A Hidden Tragedy:
Birth as a Human Rights Issue in Developing Countries
By Vicki Penwell, CPM, MSM
This would just be another sad statistic, except for the fact that 99% of the deaths of pregnant or newly delivered mothers occur in the under-developed nations, with Sub-Saharan Africa and Southern Asia accounting for 86% of them. That means only 1% of the world's maternal deaths occur in Canada, the United States, Europe and Australia combined. This distribution of maternal death is injustice by any measure.
When Jan Tritten first spoke to me about the theme of birth as a human rights violation for an upcoming issue of Midwifery Today, that concept really resonated with me. Like many midwives, I have seen women in American hospitals being bullied, coerced, and threatened with bodily harm if they did not comply with the treatment the hospital personnel wanted to administer. I have seen injections and episiotomies (a form of surgery) done expressly against a woman's will in the absence of any complication and in the presence of her verbal protestations or sometimes even pitiful begging to not be cut or injected. I have also seen, in developing countries, women in labor hit, kicked, slapped, and pinched on the inside thighs to the point of bruising. I have seen healthy women physically restrained (strapped down eagle spread) for normal births. I have also witnessed many cases of vicious verbal abuse, and once or twice even witnessed the line being crossed into behavior that appeared to be blatant sexual abuse.
However, knowing that Jan and others will be writing for this issue of Midwifery Today about these common (albeit inexcusable and intractable) examples of human rights violations during childbirth, I want to concentrate this article on the issue of inequality: the human rights violation currently happening to 3/4th of the world's women due to poverty. Maternal mortality is the health indicator with the most disparity between developed and developing countries, at a rate 100 times greater in poor countries than richer nations.
Note: Many readers in North America or Europe may not think of yourselves as "wealthy" or "rich". Yet think about this: only 10% of the world's population owns a car...therefore, by definition, if you own a car, you are in the top 10% of richest people in the world. Same if you have access to clean drinking water, or education, or a trained midwife...you get my point...
Michelle Maiese of the Conflict Research Consortium has a helpful viewpoint on what it means to violate human rights: "There is now near-universal consensus that all individuals are entitled to certain basic rights under any circumstances. These include certain civil liberties and political rights, the most fundamental of which is the right to life and physical safety. Human rights are the articulation of the need for justice, tolerance, mutual respect, and human dignity in all of our activity. Speaking of rights allows us to express the idea that all individuals are part of the scope of morality and justice. To protect human rights is to ensure that people receive some degree of decent, humane treatment. To violate the most basic human rights, on the other hand, is to deny individuals their fundamental moral entitlements. It is, in a sense, to treat them as if they are less than human and undeserving of respect and dignity." 
All women are fully human and deserving of respect and dignity. When we think about our sisters in Sub-Saharan Africa or Southeast Asia, we may not know how endangered they still are in childbirth, and how few real choices they have. It has been said that in developing countries, the most dangerous occupation is motherhood. Human rights violations, once made known, must be acted upon in some way by morally ethic people. This article is to make it known; what you do with this information is up to you. I believe the answers will come if we can move beyond pity into action.
First, we must understand the injustice of the disparity. In 2010 we know how to keep women from dying in childbirth. It is not rocket science, and as we know from numerous studies in developed countries over the past 30 years, the place of birth is not the important factor in healthy outcomes. Home birth and out-of-hospital birth centers have been proven to have as safe, or safer, outcomes than hospitals for normal deliveries. The important factor in whether childbirth will be safe or unsafe to a woman is three-fold: the overall health of the woman, her place in society, and the presence of a skilled birth attendant. Poor women, those who come to the place of birth malnourished and often unattended, die 100 times more often than their wealthier sisters.
Women in rich countries can die in childbirth too, as we know, and the overuse of cesarean delivery and labor induction is driving up the maternal mortality rate in the United States. Having said that, it remains a truism that most modern women don't fear dying in childbirth. While maternal mortality can happen anywhere, the lifetime risk of maternal death in the United States is 1 in 2,500. Compare this to a lifetime risk in Sierra Leone and Afghanistan of 1 in 6.
In Africa, women who are starting labor say goodbye to loved ones, just in case they don't survive the process. In the Philippines, there is a native saying that a pregnant woman has one foot in the grave. It is common for women in developing countries to say some variation of this phrase to their older children: "Mommy is going on a journey to fetch you a new brother or sister, but the journey is long and dangerous, and I may not return."
Yet even within poor countries, the disparity between richer and poorer women is a matter of injustice based on economic restraints. In Bangladesh, for example, among the 20% richest women, almost half have a skilled birth attendant at the time of giving birth. Among the poorest 20% of women in Bangladesh, only 4% are helped by any trained person. In Peru, almost all rich women have a midwife or doctor attend their birth, while only 20% of the poor get this basic right.
Part of the problem is that there is a worldwide shortage of midwives. The world needs at least 300,000 more midwives immediately to begin to address the problem of maternal and newborn survival. All midwives should be teaching and apprenticing other women who desire to be midwives. That is something we can all do which will make a big difference. World Health Organization says that skilled health workers at delivery are key to improving outcomes, and further states “Investing in human capital such as midwives for childbirth is the wisest investment that we make, to ensure sustainability, ownership, fulfillment, and consistently high results”
Not only are mothers dying in childbirth at unconscionable rates, but they are also losing their babies to death out of all proportion to what happens in the West. Based on the data, as many as 50% or more of neonatal deaths could be averted through improved maternal nutrition status and infection prevention, as well as skilled care of the mother during pregnancy and labor.  Maternal health is an important determinant of neonatal survival, and maternal health interventions during pregnancy and birth dramatically affect neonatal health and survival. Since over 4 million newborn babies die in the first weeks following birth, and another 3.5 million are delivered stillborn, that represents a multitude of grieving parents. Like maternal death, neonatal deaths are also disproportionate to the world’s population, with 99% of all infant deaths occurring in third world countries. Is that a violation of our basic human rights also, then, to have our children die at rates out of all proportion to richer nations of the world, when the solutions are as simple as having a midwife present for delivery?
All the nations of the world are currently working to achieve the Millennial Development Goals (MDG) laid out by the United Nations. Goal # 5 proposes to reduce by three quarters, between 1990 and 2015, the maternal mortality rate, and increase the proportion of births attended by skilled health personnel. Right now only 60% of the women in the world have a midwife, or doctor or nurse with midwifery skills to assist at their childbirths.
Ban Ki-moon, UN Secretary-General, seemed to hint that this was indeed a human rights issue when he made this statement concerning MDG: "Ours is the generation that can achieve the development goals and free our fellow men, women and children from the abject and dehumanizing conditions of extreme poverty.” 
The bad news is that globally, maternal mortality ratios essentially have NOT changed since the 1990 estimates, denoting more than 500,000 maternal deaths annually for a world rate at an estimated 400/100,000 live births, with 14 countries having a rate over 1,000/100,000.
The five direct causes of nearly two-thirds of maternal deaths worldwide are all things we have learned to prevent, treat or correct, making it all the more unjust that woman are dying of these childbirth complications. They are:
•Complications of abortions
Allow me to end this article with a quote that helps us see this human rights problem, and its solution, in a different light:
"Women are not dying because of diseases we cannot treat; they are dying because societies have yet to make the decision that their lives are worth saving." 
Vicki Penwell is a licensed midwife and CPM who has practiced for 30 years, first in Alaska and then in Asia for the past 20 years. She and her family founded a non-profit charitable organization that trains midwives and establishes birth centers in poor countries. The birth centers are funded by donations and midwifery student tuition so that every delivery is free of charge to the woman and her family. Outcomes of more than 12,000 births have been excellent: for a complete description and birth statistics, read Vicki's chapter in Birth Models That Work, Edited by Robbie Davis Floyd, Jan Tritten et al; University of California Press; (April 2009)
 Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2008 Revision, June 26, 2009
 UNICEF www.unicef.org/media/media_7594.html
 Michelle Maiese. Beyond Intractability Newsletter, 2003
 World Health Organization 2000
 Global Health Learning Courses www.globalhealthlearning.org
 State of the World's Children Report 2005
 Joy Phumaphi, Assistant Director-General, Family and Community Health, World Health Organization
 Stanton and Deller 2007
 United Nations MDG Report 2008 http://www.un.org/millenniumgoals/maternal.shtml
 Ban Ki-moon, UN Secretary-General, 2007
 WHO, UNICEF, and UNFPA 2004
 Maternal mortality in 2005 : estimates developed by WHO, UNICEF, UNFPA, and the World Bank.
 Dr. Mahmoud Fathalla, Professor of Obstetrics and Gynecology, former Dean of the Medical School at Assiut University, Egypt, and Chair of the WHO Advisory Committee on Health Research. Professor Fathalla has been an international campaigner for Safe Motherhood and a founder of the Safer Motherhood Initiative.