The Second Vatican Council called for a preferential option for the poor. Mothers at the end of the 20th century and the second millennium are in my opinion among the poorest of the poor both in body and spirit. This paper while reviewing the tragic state of health of mothers and their unborn children throughout the world and the inappropriate, unethical and destructive solutions that are currently being offered by the medical profession and international aid agencies, will take an optimistic view and present a new initiative for mothers for the 21st Century.
The conclusion that any reasonable person must come to, after reviewing current world maternal mortality, morbidity and abortion statistics, is that the world cares very little for mothers and their unborn children. At the beginning of the third millennium we are forced to consider the most important birth which brought to completion the most important event in human history, the Incarnation. Pope John-Paul II in his millennium letter, thus reminds us that we also celebrate the most important motherhood ever.
"The Father chose a woman for a unique mission in the history of salvation: that of being the Mother of the long awaited Saviour. The Virgin Mother responded with complete openness".
Motherhood has special significance for all Christians. However, two of the greatest tragedies of our times concern the suffering and deaths of hundreds of thousands, of mothers and the deliberate killing of millions of unborn children. It is an international disgrace that so many mothers should give their lives having their babies or sustain terrible birth injuries simply because they did not receive adequate care for which all of us, bear some responsibility. It is unconscionable that so many millions of women should be subjected to the indignity of having their unborn children destroyed in their wombs. Sadly, the medical profession has criminalised the unborn child and now serves mothers, in most parts of the world more frequently with death than life, having seemingly nothing better to offer.
Christian health professionals in particular, have a special responsibility to develop new ways of providing the sort of care for mothers and babies, which is a basic human right, based on life and hope, rather than on death and despair. A group of Catholic health professionals accepted the notion of a preferential options for mothers and created MaterCare International.
2. Maternal mortality and morbidity.
The World Health Organisation estimates that each year, 585,000 mothers die from causes related to pregnancy and childbirth of which 99% occur in the developing countries. While infant mortality levels are 10 times higher in developing, than in developed countries, maternal mortality in poor countries is more than 100 times that of industrialised countries. Each time a women becomes pregnant, with existing levels of health care, she runs a risk of dying, and the risk adds up over her lifetime. The lifetime risk according to the WHO for a mother in parts of Asia is enormous. It is estimated that 1:7 mothers in Afghanistan will die as a direct result of complications during pregnancy and delivery, compared to 1: 380 in Korea and 1:4,500 in Singapore, in North America or Europe the risk is 1, 7000 - 10,000. Mothers die frequently alone, in agony from obstructed labour or sepsis or in terror from haemorrhage, from pregnancy induced hypertension and induced abortion. It is not good enough for us to simply discuss these problems, it is incumbent upon us all to provide practical solutions.
Sadly, deaths from childbirth related causes only represents the tip of the iceberg. It is estimated that for every death, 30 more will suffer long-term damage to their health, most frequently. from obstetric fistulae. These arise in very young mothers, aged between 14 and 20 years, as a consequence of neglected obstructed labour and frequently also from cultural practices e.g. female circumcision. The result is that the baby dies and because of damage to the bladder and rectum the mother becomes incontinent of urine and/or faeces (obstetric fistula), and thus becomes a complete outcast and is treated worse than a leper by her husband, family and society, simply because she is wet, filthy and foul-smelling. They suffer pain, humiliation, and lifelong debility if not treated. There are tens of thousands of these poor, young and forgotten mothers throughout Asia and Africa. The tragedy is that most of this mortality and morbidity is preventable with proper maternity care and obstetric fistula can be treated surgically but at present there are insufficient trained doctors, nurses or adequate facilities .
Obstetric fistula has been termed by the World Health Organisation, the "forgotten disease", because while common in developed countries 100 years ago, it is now no longer seen because mothers are healthier and receive better care. Obstetric fistula is another form of genital mutilation, which has not had the same degree of media attention as has female circumcision. However, the consequences for a mother, in terms of discrimination, are far worse.
The disparity in maternal mortality and morbidity rates, between developed and developing countries, is greater than any other commonly used measure of health status. Deaths as a result of pregnancy complications are the number one cause of death and disability among women of reproductive age, world-wide. This loss is twice that of any other disease including AIDS, malaria, TB or sexually transmitted diseases. There is no single cause for male mortality in this age group that comes close to the magnitude of maternal mortality and morbidity. The tragedy of a maternal death has a domino effect with the death of the mothers other children under five, which in turn may lead to the death of her family. The solutions to this suffering have been known for decades and cost very little. Simply put, mothers in our world of the 21st century are being neglected basically because motherhood is not of political importance.
Mention must be made of the consequences of abortion as the basis of the health care of mothers in developed countries. We must be quite clear about what is happening, it is no less than the carnage of the unborn child. Abortion currently dominates international health policy. It is a policy which arises from the poverty of thought and more seriously the poverty resulting from the lack of love. Despite the many advances in modern perinatal medicine and obstetrical care which have almost eradicated maternal deaths and markedly reduced perinatal deaths in the developed world, deaths from abortion continue to rise throughout the world.
In Canada during the last twenty five years, the abortion rate has doubled, such in Canada since the legalising abortion over 2 million babies have been performed. Of all pregnancies 1:5 is deliberately terminated - we have no laws which restrict abortion. In my home province of Newfoundland and Labrador we destroy at least one kindergarten class per week and it is now the largest provider of abortion services as it pays for all procedures.
Ob/Gyns now provide their skills to destroy babies but make little effort to reduce the numbers. Normally all maternal or perinatal deaths are investigated carefully and discussed in depth to determine if they could have been prevented. In spite of knowing so much about the unborn child ob/gyns have connived in devaluing the human being in the womb, thus making it so much easier to destroy. It defies belief that the most powerful man in the world should twice veto a bill which would have outlawed the obscenity of partial birth abortion. We are dominated by a culture of death.
Pope John Paul has commented;
"The medical profession today is suffering fundamentally from an identity crisis; the grave danger exists that when this profession is called upon to suppress conceived life; where it is used to eliminate the dying; where it allows itself to be led to intervene against the plan of the Creator and the life of the family or to be taken by the temptation to manipulate human life; and when it loses sight of its authentic direction of purpose toward the person who is most unfortunate and most sick, it loses its ethos, it becomes sick in its turn, it loses and obscures its own dignity and moral autonomy."
In developing countries, one of the major causes of maternal mortality sadly, is illicit abortion. Mothers turn to the abortionist for help, in despair and desperation, when life giving help is not forthcoming. The international safe motherhood initiative, which was launched to reduce maternal mortality, now includes the provision of what is called safe abortion. To reduce maternal mortality it supports the killing of the unborn children. Thus maternal mortality is being replaced by foetal mortality in ever increasing numbers. Most abortions in the world are performed for social and economic reasons. The awful reality is that once the mother has had her baby destroyed she is returned to the poverty and ignorance from whence she came. Society has accepted an easy solution for the problem of so called unwanted pregnancies but it has been bought at the price of millions of babies lives and at the expense of a once noble profession.
3. The World's response
In the first book of a "Tale of Two Cities", Charles Dickens describes that period of the 19th century, which I think describes our own times;
"It is the best of times, it is the worst of times, it is the age of wisdom, it is the age of foolishness, it is the epoch of belief, it is the epoch of incredulity, it is the season of light, it is the season of darkness, it is the spring of hope, it is the winter of despair, we have everything before us, we have nothing before us, we are all going direct to heaven, we are all going direct the other waySS"
During the last 25 years technology has served mothers and babies well. The number of maternal deaths in developed countries have fallen to what are sometimes called irreducible minimums. Our mothers no longer die because they have access to essential obstetrical services, to emergency transport; to well trained specialists and midwives; to high risk intensive care facilities with sophisticated ultrasound and labour monitoring equipment; to blood transfusion; to antibiotics and other effective medications; all of which are frequently taken for granted.. In spite of all these developments in knowledge and medical technological we are still in one of the darkest ages of medical history. There exists a modern black death (a plague), when mothers and their babies in the developing world and refugee situations, are still dying and suffering in an unprecedented way because they do not have access to the basics, to safe, clean and dignified facilities in which to give birth, to clean water, to electricity, to telephones or to safe and rapid transport to hospital when complications develop. In developed countries we have perfected barbarism of abortion and now forcing it on mothers in developing countries.
The Safe Motherhood Initiative was launched at the first international safe motherhood conference in Nairobi in 1987 and a "call to action" was issued to do something about the tragedy facing mothers. Unfortunately the response has been inadequate despite being issued many times since. The reasons for this failure according to authoritative opinion has been;
(i) Missed opportunities.
(ii) Muddled thinking.
(iii) Mistaken priorities, e.g. hospitals which do not have the basic equipment to provide emergency obstetrical care
(iv) The reduction in development assistance by the world's richest countries, to 0.3% of gross national product, which is less than half of what it should be.
(v) The promotion by governments, their funding agencies and international health organisations of what is now known as "reproductive health", which is simply a euphemism for abortion and contraception.
It is estimated that billions of dollars are spent by our governments and private agencies, on birth control programmes but only a small fraction is spent on emergency obstetric care which would help mothers survive their pregnancies. What is not realised is that to be a maternal death, a mother must be pregnant. The question is how do birth control pills or condoms help mothers with obstructed labour or are bleeding to death from a postpartum haemorrhage. In my experience the women who die want to be mothers but are poor, young and have no influential voice to speak on their behalf.. This is culpable neglect by our world which has no concern for the "unimaginable suffering" of mothers and as UNICEF has put it is guilty a "conspiracy of silence" and a "lack of imagination". There is not the political will or compassion to do what is necessary.
The UN Charter of Human Rights states that the right to health care is basic. The Beijing Conference on Women identified 12 critical areas of concern one of which was the right of women to the "highest attainable standard of physical and mental health". However, the needs of mothers were not given the same emphasis. The focus must however, be on mothers who are important for their own sake. Maternal mortality does not have the same political clout as for example AIDS or landmine injuries.
4. Matercare International - A project for the millennium
Before I introduce you to the new organisation known as MaterCare International, I would like to tell you something about what has happened to obstetrics and gynaecology and in particular to Catholic specialists in particular, during the 30 years that I have been in practise.
Obstetrics was concerned with the health and well-being of couples and their offspring. It was an all round speciality, both an art and a science and most of the time was happy. When I started residency training I was struck by the following statement taken from the preface to the obstetricians bible, Williams Obstetrics (16th edition);
"Happily we live and work in an era in which the foetus is established as our second patient with many rights and privileges comparable to those previously achieved on the afterbirth."
Obstetricians used to be trained with one simple objective, to ensure that all pregnancies, as far as was humanly possible, should result in a live healthy mother, and a live healthy baby. Obs and midwives have a unique and privileged vocation in the service to life as assistants to the co-creators of new life, especially when they have to dig into their knowledge and skills to save the life of a mother and/or her baby when complications arise.
However, back in the early 70s when many of us finished residency, we did not anticipate the dark climatic changes that were about to occur that would turn professional and family life upside down and force many of us to make many serious decisions about life, living and career. The oral contraceptive and first IUDs were introduced, and laws permitting abortion were passed in many countries. Very soon abortion and contraception became the basis on which the health care of women was based. Catholics were soon told that there was no place for them in the speciality if they refused to perform abortions. As residents we were exposed to a one-sided, ill-informed and prejudice opinion by those determined to change how we thought and practised. The unborn child was devalued and from specialists in maternal health we were transformed into specialists in women's health. Pregnancy became just another condition such as cancer, or endocrine problems etc. Interestingly, in later editions the preface of Williams obstetrics has been altered and that sentence about the foetus being our second patient has been dropped.
These developments in abortion and reproductive knowledge and technology have taken us to the ethical and moral limits. At the same time the church presented the world with important teaching e.g. Humanae Vitae, with statements on abortion and reproductive technologies and the present Holy Father with clear directions. But for most of us in the early days there was nowhere to turn for guidance. All of this has had profound ethical, moral and practical significance for the Catholic, in training or in the practice of obstetrics. No other branch of medicine has been so affected by these developments. It has simply not been appreciated, that obstetricians of my generation had, from the very beginning of these developments, to take a fundamental stand in defence of human life. Many sadly were forced into compromise in order to survive. Some Catholic ob/gyns, remained faithful to the Magisterial teaching which caused them, and their families, considerable pain. Working in health services and academic institutions through out the world, they saw their careers ruined and in many circumstances they were forced to leave home, family and country or even leave the speciality, to survive. In very personal ways Catholics and their families were subjected to professional and social ostracism and they were considered an "embarrassment" and viewed as being ultra conservative, professionally outdated and even possibly negligent and were subjected to the displeasure of the profession.
It is not surprising then, that very few Catholics are entering these specialities and some who do, separate what they do from what they believe. The Catholic ob/gyn has gone or is disappearing in the same way as the dinosaur, having been frozen out by the abortion - contraceptive asteroid. The Church once the leader in developing health care for mothers has been forced out which should be a source of grave concern to the Church and to all pro-life organisations. The questions that must now be considered are; what effect does all of this have on women and mothers? where will they obtain opinions and treatment for their health problems, which are in accordance with their moral convictions; are women being unduly influenced by doctors or nurses who do not understand or care about religious convictions?. In other words who in the future will make any practical reality of the Church's teaching on reproductive health care? Who will respond to the Holy Father's challenge to improve the quality of health care for mothers and infants, especially for the poor?
A few Catholic ob/gyns began asking themselves the question if we don't do something WHO WILL?. There was a stubborn few, who believed that if they held to their ethical and moral principles, they could be just as effective in caring for mothers and unborn babies. However, they felt a need for an organisation in which to function. It was Pope John -Paul II who gave the impetuous to getting on with the job of attempting something extraordinary.
In his Encyclical Evangelium Vitae Pope John-Paul issued an urgent appeal to all, but in a special way to Catholic health professionals, to do something extra for life;
- "To the people of life for life", "to offer this world of ours new signs of hope, and work to ensure that a new culture of human life will be affirmed, for the building of an authentic civilisation of truth and love" (E.V. No 6).
- "To all health care personnel who have a unique responsibility to be guardians and servants of human life". (E.V. 89).
- "A specific contribution must come from "Catholic universities, Centres, Institutes and Committees of Bioethics and places of scientific and technological research." (E.V. 98).
5. Matercare International (MCI)
In October 1995, a small international group established MATERCARE INTERNATIONAL (MCI), an organisation which adopted a preferential option for mothers. Its mission is to contribute to the reduction of maternal mortality and morbidity rates by 75% in the next ten years and to the elimination of abortion throughout the world, through new initiatives of SERVICE, TRAINING, RESEARCH, and ADVOCACY in accordance with the teaching of the Encyclical, Evangelium Vitae (the Gospel of Life). MaterCare is;
"SS..to place itself at the service of a new culture of life offering serious and well documented contributions, capable of commanding general respect and interest by reason of merit". (E.V. 98)
Groups have been legally established in Canada, Ireland, the United Kingdom, and thus the European Union and is in the process in Australia and the United States. Other groups are suggested in Ghana, Germany and Latin America. How about one in Asia?. MCI is the parent organisation which sets policy and agrees on projects. Each national group provides two board members of MCI board and consultants to carry out projects and also the opportunity to raise funds form government and private sources in each country. MCI is developing a revolutionary structure for the 21st century i.e. no large buildings with large heating or air conditioning expenses, but has a small central core agency linked, with national groups that support flexible reference centres, distributed throughout the world, linked together through modern communication technologies. Presently, the board meets every quarter by international teleconferencing but MCI is not a talking shop. MCI is fully affiliated with FIAMC as its obstetric arm.
The idea of MCI seems to some sceptics as idealistic and unrealistic so we have gone out of our way to show what it can be just as relevant and successful as any other similar professional organisation even though it is based on a different ethic. Since its inception MCI has developed;
4.1 A West African Maternal Health project
Begun in 1998 this project is located in a rural area of Ghana, West Africa. The project has developed an essential obstetrical care service for a rural area consisting of programmes designed to improve the survival of mothers and reduce the incidence of fistulae by; training traditional birth attendants (TBAs), who are responsible for 70% of all deliveries, to recognise and refer high risk mothers using a pictorial antenatal card; by improving the care given to mothers in rural maternity centres by nurse/midwives using a labour partograph; by introducing a safe and efficient means of transporting mothers with obstetrical emergencies to the district hospital; and by providing a maternal blood transfusion service. We believe that this model can be used in any developing country
A basic research programme is also underway to evaluate oral misoprostol as a simple, effective and inexpensive of managing post-partum haemorrhage, one of the main causes of maternal mortality. The first phase consisting of two double - blind placebo controlled randomised trials of oral misoprostol and i/m oxytocin in the management of the third stage of labour conducted at my own teaching hospital at Memorial University of Newfoundland, Canada and at Korle Bu Teaching Hospital university of Ghana. These results of these studies which were published in leading journals shows that the oral misoprostol is as good as i/m oxytocin but it is cheaper, more stable in hot climates and has few side effects . The second phase of the study randomised trials comparing oral or rectal misoprostol with i/m oxytocin, which is being conducted by midwives in two rural hospitals, supervised by two residents, one from Canada and the other from Ghana. If these prove successful the final objective is to develop protocols for the use of misoprostol by traditional birth attendants, who do most of the deliveries in life threatening situations, when medical help is not available. With think it could be a major breakthrough in preventing maternal deaths. We feel fully justified as this work has received five peer reviewed awards for excellence.
4.2 A West African Regional Birth Trauma Centre MCI is being developed with 60 beds to be located near Accra, the capital of Ghana, which will provide treatment and rehabilitation programmes for fistula patients and will have a special interest in training doctors and nurses in the surgery and management of these patients. This will be the second specialised centre in Africa.
4.3 A training CD concerning the surgery and nursing of obstetric fistula has been published which is available free of charge to doctors and nurses in areas where fistulae are common.
4.4 An advocacy programme on behalf of mothers has been developed which includes presentations to the general public, politicians and the media.
4.5 Information videos about the suffering of mothers has also been produced for the general public which has also received an award.
4.6 A Website (www.matercare.org) has been opened which provides information on the policies, activities of MCI which has a unique "LifeSaver, Lift a finger to help" fund raising mechanism which relies on donors clicking each day, advertisers and the power of the internet. The site will also have the fistula training programme available as well as a course in natural family planning for which CME credits will be obtainable.
A website /email consulting service to provide alternative opinions about difficult cases for colleagues, priests, counsellors, pro-life groups is an idea for the future etc.
4.7 International task forces have been organised to consider the feasibility of creating an international specialist training programmes for Catholics wanting to specialise in obstetrics, but who wish to follow their consciences and not provide abortion and contraceptive services. Another is exploring ethical reproductive technologies.
4.8 A quarterly newsletter to provide a means of sharing opinions, ideas and practical suggestions has been produced.
4.9 Other possibilities
(i) An International membership directory of MaterCare health care providers.
(ii) A CALM (Critical activities for labour management) course for doctors and midwives in developing countries
(iii) An essential obstetrical project, similar to MCI's project in Ghana in Sierra Leone and East Timor.
5. A challenge for the Church
In June of last year MCI and FIAMC organised an international workshop on the "Future of Obstetrics and Gynaecology, the fundamental human Right to be Trained and to Practice According to Conscience". To our surprise and delight 144 registered from 40 countries. The highlight of the meeting was a private audience with Pope John Paul II. The Holy Father greeted the group warmly but was equally challenging to continue to be "the servants and guardians of life, for the Gospel of Life is at the heart of Jesus' message".
The Holy Father reminded obstetricians that;
"their profession has become still more important and their response will be still greater in today's culture and social context in which science and the practice of medicine risk loosing site of its ethical dimension in which health care professionals are strongly tempted at times to become manipulators of life and even agents of death".
He concluded his address by issuing a challenge to the whole church,
"It is my fervent hope that at the beginning of this new millennium, all Catholic medical and health care personnel, whether in research or practice, will commit themselves whole-heartedly to the service of human life. I trust that the local Churches will give due attention to the medical profession, promoting the ideal of unambiguous service to the great miracle of life, supporting obstetricians, gynaecologists and health workers who respect the right to life by helping to bring them together for mutual support and the exchange of ideas and experiences".
The second international workshop will be held this year from October 23rd - 27th again in Rome.
As we begin the 21st century, millions of mothers throughout the developing world are dying from childbirth complications frequent during the middle ages. In the developed world millions of unborn children are being destroyed by the medical profession with surgical procedures which were common in the dark ages of human ignorance. Obstetricians and midwives share a unique and privileged vocation in the service to life. A group of Catholic health professionals has taken a preferential option to care for mothers wherever they maybe and has created an international organisation, which will be different to any other professional organisation as it will provide mothers with the best of obstetrical care which is firmly based on medical excellence, love and hope. We know WHAT must be done and for WHOM, this proposal is one way of answering the question HOW are we as Catholic health professional going to do it. Much has been accomplished by a small group in short space of time think what could be done if MCI had more professional support. How about a MaterCare (Asia)?