Maternal Mortality: Can We Talk About Sex (at the UN)?

UNITED NATIONS - The statistics for maternal mortality have improved by 34 percent. That means a woman is no longer dying every minute, but one woman is still dying every minute and a half.

No doubt prenatal care, malnutrition, access to a hospital and skilled practitioners and professionals could prevent most of the deaths. As could education for girls that keeps them in school longer.

But the squeamishness of talking about family planning or contraception -- in short sex -- is a no-no in many nations. An estimated 215 million women in the developing world want to delay or avoid pregnancy but have no access to contraception or fear the side effects or their families object, says the UN Population Fund (UNFPA).

With President Obama participating, the United Nations is holding a summit this week on its Millennium Development Goals (MDGs), the world's most ambitious program to slash poverty by 2015. While the glass is half empty on many of the goals, the decline in deaths of pregnant women is nowhere near the target of a 75-percent reduction by 2015.

Consequently, UN Secretary General Ban Ki-moon scheduled a side-event on the deaths of pregnant women and children under five years of age on Wednesday, the last day of the three-day MDG summit.

It's not that UN agencies don't talk about contraception and the draft outcome document, for the summit mentions family planning, sexual and reproductive health several times, including "ensuring that women, men and young people have information about and access to the widest possible range of safe, effective and acceptable methods of family planning." But the wish list is not duplicated on the ground. (My fantasy was to offer a "morning-after pill" to the 150 women recently gang-raped in the Congo.)

Child brides
Marriage of child brides, whether forced or by consent, can be a recipe for disaster in bearing healthy children. Says the International Women's Health Coalition, an expert in the field:

Child marriage is the major cause worldwide of pregnancies before age 15. In most of the developing world, 90 percent of girls who give birth before age 18 are married. Young brides typically become sexually active as soon as they are married, sometimes before their first menstruation. Often living in their husband's household and community, they face intense pressures to bear children as soon as possible, with potentially disastrous results."

As many as 50 percent of pregnancies in developing nations are unplanned and 25 percent are unwanted. The unwanted pregnancies are disproportionately among young, unmarried girls who lack access to contraception. In Ethiopia, for example, about one third of all maternal deaths each year could be averted if women had access to reliable family planning methods, UNFPA says.

Thoraya Obaid, the executive director of UNFPA, proposes "a one-stop-shop, where they can get family planning; care before, during and after childbirth; nutrition advice and services for HIV and AIDS," adding: "If every woman enjoyed the right to sexual and reproductive health, maternal death and disability would be rare and not the devastatingly common tragedy it is today."

Mother-in-law decides
Access to birth control is one problem. But even in some nations where the government has reproductive health clinics, the "mother-in-law often makes the decision," Nafis Sadik, the former director of UNFPA, once said.

In Pakistan, for example, a government survey found that 84 percent of the women who want to limit family size do not use modern family planning methods. And among those that do, sterilization is most popular. Illegal abortions are also common with close to a million carried out each year, according to the Population Council of Pakistan.

Patricia Licuanan, a Filipino psychologist and educator, and the current chairman of the Commission on Higher Education, has said that despite the Obama administration's support of reproductive health, "religious fundamentalism is on the upsurge."

She was not wrong about the Philippines, which together with Malawi, last week sponsored a panel of gifted health specialists from around the world, who opposed contraception as well as abortion. Several argued that legal abortions were not necessarily safe and that maternal deaths would not be reduced through contraception, only by proper health care, and that condoms did not necessarily reduce AIDS. (Both the Philippines and Malawi have extraordinarily high rates of maternal mortality.)

There is another side of religious leaders as evidenced by Rev. Debra Haffner who helped organize an open letter among religious leaders on the UN conference, saying in part: "We are called to bear witness to the harsh reality that without comprehensive sexual and reproductive health services, women and girls around the world suffer illness, violence and death."

Clearly contraception is not a panacea for sepsis, severe bleeding, obstructed labor or even the consequences of illegal abortion. Health care in many countries is too tenuous that even sophisticated women worry about surviving a difficult birth. Dr. Asha-Rose Migiro, the UN deputy secretary-general, told a luncheon at the UN Foundation of her fears at the birth of her second child in her native Tanzania where she was a professor and then foreign minister. The doctors, she said, were excellent but the equipment so outmoded "I was afraid for my life" when she needed a cesarean section.

There is no easy answer and nothing works without community involvement, the reduction of extreme poverty, health practitioners at the village level, cell phones for emergencies -- and a proper analysis of available data, much of it sketchy. UNICEF, the UN Children's Fund, found that statistics masked differences within a country between those in relatively prosperous areas and the rural or slum-dwelling poor in developing countries.

And one could add -- in the United States also.