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By Emily Maistrellis
Walif was only 16 and his younger sister, Nassim, just 11 when their mother died in childbirth in Butajira, Ethiopia.
Both Walif and Nassim had been promising students, especially Walif, who had hoped to score high on the national civil service exam after completing secondary school. But following the death of their mother, their father left them to go live with a second wife in the countryside. Walif dropped out of school to care for his younger siblings, as did Nassim and two other sisters, who had taken jobs as house girls in Addis Ababa and Saudi Arabia.
Nassim was married at 15, to a man for whom she bore no affection, so that she would no longer be an economic burden to the family. By the age of 17, she already had her first child. Seven years after his mother died, Walif was still caring for his younger siblings, piecing together odd jobs to pay for their food, although he could not afford the school fees.
In all, with one maternal death, four children's lives were derailed, not just emotionally but economically.
More than 1,000 miles away, in the rural Nyanza province of Kenya, a woman in the prime of her life died while giving birth to her seventh child, leaving a void that her surviving husband struggled to fill. He juggled tending the family farm, maintaining his household, raising his children and keeping his languishing newborn son alive.
But he didn’t know how to feed his son, so he gave him cow’s milk mixed with water. At three months old, the baby was severely malnourished. A local health worker visited the father and showed him how to feed and care for the baby. That visit saved the baby’s life.
As these stories illustrate, the impact of a woman's death in pregnancy or childbirth goes far beyond the loss of a woman in her prime, and can cause lasting damage to her children — consequences now documented in new research findings from two groups: Harvard's FXB Center for Health and Human Rights, and a collaboration among Family Care International, the International Center for Research on Women and the KEMRI-CDC Research Collaboration.
The causes and high number of maternal deaths in Ethiopia, Malawi, Tanzania, South Africa, and Kenya — the five countries explored in the research — are well documented, but this is the first time research has catalogued the consequences of those deaths to children, families, and communities.
The studies found stark differences between the wellbeing of children whose mothers did and did not survive childbirth:
• Out of 59 maternal deaths, only 15 infants survived to two months, according to a study in Kenya.
• In Tanzania, researchers found that most newborn orphans weren’t breastfed. Fathers rarely provided emotional or financial support to their children following a maternal death, affecting their nutrition, health care, and education.
• Across the settings studied, children were called upon to help fill a mother's role within the household following her death, which often led to their dropping out of school to take on difficult farm and household tasks beyond their age and abilities.
How to use these new research findings to advocate for greater international investment in women’s health?
At a webcast presentation earlier this month, a panel of researchers, reproductive and maternal health program implementers, advocates and development specialists discussed that question.
Central to the discussion was the belief that the death of a woman during pregnancy and childbirth is a terrible injustice in and of itself. The vast majority of these deaths are preventable, and physicians and public health practitioners have long known the tools needed to prevent them. And yet, every 90 seconds a woman dies from maternal causes, most often in a developing country.
The panelists expressed hope that these new data, which show that the true toll of these deaths is far greater than previously understood, can help translate advocacy into action.
“It’s important to recognize that, beyond the personal tragedy and the enormous human suffering that these numbers reflect — some hundreds of thousands of women die needlessly every year — there are enormous costs involved as well,” said panelist Jeni Klugman, a senior adviser to the World Bank Group and a fellow at the Harvard Kennedy School of Government.
“So quantifying those effects in terms of [children’s] lower likelihood of surviving, the enormous financial and health costs involved and the repercussions down the line in terms of poverty, dropping out of school, bad nutrition and future life prospects are all tremendously powerful as additional information to take to the ministries of finance, to take to the donors, to take to stakeholders, to help mobilize action,” she said.
Just what does “action” mean? Currently, the countries of the world are debating the new global development agenda to succeed the eight Millennium Development Goals, an ambitious global movement to end poverty. Advocates can use this research to make the case that reproductive, maternal, newborn, and child health should play a central role in this agenda, given that it reveals the linkages between the health of mothers, stable families, and ultimately, more able communities, according to Amy Boldosser-Boesch, Interim President and CEO of FCI.
Panelists also called for more aggressive implementation of the strategies known to prevent maternal mortality in the first place; as well as for the provision of social, educational, and financial support to children who have lost their mothers; and for continued research that outlines the direct and indirect financial costs of a woman’s contributions to her household, and what her absence does to her family’s social and economic well-being.
But action is also required outside of the realm of health care, said Alicia Ely Yamin, lecturer in Global Health and Population at the Harvard School of Public Health and policy director of the FXB Center.
In fact, the cascade of ill effects for children and families documented by this research doesn’t begin with a maternal death. The plight of the women captured in these studies begins when they experience discrimination and marginalization in their societies: “It [maternal death] is not a technical problem. It’s because women lack voice and agency at household, community, and societal levels; and because their lives are not valued,” she said.
Klugman added that this research adds to work on gender discrimination, including issues like gender-based violence, which affects one in three women worldwide.
It’s a tall order: advancing gender equality, preventing maternal, newborn, and child death, and improving the overall well-being of families. But panelists were hopeful that this research can show policy makers, and the public, that these issues are intertwined, and must be addressed as parts of a whole.
As Aslihan Kes, an economist and gender specialist at ICRW and one of the researchers on the Kenya study concluded, this research is “making visible the central role women have in sustaining their households."
"This is an opportunity to really put women front and center," she said, "making all of the arguments for addressing the discrimination and constraints they face across their lives.”
Emily Maistrellis is a policy coordinator at the FXB Center for Health and Human Rights and a research study coordinator at Boston Children's Hospital.
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