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).
By taking the reader through a calculated, thorough journey of Prudence Lemokouno’s death, the authors strive to make very clear the complicated reasons for maternal death. By doing so, they urge the reader to recognize the complexity behind maternal death, and that simply providing more sympathetic doctors than Dr. Pipi would never address the problems.
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.
Dr. Pipi challenges the trope of the altruistic, good-hearted doctor—he is bitter, classist, and vocally intolerant of poor Cameroonians. But, the text’s treatment of Dr. Pipi is not vicious, nor does he represent all Cameroonian doctors. This underscores the fact that the scornful indifference of a single doctor isn’t the only culprit behind Prudence’s death. Moreover, the fact that Kristof and his videographer so determinedly intervened, yet Prudence still died, shows how immovable some obstacles to rescuing mothers can be.
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.
Part of the authors’ outline illustrates the common misuse of foreign aid resources—for instance, building hospitals is a more popular aid campaign than hiring auditors to make sure those hospitals are staffed. More broadly, this part of the book shows that, for women to receive the necessary healthcare, they must first be valued as human beings. This fact returns to the idea that women’s rights, such as maternal health, are often won through indirect paths that raise how much women are valued—for instance, the right to vote and influence elections.
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.
It would be reasonable, the authors imply, to assume that poverty is the central obstacle to achieving top maternal healthcare. But in reality, the determination to stop maternal deaths—and to make women a government priority—is a more key resource than money alone. The implication is an optimistic one, since Allan and other advocates believe that it’s possible to improve maternal health without radical budget overhauls.
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.
Another inspiring example of maternal health improvement takes place, again, in the foreigner-founded Addis Ababa Fistula Hospital, underscoring the influence of foreign aid. The model of training non-medical staff in surgical procedures provides hope for the economic problem of importing doctors into Africa, returning to Half the Sky’s positive message for the future.
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.
Mamitu upends the stereotype of surgeons as hyper-educated, just as she upends the stereotype of uneducated women as unintelligent. Mamitu’s prowess as a surgeon challenges any assumption that illiterate women in African can’t be important players in humanitarian causes.
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.
By stressing that the best argument to save mothers’ lives is ethical, not economic, Kristof and WuDunn give an important reminder: while pragmatic motives for women’s rights exist (after all, women’s rights benefit countries’ GNPs and productivity), those motives should be secondary to the issue of human rights. Just as women’s oppressors need to recognize women as wholly human, their advocates need to recognize women as worth saving because, simply, they’re human.
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.
The authors reference the “cynicism” of Westerners as an obstacle to progress. Like indifference, it can prevent participation in urgent causes. As the authors report, the most encouraging figure in Edna’s life was her father, evidence that men can be just as enlightened as women in advancing women’s rights. The fight for women’s rights is a human fight, not a female one.
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.
Edna’s story is heroic, but it’s noteworthy that early privilege made it possible. In order to maintain a realistic perspective on how people can effect change, this is important to keep in mind—while Mukhtar Mai was luckily given money with which she started her project, Edna had a career track that allowed her to build wealth. And still, Edna had to risk her lifesavings to build her hospital—without her sacrifices, the hospital couldn’t have started. So while the authors emphasize earlier that funding isn’t the foremost obstacle to maternal health advances, it remains a major obstacle.
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.
Intervention from attentive Americans rescued Edna’s noble project from the potential abandonment that many African initiatives face, another case for the influence Americans can have in faraway women’s lives. Notably, one of the features of Friends of Edna is sustained support, not providing only a batch of one-time funding, but joining Edna in her mission to give women medical help.
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.
Characterizing Edna vividly as mercurial, liable to change temperament any time, is another challenge to stereotypes about aid givers. While her sacrifices make Edna appear saintlike, she also erupts at the staff who care for her patients. This shows both the humanity of heroic figures, and that efficient change sometimes demands impatience, not saintlike calm. An alternative way of looking at Edna’s temperament is that saints are not required to enact change: any person with sufficient drive and willpower can create change.