25th October 2004
With all the death and destruction in Iraq, the Gaza Strip, Darfur and elsewhere it was a relief to find some good news in the 2004 State of the World Population report by UNFPA. It is now ten years since the Cairo Conference on Population and Development and in the introduction by Safiye Cagar, the Director of Information, she says that important gains have been made. More people now have access to family planning. New laws in many countries prohibit discrimination and violence against women. A lesser percentage of the world's people live in extreme poverty than ten years ago.
"But," to quote Ms. Cagar, "key obstacles still remain, including inadequate resources and gaps in service to poor and marginalised groups. HIV/AIDS continues to spread. Half a million mothers still die in childbirth every year. Greater commitment is needed to overcome these problems and realise the promise of Cairo."
Having worked for so many years in the Rotunda Hospital, naturally I take a keen interest in the maternal mortality figures for each country. They are a good indication of the level of health services in any country, not just that of pregnant women.
On looking through the maternal mortality figures in this report and comparing them with those in the report of 2003 there were some good improvements. Sub-Saharan Africa usually has some of the most losses and, as you will be aware, Development Aid Ireland has a particular focus on some of these countries - Ethiopia, Uganda, Zambia, Tanzania, Lesotho and Mozambique.
I have visited some of these countries - Ethiopia, Uganda and Zambia (some 'junkets' I can tell you) so, having a good idea of how difficult the situation is there, when reading the report I focus on them in particular. To give you an idea of the circumstances under which doctors and nurses work in the Ghandi Hospital in Addis Ababa, the tertiary referral hospital for maternity cases in the city, they were unable to measure blood electrolytes the last time I was there. When I asked one of the doctors how they managed he said one gets used to such problems.
So, back to the maternal mortality figures. In the 2003 report the maternal mortality rate for Ethiopia was 1,193 per 100,000 live births. To my delight in the 2004 report it had dropped to 850. Now, I wish I could tell you how this has happened and so quickly. There is only a small change in the levels of access to modern contraceptives, and little change in the number of girls in education. There was no change either in the number of teenage girls giving birth, the death rate amongst them being twice that of mature women. All of us who visit these parts have stressed the additional risks to teenage girls and urged governments to enforce the legal age of marriage, which is usually sixteen.
In Ethiopia there is also the problem of the abduction of girls to force them into marriage and the abductors are rarely pursued by either the law or the girl's parents, her departure meaning there is one less mouth to feed. Whatever caused the reduction in deaths it is to be much welcomed, but problems with collecting figures for the Central Statistics Office makes accuracy difficult. It is important to remember that 50 per cent of the population of 70 million live six hours walk from a paved road.
While the reduction in death rates was not so dramatic in Uganda - from 910 in 2003 to 880 in 2004, it is very welcome, too. There I have seen great efforts made to get teenagers to delay "sexual debut" as it is called. Between 1989 and 2000 the age of onset of sexual relations increased from 15.9 to 16.6 years for girls and 17.3 to 18.5 among boys. The sex education books for teachers are pretty explicit but the number of births per 1000 girls between 15 and 19 is 211 in both reports, twice the level of Ethiopia. Access to modern methods of contraception is much higher in Uganda, being about 18 per cent which may account for the lower death rate. Women at risk of another pregnancy may be less likely to become pregnant.
In Zambia, again, there was a reduction in maternal mortality, being 770 in 2003 and 750 in 2004. But the figures for HIV prevalence was much worse here than in either Ethiopia or Uganda. For males and females between fifteen and forty-nine the rates were 14.1 and 18.9 respectively. In 2003 they were 8.10 and 21.00. Zimbabwe, Botswana and Swaziland report even higher figures. The rate of infection is always more for women - this year's report gives the percentages for women as 41.7 in Swaziland, 28.4 in Zimbabwe and 43.1 in Botswana. It is not just the illness and death of these people which is so dreadful but the devastating effect on the economy of the country. Lesotho, another of Ireland's special countries, is very bad, too, with 25.4 per cent of men infected and 32.4 per cent of women
"Changing Behaviour" is an important part of this year's report. The Government of the United States of America will only give money to organisations which promote ABC - Abstinence, Be faithful and Condom use - which is all very well, but not of much use to women in these countries who often have little choice as to whether they will have sex or not.
Family planning clinics are mentioning HIV/AIDS more and more and have set up some voluntary counselling and testing clinics near towns where the main truck routes go. The drivers of trucks unfortunately becoming infected from women who have been obliged to enter into prostitution and who work there. They bring the infection back to wives at home, married women in some countries being more at risk of infection than women who are not married to their sexual partners, with whom they may be in a better position to insist on condom use.
The report points out how at risk displaced persons can be with no access at all to contraception. When we remember the asylum seekers here who resorted to abortion recently I feel quite sure we are not doing enough ourselves. How would we feel if one of those women had died and destroyed our excellent maternal mortality figures? Pretty badly, I'd say.
Senator Mary Henry, MD
