Hesperian Health Guides
Why do women die during pregnancy and birth?
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Most healthy women do not have serious problems during pregnancy, and most births are not emergencies. A skilled midwife or trained birth attendant can often manage a difficult birth so it does not become an emergency. But every minute of every day, a woman somewhere dies from causes related to pregnancy or giving birth. Most of these deaths occur in poor communities, and many of them could be prevented.
When a pregnant woman dies, the direct cause of her death is usually obvious. The most common direct causes of death during pregnancy and birth are bleeding too much, infection, high blood pressure (eclampsia), and obstructed labor. (Obstructed labor happens when the baby is lying sideways in the womb or cannot fit through the space between the mother’s hips.) But beneath these causes are other conditions that explain why a woman bled too much or had an infection or obstructed birth, and why she did not get the care she needed to save her life.
Vanna’s unsafe pregnancies
Vanna grew up in a village in Cambodia that was hours away from the main roads. She was the youngest child and always ate after her 4 older brothers. There was usually little food left, so Vanna was small and thin. Doing chores made her tired. When she was 15, a man who had gone to work in another province returned to live in the village, and he asked Vanna’s father for permission to marry her. Vanna did not like the man, and she did not want to be married, but her father was pleased that the family would no longer have to feed or support her. Vanna went to live with her husband and her in-laws. She gave birth to a daughter when she was 16. The birth was difficult, and Vanna lost a lot of blood. She was very weak for a long time, but she survived.
Vanna’s neighbor Arun came to visit her often and brought teas that she said would help Vanna get stronger. Arun also talked to her about waiting at least 2 years to have another baby, and she offered to go with Vanna to the health center in another village where Arun had learned about family planning. But Vanna was afraid to talk to her husband about these things, and she got pregnant again before her daughter was 1 year old. There was not a lot of food to eat, and because she was so small, no one in her husband’s family thought she needed as much food as the others.
Arun worried about Vanna and offered again to go with her to the health center. But Vanna’s mother-in-law told her not to go. It would cost money, she said, and she had heard that people at the health center insulted women from the community. She took Vanna instead to visit the local shaman, a traditional healer who gave her amulets to wear that he said would protect her and her baby from harm. He also performed a ceremony with offerings to the ancestors, asking them to favor Vanna with a healthy baby.
When Vanna was in labor with her second child, she began to bleed before the baby was born. Arun wanted to take her to the hospital right away, but Vanna’s husband was not there to give her money, and Vanna did not want to go without his permission. Arun asked the village leader to take them in his truck, but he did not have enough fuel to make the 30-kilometer round trip. So Arun talked to several neighbors and borrowed money to buy the fuel and pay the hospital. By then Vanna’s mother-in-law could see that Vanna was in danger, and she gave permission for her to go to the hospital.
When Vanna and Arun reached the hospital, Vanna was too weak to move or speak. A nurse scolded Arun for waiting so long to bring Vanna for help. The nurse was angry and said she was tired of seeing stupid people who believed in amulets.
When the doctor examined her, he told Arun that Vanna would need an operation. But it was too late. Vanna had bled so much that she died in Arun’s arms. Arun was very sad and very upset that she had not been able to help Vanna. She decided to talk with other women in the village and do something to solve the problems that had led to Vanna’s death.
Activity "But why?" game
Why did Vanna die? "But why?" is a question game that helps people discover the root causes of a problem. Practice this game with a group by telling or reading Vanna’s story and then ask the group to share ideas about why Vanna died. After each answer, ask, "But why?" to explore as many causes as possible. For example:
Activity Building a chain of causes
- Tell your own story about a woman who dies giving birth. To prepare the story, talk with midwives, health workers, family members, and other people who may know what happened to pregnant women in the community who died. Find out what problems those women had and why they did not get the help they needed. As you discover common problems, include them in the story.
- Play the "But why?" game to look at why the woman in the story died. Make a "chain of causes" by cutting pieces of paper or cardboard into shapes like links in a chain.
- If everyone knows how to read and write, pass out the links and ask people to write their answers on them. Or ask people to say their answers out loud, and you write them on the links.
- Group the causes in a chain by linking each cause to another cause it relates to. You can make this more active by asking people to walk around and share their links with each other. Ask them to link arms when they find a person with a link that has a related cause written on it.
- Give people a chance to talk about their own experiences. You might ask, "What parts of the story remind you of things that have happened to women you know?" You can go around in a circle and give everyone a chance to share, or people may want to talk in pairs and then share with the whole group.
- Break the chain! Look at the links on the chain and ask a question such as, "What would happen if we broke the link called No pregnancy check-ups?" With that link gone, Death from bleeding during labor is less likely, as is Got medical help too late. The chain is still there, but not as strong as before. If you can take action to break off some links, more women could experience safer motherhood.
Think of solutions to save women’s lives
One way to do this is to change what happens in the story. Ask people to retell the story with changes in it that could save the woman’s life. Small groups could act out different solutions. You might ask how men in particular could help. To help the group to think about change, see the activity, "Happy ending" role plays.
Another way to look at root causes and solutions is doing a Problem Tree activity.
Activity Voting with dots
A group may think of many possible solutions or things they would like to change. Sometimes there are so many ideas, it can feel overwhelming! It can be difficult to decide how to begin or where to focus the energy of the group in its organizing work. This activity is a fast and amusing way to let everyone share about what are the most important ideas, solutions, or problems to address. This can make it easier for the group to plan and carry out action.
- On paper that you can hang on a wall, make a list of all of the different ideas that have been suggested for actions to make pregnancy and birth safer. Be sure to write large enough so everyone can see the list.
- Review the list with the group to make sure all the ideas have been included and add any that are missing. Let anyone in the group ask questions about the list to make sure everyone understands all the ideas.
- Ask the group to look at the list and think about: What actions are the best to address the challenges in our community? What are the easiest actions to do with our existing resources? What action would make the biggest change for women?
- Give each person 5 colored dots made of tape (or cut out small squares of colored paper with masking tape on the back), and ask them to place one dot for each of the 5 ideas they think are the most important. If there are not many ideas on your list you can give people fewer dots to vote with.
When all dots have been placed on the list on the wall, review as a group which ideas have the most votes and which did not get very many votes. Discussing the results of dot voting can help the group select what to focus on.
After dot voting, you may have complete agreement. If you do not, you may need more discussion and another round of voting. At some point, you may agree to let the majority rule.
See the activity, "Making an action plan" to learn more about making an action plan, and about the work that a community in Peru did over time to improve care for pregnant women.