Why did Mrs X die?

I have been reading the first of the World Health Organizations midwifery education modules. More than 500,000 women die of complications of pregnancy and birth each year, a number that it is hard to get your head around, but works out to be almost one every single minute. Next year we go with the Ship to Sierra Leone, the country currently with the highest maternal mortality rate and where midwives are working hard to set up a maternity clinic in Freetown at the moment.

The teaching started with a case story of Mrs X who died during labour.

"The physician in charge had no doubt why Mrs X died. It was a straight forward clinical diagnosis - a case of antepartum haemorrhage due to placenta praevia, which means that the placenta, or what we call the “afterbirth”, was situated too low down in the uterus". 

When the records were examined in more detail they found two factors contributed to her death:

1. she had only a very small blood transfusion as the hospital didn't have any more blood
2. there was a delay in getting the emergency caesarean section

So why did she really die?

In some parts of the world other factors come into play as well

• was it that there was no transport so she had to walk or be carried to the hospital causing a delay in getting treatment?
• was it that there was no doctor on duty or that she had no money to pay for treatment?
• was it that risk factors such as bleeding during pregnancy were not picked up and recognised because there was no antenatal care?
• was it that pre-existing conditions such as anaemia were not picked up and treated which made the birth more risky
• was it that the village custom was to feed the men first or that certain nutritional foods were thought to be bad for pregnant women leaving her malnourished and less able to cope with childbirth?
• was it that she already had five living children and was now an older mother, making this pregnancy more risky than previous ones, or that she had no access to family planning despite not wanting more children 
• was it that she didn't even understand the need for health care outside what happens in the village or care by untrained birth attendants?
• was it that she was from a poor household, illiterate and lived in a remote village making her risk of maternal mortalilty
  - five times more than the country average
  - ten times more than a woman of a higher socioeconomic standing in the same country
  -100 times more than a woman in a developing country.

Maybe it is not suprising that so many women die each year, we all know that some places don't even have clean drinking water or a hospital nearby. But it is so unfair, unjust, wrong that a woman's chance of dying in childbirth depends to such a large extent on where she lives. Back home it was so extremely rare for a woman to die in pregnancy or childbirth, but the blogs of midwives in the developing world suggest it is part of their working reality and will one day be part of ours. So what needs to happen? Answers may lie partly in training more midwives and improving knowledge of traditional birth attendants, but some of the answers lie within changing mindsets of cultures, placing a higher value on women's nutrition for example, and I have no idea just how hard that is. That is the challenge the teaching module gives to the participants, there is hope and potential for things to improve as individual communities are examined to identify factors compromising womens health and are challenged to make improvements.