The most dangerous day in a woman’s life

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The risk of dying during pregnancy or childbirth for rural Zambian women is up to 100 times greater than for women in developed nations; one of 23 will die from maternal causes over her lifetime.  Fewer than half deliver with a skilled birth attendant in a health facility. 

The risk of dying during pregnancy or childbirth for rural Zambian women is up to 100 times greater than for women in developed nations; one of 23 will die from maternal causes over her lifetime.  Fewer than half deliver with a skilled birth attendant in a health facility.

In northern Zambia, the standard greeting after a woman gives birth is “Mwapusukeni” (“You have survived!”).  This mix of surprise and relief reflects the frequent deaths of women during pregnancy and childbirth in Africa.

Much attention has rightly focused on addressing AIDS in Africa.  Access to anti-retroviral medications has rapidly reduced AIDS mortality.  Reducing maternal mortality has proven much more difficult.  The risk of dying during pregnancy or childbirth for rural Zambian women is up to 100 times greater than for women in developed nations; one of 23 will die from maternal causes over her lifetime.  Fewer than half deliver with a skilled birth attendant in a health facility.  Newborns also face a daunting entry into the world, with one in 30 dying in their first month.

The governments of Zambia and the United States have reduced maternal mortality through a new partnership, Saving Mothers, Giving Life.  Within just one year, using a district-level approach and work in both community and facility in four districts, preliminary data from this pilot project show an increase in the number of women delivering in facilities in four districts by over 30 percent, from 22,842 to 29,927.  More striking, results suggest the maternal mortality for women who deliver in facilities was reduced by 58 percent and the rate of stillbirths declined.

What have been the key ingredients to this success?

– A census of deaths and verbal autopsy interviews in the four selected districts increased understanding of the specific causes of death.  Learning from each tragic case drove home that maternal deaths are preventable and helped indicate the actions to prevent many deaths.  This is a change from the fatalism expressed by “Mwapusukeni.”

– Health workers were posted at remote clinics that previously had no midwives or nurses.

– All nurses and midwives were trained and drilled in rapid response to the most critical emergencies: toxemia, post-partum hemorrhage and newborn resuscitation.

– Where rural women may be hours by oxcart from the nearest health facility and totally cut off from roads during the flood season, Zambian safe motherhood volunteers and American Peace Corps volunteers encouraged women to seek early pre-natal care and to have a birth plan, including, if necessary, staying at a shelter near a hospital during the last weeks of pregnancy.

– Blood transfusions were made more available.

– Electronic health records improved continuity of care and portable solar power was introduced in the 60 percent of facilities with no electricity.
An overarching theme has been a spirit of partnership between national and district leadership and organizations supporting HIV care, malaria control, family planning and maternal and child health and among US government agencies (Centers for Disease Control and Prevention, Departments of Defense and State, the Peace Corps and the United States Agency for International Development).  Public, private and mission health facilities improved the care they provided.

This partnership is consistent with two key principles of President Obama’s Global Health Initiative and the President’s Emergency Plan for AIDS Relief (PEPFAR) initiated by President Bush: ownership and leadership by host countries and co-investment to ensure sustainability. The Zambian government guided this plan and chose pilot districts.  It also increased its health budget by over 40 percent two years in a row; this means more health workers, especially in rural areas.

As the United Nations General Assembly meets in September and considers progress in achieving Millennium Development Goals, the fifth goal of reducing maternal deaths and universal access to reproductive health care has been considered “off track,” especially in sub-Saharan Africa.  The MDG target date is 2015.  Saving Mothers, Giving Life, which also works in Uganda, has demonstrated that strong partnerships, bureaucratic agility and local leadership can dramatically and rapidly reduce deaths in pregnancy and childbirth.  Maintaining this momentum requires strong global partnerships.  The governments of the United States and Norway, as well as a public-private partnership with Merck for Mothers, Every Mother Counts, Project CURE and the American College of Obstetricians and Gynecologists have pledged continued support for Saving Mothers, Giving Life. The government of Zambia with other partners has incorporated lessons to expand efforts to reduce maternal deaths.

Much still needs to be done, including continued data review to ensure these early positive results are sustained and identify program components essential for national scale-up.  But Saving Mothers, Giving Life has already demonstrated that giving birth can be much safer in Zambia and elsewhere in Africa.

Christine Kaseba-Sata, an obstetrician/gynecologist, is the First Lady of Zambia.  Mark Storella was U.S. Ambassador to Zambia during 2010 – 2013. 

* All opinions, views, and comments in this article are solely the author’s and in no way represent or reflect those of the United States Department of State and its agencies or affiliated entities.

Mark C. Storella was sworn in as President Obama’s personal representative and Ambassador to the Republic of Zambia on August 30, 2010. He presented his credentials to His Excellency President Rupiah Banda on September 21, 2010. He served simultaneously as the U.S. Representative to the Common Market for Eastern and Southern Africa (COMESA) until his departure in August 2013.
Ambassador Storella is a career member of the Senior Foreign Service. He most recently served as the Senior Coordinator for Iraqi Refugees and Internally Displaced Persons at the U.S. Embassy in Baghdad. From 2007-2009, he was Deputy Permanent Representative at the U.S. Mission to the United Nations and Other International Organizations in Geneva. He also served as Counselor for Refugee and Migration Affairs in Geneva from 2006-2007. Ambassador Storella was Deputy Chief of Mission at the U.S. Embassy in Phnom Penh, Cambodia from 2003 to 2006.

Ambassador Storella previously served at U.S. embassies in Rome, Phnom Penh, Paris and Bangkok. He has served at the Department of State as Executive Assistant to the Counselor and on the Japan and NATO desks. Ambassador Storella was Rusk Fellow at Georgetown University from 2001-2002 where he was also an Adjunct Professor teaching graduate and undergraduate courses on humanitarian action. He is author of monographs and articles on such diverse topics as multilateral arms control, humanitarianism in conflict situations and U.S.-Japan trade.

Ambassador Storella was the 2009 recipient of the Thomas Jefferson Award, granted by American Citizens Abroad. He received his A.B. from Harvard College, and holds a masters degree from the Fletcher School of Law and Diplomacy. His foreign languages are French, Khmer, Italian and Thai. He is married and has two sons.

Dr. Christine Kaseba is the wife of Michael Chilufya Sata and First Lady of the Republic of Zambia, since her husband’s swearing in on September 23, 2011. Since assuming the First Lady position, Dr. Kaseba has publicized her intention to do more to focus national attention on reducing maternal mortality and promoting reproductive health rights, among her many other interests and causes.

Dr. Kaseba is a Senior Consultant Obstetrician and Gynaecologist at the University Teaching Hospital (UTH) in Lusaka, Zambia, where she has worked since 1996. For the past 15 years, she has been an Honorary Lecturer at the University of Zambia’s School of Medicine. She also served as Head of the university’s Department of Obstetrics and Gynecology from 2000 through 2006. Dr. Kaseba has worked with the Government of Zambia in various capacities, including serving as a national trainer in: emergency obstetric care; maternal death reviews; long-term family planning; preventing mother-to-child transmission of HIV; and gender-based violence. She is a strong advocate for women’s sexual and reproductive rights.

Dr. Kaseba studied medicine at the University of Zambia. She continued her specialized obstetrics and gynecology studies at Trinity College in Dublin, Ireland. In 1995, she became a Member of the Royal College of Obstetrics and Gynaecology (MRCOG), Royal College Of Obstetricians, United Kingdom. She holds a variety of other ancillary professional certificates in public health, leadership and consultancy skills.

Dr. Kaseba is also an accomplished researcher, public speaker and author. She has made numerous scientific presentations at various local, regional and International fora. She has written on a variety of public health issues including: pregnancy, contraception and mother-to-child HIV transmission.

Dr. Kaseba is married to President Michael Sata. Together, they have several children.


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