We know why they die

BMJ 1996; 312 doi: (Published 20 April 1996) Cite this as: BMJ 1996;312:1044
  1. James Owen Drife

    Last month I was photographed in front of the Taj Mahal. All British tourists pose soulfully on Princess Di's bench, but our giggles were soon stifled by the beauty of the building. It commemorates a queen who, in 1630, died in childbirth. In 1996 over 100000 Indian women will do the same.

    Later, in a Delhi conference hall filled with obstetricians, a small Indian doctor in a green sari asked us to imagine a jumbo crashing every 30 hours. She pointed out that India has world class hospitals and many doctors. The problem of maternal mortality lies in primary care.

    About 40% of the deaths occur at home, mainly from sepsis and bleeding. About half could be prevented by an adequate system of referral and transport. In one study of 140 women moribund on admission to hospital, 97 arrived by bus. Some came by bullock cart and only 12 by ambulance.

    There have been many studies. In the decade since the World Health Organisation, with touching optimism, announced its target of halving maternal mortality worldwide by the year 2000, the causes have been researched to death. As one woman speaker remarked, “we know why they die.” We do indeed, and the knowledge is hard to live with.

    It is of course the poor who die. The problem, however, is not resources. Maternal death rates are related not to each state's income but to its rate of female literacy. This shifts responsibility to teachers but offers cold comfort to doctors. It suggests that poor women have no effective advocates. Only when they can speak up for themselves do matters improve.

    In 1935 Britain's and India's maternal mortality rates were similar. The reason ours fell was only partly antibiotics. More importantly, people got angry about it. Remember that scene in Lawrence of Arabia where a blimpish medical officer finds prisoners dying of thirst in hospital? Furious, he stalks around shouting, “Outrageous!” This is the only civilised reaction to a medical disgrace.

    Although the Delhi conference committee had highlighted the problem, what was chilling was the lack of anger in the hall. The speakers had lived with this for years and seemed to be going through the motions, their passion almost spent. The Europeans felt upset: these were not our patients but how could we ignore them?

    The rest of the audience was blase. While one speaker, formerly a consultant in England, spoke about his new job training primary care workers in Bangladesh there was a small, steady exodus of expensively dressed lady obstetricians. Later that day the organisers shrewdly chose the smallest hall for the safe motherhood seminar. Afterwards its chairs were taken to pack the largest hall for the session on in vitro fertilisation.

    Perhaps it is patronising to visit a country for a few days and then write about its troubles. It would be worse not to. Besides, they are not so far from home. In the NHS we are already seeing how public indignation about inadequate services can be silenced by financial arguments. Any nation without the will to get angry is a pitiful place.—JAMES OWEN DRIFE, professor of obstetrics and gynaecology, Leeds

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