Every two minutes, a woman dies in pregnancy somewhere in the world (Canberra Doctor - August 2017)
By Prof Steve Robson*
Australia is one of the safest places in the world to have a baby, or to be born. There are certainly some inequalities – Aboriginal and Torres Strait Islander women face higher risks of a preterm birth, for example – but all things considered Australia is a great place to have a baby.
Yet a short plane flight from our shores it is a very different story. Papua New Guinea has one of the worst rates of maternal death in the world. About one PNG woman in 20 will lose her life while pregnant. The majority of women giving birth have no skilled birth attendant with them. The story is similar in many other Pacific nations.
Across the Pacific women face incredible disadvantages. A combination of geographical factors, economic circumstances, and societal standards all conspire to make pregnancy dangerous and disempower women. If you look around most primary school classrooms, one of the young girls you see will lose her life in pregnancy.
Many of you will be aware that the Millennium Development Goals (MGDs) passed into history with little actually achieved for women. MDG5 – reducing maternal mortality and achieving universal access to reproductive health – yielded the worst result of all. That women continue to suffer in pregnancy in 2017 should be an international scandal.
Death is an everyday occurrence
During my 26 years of full-time obstetric practice, I have had only one woman die in pregnancy. Many of my colleagues, particularly younger obstetricians, will never have seen a maternal death. In Australia, direct maternal deaths occur once in about 20,000 births. It is entirely possible never to see a woman die during an entire obstetric or midwifery career. This is a testament to standards in Australia.
When I was on a teaching visit to Papua New Guinea last year, every single obstetric trainee I was teaching had personally dealt with pregnancy-related deaths in the month or two before. Rather than becoming inured to this level of suffering and loss, all of the trainees were distressed and upset. Because such outcomes are so common does not make them any more bearable.
About eight years ago, I began a journey to try to do something positive. I had been struck by the incredible amount of money spent on flowers for my private maternity patients. Each morning I would work through my ward round, and all of the new mothers’ rooms would be filled with beautiful flowers. Yet on the day the woman and her new baby left the maternity ward to return home, the flowers were usually thrown out. Hundreds and hundreds of dollars were wasted.
It struck me that birth was such a time of goodwill and generosity, with family and friends wanting to express congratulations, that it might be possible to put this to humanitarian use. So was born the not-for-profit Send Hope Not Flowers. Through our website sendhope.org people wanting to celebrate a birth can spend the money they would have spent on flowers, instead on a maternal health project. In place of flowers, women receive a card with well wishes, and the comfort that their safe birth has been celebrated by contributing to a safe birth in the Pacific.
Taxing times
Send Hope Not Flowers is unusual as a charity. We have no paid staff, instead a group of committed and hard-working volunteers who perform their duties pro bono. Because of goodwill and generosity, the only money lost from donations is for banking charges. Even the printing and postage of the cards is paid from our own businesses.
Because almost all the money we raise is spent on aid projects overseas, it was not possible to obtain automatic tax deductibility. For Australian not-for-profit organisations to be eligible for tax-deductible status, the majority of money raised must be spent within Australia. More than 96% of donations to Send Hope went directly to overseas projects.
This had two effects – not being tax deductible made it very difficult to entice larger corporate donors and sponsors, and it also made some potential donors suspicious. The paradox was that if we had spent most of the money we raised on staff pay, travel, and perks, we would have qualified for tax deductibility! We were victims of our own probity.
Aiming to become gazetted for overseas deductible gift recipient status is a massive bureaucratic challenge. It took the Send Hope team more than three years of careful negotiation with DFAT, as well as the Treasury and other Commonwealth Departments, to crack this ultimate barrier. It was an incredible thrill for us to finally achieve tax deductibility in June this year. We were one of only four charities in the entire country to achieve this in the last two years.
We were thrilled to receive an invitation to meet Foreign Minister Julie Bishop in her office a few weeks ago, and gave us an inkling of what we had achieved. Now, all donations to lifesaving maternal health projects through Send Hope are fully tax-deductible.
What helps?
If a woman doesn’t become pregnant, she is not going to die from a pregnancy complication or unsafe abortion. Family planning should be the first and foremost strategy to help women in the Pacific. Unfortunately, there is enormous unmet need for family planning in Pacific countries. Unwanted pregnancy is a disaster for women, their families, and their communities.
There are various reasons for this sorry situation, but the most important is that women are disempowered. They are at economic disadvantage, often geographically isolated, and at the mercy of men. It is a very sad fact that misogyny is at the heart of many of these problems. Most women in the Pacific are brought up to think themselves second class citizens. It is a regrettable and dangerous state of affairs.
Once pregnant, women have a burden of chronic disease – malaria for example – and poor nutrition and preventive care. Access to skilled pregnancy carers is scarce, and many women will have limited or no access to antenatal care as we recognise it. Skilled and trained birth attendants are few and far between in many places. Large health centres and hospitals are under-resources and stressed, placing enormous pressures on the dedicated staff running them.
Access to safe and hygienic birth practices, surgical facilities, and lifesaving medications such as antibiotics or blood transfusions, all are severely curtailed. Many women must travel for days to reach a health centre, and have little support when they arrive. Escalation and retrieval chains are poorly developed, if they exist at all.
The way forward
Women’s health is not an abstract issue, and cannot be isolated from the social and political environment in which women live. Women who are disempowered are prevented from reaching their human, social, economic, and intellectual potential. Unfortunately, one of the major barriers facing women and girls in Pacific nations is culture of discrimination.
In many regions women are brought up to believe themselves second-class citizens, and commonly are subject physical, sexual and emotional violence. Violence imposes high costs - both direct and indirect - on society and the wider economy. When women’s low status is low it limits their access to healthcare of an appropriate standard, and hampers their power to make decisions about their own sexual and reproductive health.
For these reasons, it is unlikely that large improvements in the health of women will happen without major societal changes. This should not be a disincentive to trying to help – it should not daunt us. The challenge should not overwhelm us. It should never stop us from trying to send hope.
*Prof Steve Robson is the President of AMA (ACT), President of RANZCOG and an Obstetrics & Genaecology consultant.