Would You Rather Give Birth in Dickensian England Or Modern Day Nigeria?

Assume you’re pregnant. Would you rather give birth in a). Nigeria, tomorrow; or b). Dickensian England, say 1850-ish?

Before you answer, consider that 1850 was about two decades before Louis Pasteur and Robert Koch’s work on what would become the Germ Theory of Disease. At the time, physicians and researchers had a variety of theories to explain why people kept dying, the most prominent of which held that disease was “in the air” — miasma theory. Some — most famously, John Snow and Ignaz Semmelweis — challenged the prevailing orthodoxy and amassed strong, empirically-sound cases for hygiene and sanitation (really, for the presence of germs) but were considered either apostates or idiots and rejected. It would be years before Louis Pasteur and Robert Koch proved the presence of bacteria, and decades before Germ Theory replaced miasma theory — paving the way for sulfa drugs and antibiotics.

Consider also that 1850 was a period when surgical anesthesia was in its infancy. The British chemist Humphry Davy may have played with nitrous oxide a half-century prior (by experimenting on himself, naturally), but it wasn’t until the mid-1840s that John Collins Warren used it and ether as pain-blunting agents in surgery. In 1850, you were much more likely to get a shot of whiskey and a belt — or, just a mallet to the head — to help you get through the birth.

And finally, consider that William Farr (one of the first to use statistics for epidemiology) regarded maternal mortality in England, at the time, to be “a deep, dark, a continuous stream of mortality.”

Modern day Nigeria, on the other hand, is one of the world’s largest economies — it’s lousy with oil, among other things — and tomorrow has the distinct advantage of being after the American Civil War (with all of the modern science and knowledge such a thing entails).

So: where would you rather give birth?

You’ve probably seen through the flimsy rhetorical device and have concluded that, modern science be damned, you’d rather give birth in England. Your choice has the virtue of being the “right” choice, if you define right as “not dying.” Seriously — you have a better chance of surviving birth in 1850 in England than you do in Nigeria tomorrow (the rates are 580 and 630 deaths per 100,000 live births, respectively).

This is, in a word, appalling.

I’ve written previously about the basics of maternal mortality, so I won’t go into much detail here. But suffice it to say that our understanding of, and technology for, the birth process is so comprehensive that it is simply nauseous that Victorian England is a safer place to give birth than present day Nigeria. 

As a global community, we will fail to reach Millennium Development Goal (MDG) 5a (in the clunky verbiage of the UN: “Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio”). That’s not to say significant progress hasn’t been made — hundreds of thousands of mothers’ deaths have been prevented in the past decade — only that the scale of the problem remains quite daunting. 

Which brings us to the ever-important question of “What can be done?” and the ever-frustrating answer of “Well … Everything.” This is part of the issue; with so many interconnected components, it’s hard to know where to begin; finance, supply chain management, education, geography, and culture are only a few of the myriad pieces we must consider. None of the components exist in a vacuum, and while an individual intervention could have a positive effect, it would be dulled by everything that didn’t change.

For example: A campaign launched at the World Economic Forum recently hits on one such component: a lack of health workers in rural communities. Called “One Million Community Health Workers”, its goal is to, well, get one million community health workers deployed in sub-Saharan Africa by 2015. The theory is, more or less, that these health workers will be able to diagnose and treat a range of common illnesses, and that they will know the warning signs of a complicated pregnancy — at which point the mother-to-be would be referred to a district hospital. We should expect this initiative to have a positive effect on the health of rural communities, full stop.

But think about what else has to work in order for that mother-to-be to admitted to a hospital. First, she has to want to go to the hospital; in some cultures, it is seen as a moral failing for the woman to need help with her pregnancy, and they prefer to go it alone. Even if it’s acceptable culturally, a woman may not want to go to a hospital that is under-staffed and bereft of the equipment and pharmaceuticals needed — it’s basically a waste of time and money.

Then, she has to be transported to the hospital; in some areas, the infrastructure is so poor that this option is a non-starter for a pregnant woman (innovations like “BodAmbulances” are helping tear down this barrier, ride by ride). Finally, she has to have the money to pay; while many countries have decided to offer nominally-free care (Rwanda and Uganda, for two), women often need to purchase the basic drugs and equipment for the procedure.

The issue of maternal mortality in the developing world doesn’t lend itself to simple solutions. Thankfully, progress is being made; lives are being saved. But it’s still riskier to give birth in Nigeria today than it was in England 160 years ago, a fact that compels further action. 

We’re going to fail to meet the Millennium Development Goal for maternal mortality; we should at least be able to meet the more modest goal of ensuring that no country in the world has a maternal mortality ratio greater than Dickensian England.