contributed, since the hospital denied Prudence the immediate treatment she needed. Also, the shortage of supplies, antibiotics, and doctors (caused partly by emigration of African doctors). Fourth, disregard for women contributes to maternal mortality—“As late as I920, America had a maternal mortality rate equivalent to poor parts in Africa today,” the authors write, but women’s suffrage raised women’s perceived value in society, and better women’s health followed.

It’s crucial to note that poverty does not make a high MMR inevitable. The authors write that over fifty years, Sri Lanka brought its MMR down from 550 per 100,000 live births to 58, because Sri Lanka gives attention to gender issues that have major public health benefits, from promoting literacy to providing ambulances and mosquito nets. One doctor describes maternal health as a good metric for healthcare as a whole, because varied strategies must be used to achieve good maternal health. In India, an experimental program that pays women to give birth in hospitals has had success, the authors report. Allan Rosenfield stressed that “we have what it takes”—money is not the foremost obstacle to maternal health.

The authors describe previous (and preventable) obstacles to maternal health improvements. UN goals to reduce maternal mortality go perennially unreached, due in part to emphasis on birth attendants for the sake of newborn health, which didn’t actually save mothers’ lives. Emergency obstetric resources, Allan and others argue, like C-sections, are essential. A key quandary, according to the authors, is how to pay for such emergency services? They use the Addis Ababa Fistula Hospital as a model with an answer: the hospital has trained staff without medical degree to give anesthesia and even perform fistula surgeries.

The authors introduce Mamitu Gashe, an Ethiopian woman who grew up illiterate and with no schooling, and is now among the hospital’s top surgeons. She began by making beds in the hospital, eventually assisted doctors, and finally received training herself. With superb technical skills, she became a master surgeon, the authors report. Meanwhile, she gradually worked her way through elementary school.

Globally, a major obstacle to maternal healthcare is the absence of a constituency. The authors specify the U.S. as lacking in advocates to reduce maternal deaths. They stress, however, the importance of avoiding exaggeration—“saving women's lives is imperative, but it is not cheap,” they write, nor does it contribute to national economies the way girls’ education does. To make maternal health a global priority might cost some $9 billion a year, the authors report, or roughly $22,000 per life saved. Vaccines, by contrast, may save a child’s life for only $1. The best motive to stop maternal deaths “isn't economic but ethical,” they write, as it comprises a human rights issue, and an urgent one.

Edna’s Hospital. In Somaliland, a place where few Westerners venture, Edna Adan founded a beautiful new maternity hospital. Kristof and WuDunn think that some Westerners have become so cynical about corruption in Africa that they doubt any cause there is worth pursuing, but Edna, through collaboration with Western donors, shows how deeply misguided that stance is. The authors describe speaking to Edna in her modern home, where she tells them she grew up in a time when school for girls was nearly unthinkable. Her family, however, was elite, her father a pioneering doctor. Nonetheless, at eight Edna’s genitals were cut, with Edna in shock and restrained, in the customary process known as “female circumcision.” Her father’s discovery that Edna had been cut – the procedure was enacted by her mother – was the only time she ever saw him cry. The event motivated Edna’s later advocacy for women’s health.

Class privilege and her father’s resolve enabled Edna to have an excellent education, studying in England to become her country’s first qualified nurse-midwife and first woman to drive. She later worked for the UN, but dreamed of returning home to improve the healthcare in Somalia (modern-day Somaliland). War thwarted her mission, but despite her wealth and status at the UN, she was determined to found a hospital. She asked Somaliland’s president (who was her ex-husband) for a land grant. Edna spent her entire lifesavings building a hospital on the former site of government torture and executions, then a waste dump.

Nearly finished, the construction halted when there was no money left for a roof. But when a writer for The New York Times published an article about Edna, it moved an American named Anne Gilhuly, who lived in a wealthy Connecticut suburb, to take action. Anne and a friend collaborated with a group from Minnesota, who started Friends of Edna, and provided the remainder needed to finish Edna’s hospital. The authors describe the tenacity Edna had in every step of her project, including her demand that irreverent construction workers teach women how to lay bricks. Hand-me-down equipment from other groups and Edna’s demand for first-rate hygiene make the hospital exemplary in Somaliland, where even surgical masks are a rarity in the country. Today, the Friends of Edna are working toward building an endowment so that hospital will continue after Edna dies.

Kristof and WuDunn describe the unlikely ways the hospital functions, such as treating a woman who was pushed into the hospital in a wheelbarrow, and rescuing a woman with a fistula whose husband, disgusted by her smell and waste, stabbed her in the throat. The authors characterize Edna, walking through the hospital, as “like the weather in October: alternately stormy and sunny.” She might be furious with a nurse one minute and warm to a patient the next. Once, the authors report, a man drove into the hospital while his wife was in labor, and his wife had the baby at that moment in the car. Refusing to pay hospital fees, the husband tried to leave but Edna shouted for the gate to be closed, so she could pull out the placenta in the backseat. When Anne Gilhuly and other American backers visited Somaliland and the hospital, Anne reported that being in Somaliland is “much more interesting than playing bridge at the local Y.” Anne also, having seen Edna’s unforgiving side, decided that such ferocity is necessary given the high stakes of failure in the hospital.