P
ROMOTING MATERNAL HEALTH IN DEVELOPING COUNTRIES MICHAEL M. 0. SEIPEL Most maternal deaths are preventable, yet more than 500,000 women die annually worldwide. However, the risk of maternal mortality is unevenly distributed; 99 percent of all maternal deaths occur in developing countries. This article examines the causes of this disparity and suggests several recommendations for social workers to promote maternal health in developing countries.
The health-promoting efforts of the World Health Organization (WHO) and other worldwide health care organizations have significantly improved the health status of all people regardless of political, economical, or geographical differences. Their work, combined with the work of the international social work community, local citizens, and high-level political entities, has made the world safer; smallpox has been eradicated, the infant mortality rate has been decreasing in recent times, and there now is less of a threat for pandemie outbreak of several infectious diseases (Henderson, 1980; WHO, 1989). Although the overall health standard of both developed and developing countries has improved, the degree of improvement in these countries varies widely. The most significant difference is in maternal health; the number of women dying from pregnancy and childbirth is dramatically higher in developing countries than in developed countries. Waldron (1987) noted 200
that in developed countries, males have a higher mortality rate than do females, but in many developing countries the reverse is true because of high maternal mortality. This article examines worldwide maternal mortality data, discusses the reasons for the high rate of maternal mortality in developing countries, and explores solutions to improve the current situation. Finally, the specific role of social workers is reviewed. WORLDWIDE MATERNAL MORTALITY RATE
No one knows exactly how many women in developing countries die from pregnancy and childbirth, because much of the data gathered are unreliable. Whereas most developed countries have largely reliable registration systems, many developing countries do not have similar systems that can be used for comparative study over time (WHO, 1988). WHO uses uniform data collection methods to collect data
CCC Code: 0360-7283/92 $3.00 © 1992, National Association of Social Workers, Inc.
from its member countries and believes its methods yield useful and discernible information for analysis. In 1985 about half a million women died from causes related to pregnancy and childbirth (WHO, 1988). Ninety-nine percent of these maternal deaths took place in developing countries (Figure 1). Even within developing countries, maternal death is not evenly distributed. Sixtytwo percent of all maternal deaths occurred in Asia; 59 percent were in South Asia, and only 3 percent were in East Asia. Thirty percent of maternal deaths occurred in Africa, and 7 percent occurred in Latin America. The maternal mortality rate in Western Europe and Northern Europe is about 10 per 100,000 live births. In Romania and other Eastern European countries, the rate is higher. The
rates for other countries (United States, Canada, New Zealand, Japan) are similar to other developed countries. In contrast, Africa had the highest rate of maternal death resulting from pregnancy and childbirth in the world (Table 1): About 640 African women die from pregnancyrelated causes per 100,000 live births. The rate is highest in rural areas of Africa and lowest in urban areas. The contrast between developed and developing countries is striking. Theoretically, a woman in the developing countries has about 100 times more chance of pregnancy-related death than her counterpart in the developed countries. The contrast could be even more striking if the death registry system of developing countries were more widely placed and records were kept more accurately.
Figure 1. Estimated Maternal Deaths by Major Regions, 1985
Latin America 7% Developed countries 1% East Asia 3%
Africa 30%
South Asia 59%
SOURCE: Reprinted with permission from World Health Organization. (1988). World health statistics annual (p. 3). Geneva: Author. PROMOTING MATERNAL HEALTH IN DEVELOPING COUNTRIES
201
Table 1. Estimated Matemal Mortality Rate Caused by Childbirth per 100,000 Live Births, 1985 Highest Rate and Lowest Rate
Country Developing countries Africa Highest (rural) a Lowest (urban)a Asia Highest (southern)a Lowest (eastern) a Latin America Highest (tropical) Lowest (temperate) b Developed countries Highest (Romania) a Lowest (Luxembourg) b Others (United States, Canada, Japan, New Zealand)a
Combined Estimated Rate 640
1,000 500 420 700 10 270 310 110 10 30 0
10
World Health Organization. (1988). World health statistics annual (pp. 11-12). Geneva: Author. bSouxcE: Royston, E., & Lopez, A. D. (1987). On the assessment of maternal mortality (p. 221). World Health Statistics Quarterly, 40, 214-224. 'SOURCE:
FACTORS CONTRIBUTING TO MATERNAL MORTALITY
The following factors contribute to maternal mortality: inaccessible health care, gender inequality, and high-risk pregnancy. Inaccessible Health Care
Many women in the developing countries do not receive adequate maternal health care throughout their pregnancy. Information provided by the participating countries of WHO in 1988 indicated that about 40 million pregnant women in the developing countries received no medical care during pregnancy. Moreover, 46 million were unattended by trained health care providers during the delivery (WHO, 1989). In contrast, nearly all of the women in the developed countries received both maternal health care during pregnancy and delivery by trained health care providers (WHO, 1989). Additionally, in developed countries, many women receive psychosocial care from social workers to further minimize any potential complications (Combs-Orme, 1987). Inadequate or nonexistent health care facilities, a lack of trained health care providers, high costs, and a lack of meaningful health care poli202
cies contribute to inaccessibility of health care. However, little is being done to change the situation. Two indicators that measure the accessibility of health care (health care facilities within one hour of travel and availability of trained health care providers) are still short of the acceptable standard: More than 40 percent of WHO member countries are without health care facilities within one hour of travel from their homes for 90 percent of their people (Seipel, 1990). Also, health care workers are unevenly distributed throughout the world. Africa, for example, has about one physician per 100,000 people, whereas there are 15 to 30 physicians per 100,000 people in Europe (WHO, 1988). Gender Inequality
A pattern of sociocultural practices may help explain the high maternal mortality rate in developing countries. As Waldron (1987) and Bhatia (1985) observed, many women in developing countries are openly discriminated against in obtaining vital services, including good nutrition and health care. The pattern of inequality begins at birth. The birth of a female child is frequently unwelcome. As a consequence, female infants are generally neglected, and when medical attention becomes necessary, they
HEALTH AND SOCIAL WORK/VOLUME 17, NUMBER 3 / AUGUST 1992
receive less medical care. There is also a marked gender differente in food allocation. Typically, male children enjoy greater intake of protein and calories than do female children. Male children also receive more family resources for education and other necessities for future well-being. Female children in many rural communities are married off as soon as they reach puberty, thus preventing them from achieving educational status comparable to that of their male counterparts. Even marriage is no guarantee of a better life. In fact, the status of daughter-in-law in a dowry system might be little or no better than that of a household servant if the dowry was small. Her status might improve with the birth of a son, but childbearing presents a real risk for her. In certain conditions, some pregnant women may be denied even the basic necessities. It is not unusual in certain circumstances for a mother-inlaw to withhold food or medical care from her pregnant daughter-in-law (Bhatia, 1985). This differential treatment makes women more susceptible to complications during pregnancy that can lead to death or permanent injury. High-Risk Pregnancy
Apart from all other factors that contribute to maternal mortality, certain biological and behavioral conditions increase risk. Risk increases when the pregnancy occurs at either a very early age or a late age. A survey from Bangladesh showed that women between 15 and 19 years of age had twice the maternal mortality rate of women between 20 and 24 (Fauveau, Koenig, Chakraborty, & Chowdhury, 1988). A similar pattern was found in Africa (Royston & Lopez, 1987). Even in the United States, teenagers are at higher risk of maternal mortality. A symposium of the National Academy of Sciences on teenage pregnancy showed that teenagers contributed to higher maternal mortality and morbidity than women in their twenties ("Risking the Future," 1987). Similarly, a comprehensive study of reproductive mortality in the United States showed that the rate of decline for maternal mortality between 1965 and 1975 was slower for teenagers than for those in the 20-to-34 age
group, even though the actual mortality rate between the two groups was not significantly different (Sachs, Layde, Rubin, & Rochat, 1982). The risk of mortality rises again after the age of 35. This pattern appears to be consistent in both developed and developing countries. In Bangladesh, women over 35 have twice the risk of mortality as those between 20 and 24 (Royston & Lopez, 1987). Similarly, older women in the United States have a significantly higher mortality rate than younger women and even than teenage women (Makinson, 1985; Rosenberg & Rosenthal, 1987; Sachs et al., 1982). The higher mortality risk for teenage women is especially significant in developing countries because high percentages of young women are married as soon as they reach puberty. In Bangladesh, more than 90 percent of all women are married by age 18, and 50 percent are married by age 15 (Royston & Lopez, 1987). The higher mortality risk is equally significant for older women, because in many developing countries childbearing not only takes place at an early age, but also continues into late age. An estimated 25 percent of all births in Bangladesh were by women over 35 (Royston & Lopez, 1987). However, age should not be viewed as the only factor in high-risk pregnancy. Recent reports show that with proper obstetric care, women can experience safe pregnancy at any reasonable age ("A Look at Pregnancy," 1987; Mansfield, 1987). Because the age of women may not be the only risk factor involved, how these women manage their pregnancy may also contribute to risk. Maternal immaturity, an attitude of indifferente to pregnancy, and poor health conditions can make pregnancy more problematic. CHALLENGES FOR SOCIAL WORK ACTION
A country's maternal mortality statistics reflect the availability of health resources and status of women in that society. For countries with sufficient health provisions and a strong commitment to gender equality, childbearing is now only a minor health hazard. Nonetheless, if childbearing in developing countries does not
PROMOTING MATERNAL HEALTH IN DEVELOPING COUNTRIES
203
become safer between now and the year 2000, another 7 million women of childbearing age worldwide can be expected to die, and perhaps millions more might live with handicaps resulting from complications. Equally serious is the fact that millions of children would live without mothers (WHO, 1988). Development of Health Care I nfrastructu re
Because most maternal deaths can be prevented by basic obstetric care and sound support systems, it is important that each nation's health care system be committed to developing and providing basic health care benefits for all. More medical and health facilities with welltrained personnel must be built in the villages and communities of developing countries. Currently, less than 50 percent of the women in developing countries receive medical care from pregnancy to delivery, whereas virtually all women in the developed countries do. The development of nonconventional health care facilities and personnel is also important. Welltrained midwives or indigenous health workers can perform outreach services to facilitate use of conventional health care when necessary, and through workers' home visits and frequent contacts, potential problems or complications can be detected at an early stage. Having a social work team in both conventional and nonconventional health facilities can be indispensable to promoting maternal health care. Social workers can be especially helpful to disadvantaged women who are without knowledge and resources. The social work system can provide or direct clients to prenatal care, nutritional information, and information regarding personal rights that otherwise may not be obtained outside the system. Meeting the challenge of developing a viable health care infrastructure is a difficult task, but it can be achieved if all nations, beginning with WHO members, actively pursue resolutions endorsed at the Thirty-second World Health Assembly held in Alma-Ata in the former Soviet Union in 1979 (Barton, 1979; WHO, 1981). The following five resolutions can help the task: 204
1. Health care policy must receive the highest endorsement from the heads of states, and a suitable organizational framework for national health development must be established. 2. A mechanism must exist for people to express, demand, and participate in decisions on health matters. 3. At least 5 percent of a country's gross national product must be spent on health care. 4. Resources must be equitably distributed so that personnel and facilities are located over various geographical areas and for various people. 5. More affiuent nations must commit additional resources to less affluent countries to assist them in establishing health care infrastructures. Improving the Status of Women
There is a curious health care paradox in developing countries. Although women provide basic health care for family members, their own health needs are often ignored. Halfdan Mahler (1985), Director General of WHO, predicted that when women are malnourished, overworked, pushed to have large numbers of children at an early age, and kept ignorant, the health of their families is jeopardized, and in the long run the society will be at risk. Clearly the development of health care cannot succeed if women are left out of the process. Promoting the status of women has not always received priority consideration from either developed or developing countries. To some degree, the social work profession also fails to promote the status of women. Consequently, many women and children are facing unnecessary health and economic risks (Combs-Orme, 1987; Sidel, 1986). The social work profession must take a stronger leadership role in this issue. The status of women can be best improved through three approaches. First, current societal attitudes must be challenged to encourage recognition of the contributions of women. The preferential treatment of males over females is embedded in sociocultural and economic beliefs that suggest that females are economic liabilities. Because this attitude damages women's
HEALTH AND SOCIAL WORK /VOLUME 17, NUMBER 3 /AUGUST 1992
status, people must be made aware of how women contribute to various societal and labor activities. Notably, women's labor accounts for nearly two-thirds of the total working hours in the world. Women tend livestock, work in factories, sell in markets, and manage domestic affairs ("Health for All," 1985). Second, women's health care must be professionally upgraded. Health care communities must pay more attention to women's health problems. More financial and technical resources must be allocated to research and other scientific activity on reproductive technology, sexually transmitted diseases, breast and cervical cancer, breastfeeding, nutrition, and other health problems. This research will act as a catalyst to increase awareness of health issues and other large problems facing women. Third, women can begin improving their status by organizing and working with other grassroots women's movements. In the past few years, African women have made important strides toward better health by challenging and removing various taboos related to childbearing, nutrition, and the cruel practice of female circumcision (Diallo, 1985). These changes were initiated by women reaching other women in the community dialogue. The problem of maternal health is clearly a social work concern. Although maternal mortality is a medical issue, the factors contributing to it are found in the sociopolitical arena. To promote better maternal health, social workers must take an active role in resolving the problems of access to health care, Bender inequality, and high-risk pregnancy. This work must be performed by social workers, because physicians, indigenous workers, and other health care professionals have not shown leadership in these areas.
an important role in this trend through counseling, education, and advocacy work. Because maternal mortality and health in general are a result of social, cultural, economic, and medical interplay, nations of the world must create environments that are conducive to promoting health. Social workers must commit themselves to making these healthy environments the reality. About the Author
Michael M. 0. Seipel, PhD, is Associate Professor, School of Social Work, BrighamYoung University, Provo, UT 84602. References
Barton, W. L. (1979, July). Alma-Ata: Signpost to a new health era. World Health, pp. 3-5. Bhatia, S. (1985, April). Status and survival. World Health, pp. 12-14. Combs-Orme, T. (1987). Infant mortality: Priority for social work. Social Work, 32, 507-511. Diallo, B. (1985, April). The dream of domination. World Health, pp. 26-28. Fauveau, V., Koenig, M. A., Chakraborty, J., & Chowdhury, A. I. (1988). Cause of maternal mortality in rural Bangladesh, 1976-85. Bulletin of the World Health Organization, 66, 634-651. Health for all: Women's role and women's need. (1985, April). World Health, pp. 16-17. Henderson, D. A. (1980, May). A victory for all mankind. World Health, pp. 3-5. A look at pregnancy later in life. (1987). Emergency Medicine, 19(5), 130-131. Mahler, H. (1985, April). Women—The next ten years. World Health, p. 3. Makinson, C. (1985). Health consequences of teenage fertility. Family Planning Perspectives, 17,132-139.
CONCLUSION
Most maternal deaths are preventable. The developed nations have shown the way by making pregnancy and childbearing of little or no health hazard in the absence of significant economic or social hardship. Social workers and other health care professionals have played
Mansfield, P. K. (1987). Teenage and midlife childbearing update: Implication for education. Health Education, 18(4), 18-23. Risking the future: A symposium on the National Academy of Sciences report on teen pregnancy. (1987). Family Planning Perspectives, 19, 119-121. Rosenberg, M. J., & Rosenthal, S. M. (1987). Reproductive mortality in the United States: Recent
PROMOTING MATERNAL HEALTH IN DEVELOPING COUNTRIES
205
trends and methodological consideration. American Journal of Public Health, 77, 833-836. Royston, E., & Lopez, A. D. (1987). On the assessment of maternal mortality. World Health Statistics Quarterly, 40, 214-224. Sachs, B. P., Layde, P. M., Rubin, G. L., & Rochat, R. W. (1982). Reproductive mortality in the United States. Journal of the American Medical Association, 247, 2789-2792. Seipel, M. M. (1990). The social factor: Key to fighting infectious diseases. International Social Work Journal, 33, 269-279. Sidel, R. (1986). Women and children last. New York: Penguin Books.
Waldron, I. (1987). Pattern and causes of excessive female mortality among children in developing countries. World Health Statistics Quarterly, 40, 194-210. World Health Organization. (1981). Handbook of resolution and decision of the World Health Assembly and Executive Board (4th ed.). Geneva: Author. World Health Organization. (1988). World health statistics annual. Geneva: Author. World Health Organization. (1989). World health statistics annual. Geneva: Author. Accepted December 12, 1991
NASW Diplomate in Clinical Social Work
A
PPLY NOW FOR the NASW Diplomate in Clinical Social Work or the Qualified Clinical Social Worker credent tal to be Ikted in the 1')9 3 Workers. (Peroth Ikted in the 1 0 (, , r 19`)1 reLeive NAS\X/
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HEALTH AND SOCIAL WORK/ VOLUME 17, NUMBER 3 /AUGUST 1992
ROMOTING MATERNAL HEALTH IN DEVELOPING COUNTRIES MICHAEL M. 0. SEIPEL Most maternal deaths are preventable, yet more than 500,000 women die annually worldwide. However, the risk of maternal mortality is unevenly distributed; 99 percent of all maternal deaths occur in developing countries. This article examines the causes of this disparity and suggests several recommendations for social workers to promote maternal health in developing countries.
The health-promoting efforts of the World Health Organization (WHO) and other worldwide health care organizations have significantly improved the health status of all people regardless of political, economical, or geographical differences. Their work, combined with the work of the international social work community, local citizens, and high-level political entities, has made the world safer; smallpox has been eradicated, the infant mortality rate has been decreasing in recent times, and there now is less of a threat for pandemie outbreak of several infectious diseases (Henderson, 1980; WHO, 1989). Although the overall health standard of both developed and developing countries has improved, the degree of improvement in these countries varies widely. The most significant difference is in maternal health; the number of women dying from pregnancy and childbirth is dramatically higher in developing countries than in developed countries. Waldron (1987) noted 200
that in developed countries, males have a higher mortality rate than do females, but in many developing countries the reverse is true because of high maternal mortality. This article examines worldwide maternal mortality data, discusses the reasons for the high rate of maternal mortality in developing countries, and explores solutions to improve the current situation. Finally, the specific role of social workers is reviewed. WORLDWIDE MATERNAL MORTALITY RATE
No one knows exactly how many women in developing countries die from pregnancy and childbirth, because much of the data gathered are unreliable. Whereas most developed countries have largely reliable registration systems, many developing countries do not have similar systems that can be used for comparative study over time (WHO, 1988). WHO uses uniform data collection methods to collect data
CCC Code: 0360-7283/92 $3.00 © 1992, National Association of Social Workers, Inc.
from its member countries and believes its methods yield useful and discernible information for analysis. In 1985 about half a million women died from causes related to pregnancy and childbirth (WHO, 1988). Ninety-nine percent of these maternal deaths took place in developing countries (Figure 1). Even within developing countries, maternal death is not evenly distributed. Sixtytwo percent of all maternal deaths occurred in Asia; 59 percent were in South Asia, and only 3 percent were in East Asia. Thirty percent of maternal deaths occurred in Africa, and 7 percent occurred in Latin America. The maternal mortality rate in Western Europe and Northern Europe is about 10 per 100,000 live births. In Romania and other Eastern European countries, the rate is higher. The
rates for other countries (United States, Canada, New Zealand, Japan) are similar to other developed countries. In contrast, Africa had the highest rate of maternal death resulting from pregnancy and childbirth in the world (Table 1): About 640 African women die from pregnancyrelated causes per 100,000 live births. The rate is highest in rural areas of Africa and lowest in urban areas. The contrast between developed and developing countries is striking. Theoretically, a woman in the developing countries has about 100 times more chance of pregnancy-related death than her counterpart in the developed countries. The contrast could be even more striking if the death registry system of developing countries were more widely placed and records were kept more accurately.
Figure 1. Estimated Maternal Deaths by Major Regions, 1985
Latin America 7% Developed countries 1% East Asia 3%
Africa 30%
South Asia 59%
SOURCE: Reprinted with permission from World Health Organization. (1988). World health statistics annual (p. 3). Geneva: Author. PROMOTING MATERNAL HEALTH IN DEVELOPING COUNTRIES
201
Table 1. Estimated Matemal Mortality Rate Caused by Childbirth per 100,000 Live Births, 1985 Highest Rate and Lowest Rate
Country Developing countries Africa Highest (rural) a Lowest (urban)a Asia Highest (southern)a Lowest (eastern) a Latin America Highest (tropical) Lowest (temperate) b Developed countries Highest (Romania) a Lowest (Luxembourg) b Others (United States, Canada, Japan, New Zealand)a
Combined Estimated Rate 640
1,000 500 420 700 10 270 310 110 10 30 0
10
World Health Organization. (1988). World health statistics annual (pp. 11-12). Geneva: Author. bSouxcE: Royston, E., & Lopez, A. D. (1987). On the assessment of maternal mortality (p. 221). World Health Statistics Quarterly, 40, 214-224. 'SOURCE:
FACTORS CONTRIBUTING TO MATERNAL MORTALITY
The following factors contribute to maternal mortality: inaccessible health care, gender inequality, and high-risk pregnancy. Inaccessible Health Care
Many women in the developing countries do not receive adequate maternal health care throughout their pregnancy. Information provided by the participating countries of WHO in 1988 indicated that about 40 million pregnant women in the developing countries received no medical care during pregnancy. Moreover, 46 million were unattended by trained health care providers during the delivery (WHO, 1989). In contrast, nearly all of the women in the developed countries received both maternal health care during pregnancy and delivery by trained health care providers (WHO, 1989). Additionally, in developed countries, many women receive psychosocial care from social workers to further minimize any potential complications (Combs-Orme, 1987). Inadequate or nonexistent health care facilities, a lack of trained health care providers, high costs, and a lack of meaningful health care poli202
cies contribute to inaccessibility of health care. However, little is being done to change the situation. Two indicators that measure the accessibility of health care (health care facilities within one hour of travel and availability of trained health care providers) are still short of the acceptable standard: More than 40 percent of WHO member countries are without health care facilities within one hour of travel from their homes for 90 percent of their people (Seipel, 1990). Also, health care workers are unevenly distributed throughout the world. Africa, for example, has about one physician per 100,000 people, whereas there are 15 to 30 physicians per 100,000 people in Europe (WHO, 1988). Gender Inequality
A pattern of sociocultural practices may help explain the high maternal mortality rate in developing countries. As Waldron (1987) and Bhatia (1985) observed, many women in developing countries are openly discriminated against in obtaining vital services, including good nutrition and health care. The pattern of inequality begins at birth. The birth of a female child is frequently unwelcome. As a consequence, female infants are generally neglected, and when medical attention becomes necessary, they
HEALTH AND SOCIAL WORK/VOLUME 17, NUMBER 3 / AUGUST 1992
receive less medical care. There is also a marked gender differente in food allocation. Typically, male children enjoy greater intake of protein and calories than do female children. Male children also receive more family resources for education and other necessities for future well-being. Female children in many rural communities are married off as soon as they reach puberty, thus preventing them from achieving educational status comparable to that of their male counterparts. Even marriage is no guarantee of a better life. In fact, the status of daughter-in-law in a dowry system might be little or no better than that of a household servant if the dowry was small. Her status might improve with the birth of a son, but childbearing presents a real risk for her. In certain conditions, some pregnant women may be denied even the basic necessities. It is not unusual in certain circumstances for a mother-inlaw to withhold food or medical care from her pregnant daughter-in-law (Bhatia, 1985). This differential treatment makes women more susceptible to complications during pregnancy that can lead to death or permanent injury. High-Risk Pregnancy
Apart from all other factors that contribute to maternal mortality, certain biological and behavioral conditions increase risk. Risk increases when the pregnancy occurs at either a very early age or a late age. A survey from Bangladesh showed that women between 15 and 19 years of age had twice the maternal mortality rate of women between 20 and 24 (Fauveau, Koenig, Chakraborty, & Chowdhury, 1988). A similar pattern was found in Africa (Royston & Lopez, 1987). Even in the United States, teenagers are at higher risk of maternal mortality. A symposium of the National Academy of Sciences on teenage pregnancy showed that teenagers contributed to higher maternal mortality and morbidity than women in their twenties ("Risking the Future," 1987). Similarly, a comprehensive study of reproductive mortality in the United States showed that the rate of decline for maternal mortality between 1965 and 1975 was slower for teenagers than for those in the 20-to-34 age
group, even though the actual mortality rate between the two groups was not significantly different (Sachs, Layde, Rubin, & Rochat, 1982). The risk of mortality rises again after the age of 35. This pattern appears to be consistent in both developed and developing countries. In Bangladesh, women over 35 have twice the risk of mortality as those between 20 and 24 (Royston & Lopez, 1987). Similarly, older women in the United States have a significantly higher mortality rate than younger women and even than teenage women (Makinson, 1985; Rosenberg & Rosenthal, 1987; Sachs et al., 1982). The higher mortality risk for teenage women is especially significant in developing countries because high percentages of young women are married as soon as they reach puberty. In Bangladesh, more than 90 percent of all women are married by age 18, and 50 percent are married by age 15 (Royston & Lopez, 1987). The higher mortality risk is equally significant for older women, because in many developing countries childbearing not only takes place at an early age, but also continues into late age. An estimated 25 percent of all births in Bangladesh were by women over 35 (Royston & Lopez, 1987). However, age should not be viewed as the only factor in high-risk pregnancy. Recent reports show that with proper obstetric care, women can experience safe pregnancy at any reasonable age ("A Look at Pregnancy," 1987; Mansfield, 1987). Because the age of women may not be the only risk factor involved, how these women manage their pregnancy may also contribute to risk. Maternal immaturity, an attitude of indifferente to pregnancy, and poor health conditions can make pregnancy more problematic. CHALLENGES FOR SOCIAL WORK ACTION
A country's maternal mortality statistics reflect the availability of health resources and status of women in that society. For countries with sufficient health provisions and a strong commitment to gender equality, childbearing is now only a minor health hazard. Nonetheless, if childbearing in developing countries does not
PROMOTING MATERNAL HEALTH IN DEVELOPING COUNTRIES
203
become safer between now and the year 2000, another 7 million women of childbearing age worldwide can be expected to die, and perhaps millions more might live with handicaps resulting from complications. Equally serious is the fact that millions of children would live without mothers (WHO, 1988). Development of Health Care I nfrastructu re
Because most maternal deaths can be prevented by basic obstetric care and sound support systems, it is important that each nation's health care system be committed to developing and providing basic health care benefits for all. More medical and health facilities with welltrained personnel must be built in the villages and communities of developing countries. Currently, less than 50 percent of the women in developing countries receive medical care from pregnancy to delivery, whereas virtually all women in the developed countries do. The development of nonconventional health care facilities and personnel is also important. Welltrained midwives or indigenous health workers can perform outreach services to facilitate use of conventional health care when necessary, and through workers' home visits and frequent contacts, potential problems or complications can be detected at an early stage. Having a social work team in both conventional and nonconventional health facilities can be indispensable to promoting maternal health care. Social workers can be especially helpful to disadvantaged women who are without knowledge and resources. The social work system can provide or direct clients to prenatal care, nutritional information, and information regarding personal rights that otherwise may not be obtained outside the system. Meeting the challenge of developing a viable health care infrastructure is a difficult task, but it can be achieved if all nations, beginning with WHO members, actively pursue resolutions endorsed at the Thirty-second World Health Assembly held in Alma-Ata in the former Soviet Union in 1979 (Barton, 1979; WHO, 1981). The following five resolutions can help the task: 204
1. Health care policy must receive the highest endorsement from the heads of states, and a suitable organizational framework for national health development must be established. 2. A mechanism must exist for people to express, demand, and participate in decisions on health matters. 3. At least 5 percent of a country's gross national product must be spent on health care. 4. Resources must be equitably distributed so that personnel and facilities are located over various geographical areas and for various people. 5. More affiuent nations must commit additional resources to less affluent countries to assist them in establishing health care infrastructures. Improving the Status of Women
There is a curious health care paradox in developing countries. Although women provide basic health care for family members, their own health needs are often ignored. Halfdan Mahler (1985), Director General of WHO, predicted that when women are malnourished, overworked, pushed to have large numbers of children at an early age, and kept ignorant, the health of their families is jeopardized, and in the long run the society will be at risk. Clearly the development of health care cannot succeed if women are left out of the process. Promoting the status of women has not always received priority consideration from either developed or developing countries. To some degree, the social work profession also fails to promote the status of women. Consequently, many women and children are facing unnecessary health and economic risks (Combs-Orme, 1987; Sidel, 1986). The social work profession must take a stronger leadership role in this issue. The status of women can be best improved through three approaches. First, current societal attitudes must be challenged to encourage recognition of the contributions of women. The preferential treatment of males over females is embedded in sociocultural and economic beliefs that suggest that females are economic liabilities. Because this attitude damages women's
HEALTH AND SOCIAL WORK /VOLUME 17, NUMBER 3 /AUGUST 1992
status, people must be made aware of how women contribute to various societal and labor activities. Notably, women's labor accounts for nearly two-thirds of the total working hours in the world. Women tend livestock, work in factories, sell in markets, and manage domestic affairs ("Health for All," 1985). Second, women's health care must be professionally upgraded. Health care communities must pay more attention to women's health problems. More financial and technical resources must be allocated to research and other scientific activity on reproductive technology, sexually transmitted diseases, breast and cervical cancer, breastfeeding, nutrition, and other health problems. This research will act as a catalyst to increase awareness of health issues and other large problems facing women. Third, women can begin improving their status by organizing and working with other grassroots women's movements. In the past few years, African women have made important strides toward better health by challenging and removing various taboos related to childbearing, nutrition, and the cruel practice of female circumcision (Diallo, 1985). These changes were initiated by women reaching other women in the community dialogue. The problem of maternal health is clearly a social work concern. Although maternal mortality is a medical issue, the factors contributing to it are found in the sociopolitical arena. To promote better maternal health, social workers must take an active role in resolving the problems of access to health care, Bender inequality, and high-risk pregnancy. This work must be performed by social workers, because physicians, indigenous workers, and other health care professionals have not shown leadership in these areas.
an important role in this trend through counseling, education, and advocacy work. Because maternal mortality and health in general are a result of social, cultural, economic, and medical interplay, nations of the world must create environments that are conducive to promoting health. Social workers must commit themselves to making these healthy environments the reality. About the Author
Michael M. 0. Seipel, PhD, is Associate Professor, School of Social Work, BrighamYoung University, Provo, UT 84602. References
Barton, W. L. (1979, July). Alma-Ata: Signpost to a new health era. World Health, pp. 3-5. Bhatia, S. (1985, April). Status and survival. World Health, pp. 12-14. Combs-Orme, T. (1987). Infant mortality: Priority for social work. Social Work, 32, 507-511. Diallo, B. (1985, April). The dream of domination. World Health, pp. 26-28. Fauveau, V., Koenig, M. A., Chakraborty, J., & Chowdhury, A. I. (1988). Cause of maternal mortality in rural Bangladesh, 1976-85. Bulletin of the World Health Organization, 66, 634-651. Health for all: Women's role and women's need. (1985, April). World Health, pp. 16-17. Henderson, D. A. (1980, May). A victory for all mankind. World Health, pp. 3-5. A look at pregnancy later in life. (1987). Emergency Medicine, 19(5), 130-131. Mahler, H. (1985, April). Women—The next ten years. World Health, p. 3. Makinson, C. (1985). Health consequences of teenage fertility. Family Planning Perspectives, 17,132-139.
CONCLUSION
Most maternal deaths are preventable. The developed nations have shown the way by making pregnancy and childbearing of little or no health hazard in the absence of significant economic or social hardship. Social workers and other health care professionals have played
Mansfield, P. K. (1987). Teenage and midlife childbearing update: Implication for education. Health Education, 18(4), 18-23. Risking the future: A symposium on the National Academy of Sciences report on teen pregnancy. (1987). Family Planning Perspectives, 19, 119-121. Rosenberg, M. J., & Rosenthal, S. M. (1987). Reproductive mortality in the United States: Recent
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trends and methodological consideration. American Journal of Public Health, 77, 833-836. Royston, E., & Lopez, A. D. (1987). On the assessment of maternal mortality. World Health Statistics Quarterly, 40, 214-224. Sachs, B. P., Layde, P. M., Rubin, G. L., & Rochat, R. W. (1982). Reproductive mortality in the United States. Journal of the American Medical Association, 247, 2789-2792. Seipel, M. M. (1990). The social factor: Key to fighting infectious diseases. International Social Work Journal, 33, 269-279. Sidel, R. (1986). Women and children last. New York: Penguin Books.
Waldron, I. (1987). Pattern and causes of excessive female mortality among children in developing countries. World Health Statistics Quarterly, 40, 194-210. World Health Organization. (1981). Handbook of resolution and decision of the World Health Assembly and Executive Board (4th ed.). Geneva: Author. World Health Organization. (1988). World health statistics annual. Geneva: Author. World Health Organization. (1989). World health statistics annual. Geneva: Author. Accepted December 12, 1991
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HEALTH AND SOCIAL WORK/ VOLUME 17, NUMBER 3 /AUGUST 1992
