EDITORIAL

Why maternal mortality in developing countries is our problem

I've written before about the impact on our society of fraying of the "social contract" between physicians and their patients. Simply put, physicians undergo rigorous and lifelong training and are charged with taking the best possible care of their patients and adhering to the highest ethical principles. In return, they get remuneration from patients, who also trust them, contribute to physicians' medical training and research, and bolster their social status.

Erosion of this contract, I firmly believe, underlies many of our current problems including the professional liability crisis, reduced reimbursements, HIPAA, the 80-hour resident workweek, and growing patient unwillingness to be involved in research and training. Why did the contract fray? Without a doubt, external forces—such as trial lawyers, the staggering costs of modern medicine, and distorted presentations in the media of both the promise and foibles of medicine—have contributed. I also believe, however, that physicians are to blame. We've done little to counter many patients' perception that doctors are primarily interested in money, do not stay clinically up to date, and collectively cover up their mistakes.

Regardless of how our "contract" became frayed, we need to repair it, and quickly. One way to do it is to champion women's health initiatives, and I would contend our single most important initiative should be a reduction in maternal mortality—both here and abroad. For example, in the United States, there were 11.8 deaths per 100,000 live births from 1991 through 1998, while over the past 10 years in Mozambique, the maternal mortality rate has risen to 1,000 per 100,000 live births, or 1%. This staggering statistic was quoted by Mozambiquan Prime Minister Dr. Pascoal Mocumbi during his plenary presentation at the 17th FIGO World Congress, in Santiago, Chile, last month.

Until recently a practicing obstetrician, Dr. Mocumbi has first-hand knowledge of the plight of pregnant women in Sub-Saharan Africa. The primary causes of the maternal-mortality crisis in Mozambique are no different than the chronic causes of maternal mortality in the US: postpartum hemorrhage, infections, and embolism. The difference is that in Mozambique, such events often follow unattended births far from health-care personnel or facilities. Even more distressing, Dr. Mocumbi pointed out that for every dead mother, there are 20 more who suffer disabling injuries, such as vesicovaginal fistulas, chronic pelvic pain, and infertility—all of which can lead to domestic abuse and/or estrangement from family and home.

Like many areas of Sub-Saharan Africa, Mozambique owes its high rate of maternal morbidity and mortality to lack of health-care infrastructure, supplies, and personnel. Several decades of bloody civil wars, which ended in 1992, destroyed about 50% of the nation's health-care facilities. What was left of the health-care infrastructure then was devastated by a series of natural disasters, floods, and famine. This pattern, common from Ethiopia to Angola, has left Mozambique and other Sub-Saharan nations with precious few resources to commit to health care. Mozambique's per capita spending on health care is $7, compared with the $4,600 that we spend in the US. And even that meager spending is being siphoned off to cope with the nation's burgeoning HIV epidemic, which now affects 20% of the population. As Dr. Mocumbi pointed out, HIV directly impacts pregnant women by making them more susceptible to malaria and other infections, and—because of its association with anemia—to hemorrhage. The epidemic also indirectly contributes to maternal mortality by draining meager dollars that could have been used to build hospitals, train midwives, and provide life-saving oxytocics and antibiotics.

What does the crisis in maternal mortality in Africa have to do with physicians in the US and our fraying social contract? A LOT! One reason that we've lost stature is the public's perception that we are no longer healers, first. The newspapers are filled with stories about new drugs and technology, medical mistakes and billing fraud, but seldom does the media portray average American physicians as champions of public health or advocates for the poor. We need to make clear to the American people that we care profoundly for the health of everyone on this planet. As gynecologists, we need to be the champions of women's reproductive health. From a global perspective, we obstetricians face no greater challenge then the horrifically high rates of maternal mortality in developing nations.

What concrete steps can a clinician take? I suggest the following:

1. Publicize the problem of maternal mortality. Talk about it with your colleagues, patients, and contacts in the media. Every ob/gyn must be seen as an advocate for reducing maternal mortality—not only among his or her own patients and women in this country, but also throughout the world.

2. Lobby for increased developmental aid to developing countries, targeting efforts aimed at reducing maternal mortality. Former President Clinton's efforts to have pharmaceutical companies provide free HIV medication and President Bush's $10 billion effort to supply nations with such therapies are laudable, but each year 529,000 women die as a consequence of childbirth. Third-world nations also need hospitals, clinics, supplies, and trained personnel.

3. Volunteer your time or money through aid agencies such as Doctors Without Borders/Medecins Sans Frontiers (MSF) (e-mail doctors@newyork.msf.org), Catholic Medical Mission Board ( http://www.cmmb.org/Help/medical.htm ), and Mission Doctors Association ( http://www.MissionDoctors.org ). Gynecologists with an interest in vesicovaginal fistula repair who are willing to volunteer their time should contact the Worldwide Fund for Mothers Injured in Childbirth, which works in Nigeria ( http://www.wfmic.org/training.htm ), or the American Friends Foundation for Childbirth Injuries, which is exclusively devoted to supporting the Addis Ababa (Ethiopia) Fistula Hospital ( http://www.fistulahospital.org/ ). For a full listing of physician volunteer opportunities see http://www.physiciansguide.com/volunteer .

4. If you prefer, organize your own hospital or departmental efforts. For example, Dr. Maria Small from our institution is leading an initiative in Haiti—a nation with one of the highest maternal mortality rates in the Western Hemisphere—to identify patients at high risk for eclampsia so they can be transported to basic care facilities for magnesium sulfate therapy, labor induction, and attended delivery.

These are the right things to do, and frankly, they are also our responsibility as physicians. But doing our part to reduce maternal mortality throughout the globe also may help reconstitute our social contract with patients by restoring their view of ob/gyns as healers and tireless advocates for public health.

Charles J. Lockwood, MD

Charles J. Lockwood, MD, Editor in Chief, is Anita O'Keefe Young Professor and Chair, Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, Conn.

Charles Lockwood. Editorial: Why maternal mortality in developing countries is our problem.

Contemporary Ob/Gyn

Dec. 1, 2003;48:8-11.