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Women die or become ill during pregnancy and childbirth for many reasons. In poor countries multiple disadvantages combine to put women at risk. Improving women's nutrition, general health and socio-economic status will reduce the maternal mortality and morbidity rates. So will access to contraceptives, to safe, legal abortion services, to tetanus toxoid vaccination, to iron supplementation and other simple technologies.

Appropriate maternity care during delivery will both prevent emergencies and save lives.

Worldwide - which effectively means in developing countries because that is where the overwhelming majority of deaths take place - the biggest direct cause of maternal death is severe bleeding. Indirect causes are the next most common - they result from women being already in very poor health and anaemic or suffering from conditions such as malaria or HIV while pregnant. The other main causes are infection, unsafe abortion and eclampsia. Regionally, these levels may vary.

Causes of maternal death

1. Severe bleeding or post partum haemorrhage has a number of causes - a small piece of placenta being retained in the uterus, or the uterus failing to contract, for example.

2. Indirect causes include anaemia, malaria and heart disease.

3. Infection or sepsis is caused by unclean delivery practices. It can also arise without being introduced from outside the woman's body - from damaged tissue.

4. Unsafe abortion is defined as a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both.

5. Eclampsia refers to convulsions and coma occurring during pregnancy labour or soon after childbirth. Pre-eclampsia - a condition in manifested oedema (fluid retention of the ankles, hands or face) also kills women. Both can be associated with hypertension (raised blood pressure).

6. Obstructed labour occurs when the foetus cannot descend through the birth canal. It is usually caused by malpresentation of the foetus or too narrow a pelvis as a result of childhood malnutrition.

7. Other direct causes include ectopic pregnancy - when the fertilised egg becomes implanted and begins to develop outside of the uterus, usually in a fallopian tube. This can occur as a result of damage caused by a reproductive tract infection; embolism - the formation of obstructive blood clots dangerous to health; and deaths related to the use of anaesthesia.

Poverty and ill health

In Asia, 60 per cent of pregnant women are anaemic, in Africa 52 per cent, in Latin America 39 per cent and in Europe and the US 17 per cent. Anaemia causes babies to be born prematurely and with a low birth weight, both of which hugely increase their chances of dying before they are a year old, and cause serious maternal illness. Severe anaemia, which affects 5 to 15 per cent of African women can kill pregnant women by causing heart failure.

The heart of a severely anaemic woman has to pump harder to get oxygen around the body.

A woman may experience palpitations and dizziness. She will become profoundly tired, pale (especially on the palms of the hands and inside the eyelids) and breathless.

Eventually her heart will give up. Anaemic women are also much more vulnerable to the effects of any haemorrhage or infection that might occur after giving birth.

Food sources of iron are unlikely to meet the increased needs of pregnant women, therefore iron tablets (usually combined with folic acid, a vitamin necessary for blood synthesis) should be part of all prenatal care regimes.

However, anaemia control in pregnancy in developing countries appears to have failed. The overall prevalence of anaemia in pregnancy does not appear to have changed much in years.

There may be several reasons why: programmes may not have succeeded in reaching severely anaemic women who are the ones most at risk, important causes such as malaria, hookworm and Vitamin A deficiency may not have been adequately addressed, and other causes such as advanced HIV infection may be increasing.

HIV infection and AIDS are an increasingly common cause of complications of pregnancy, delivery and induced abortion. Many women are denied the opportunity in their sexual lives to protect themselves from HIV. For women attempting to become pregnant, there is almost no likelihood that they can do so. Frequently women only learn they are HIV-positive from an antenatal HIV test. Monitoring of tests in such settings shows that increasing numbers of women attending antenatal clinics are HIV-positive.

Where HIV infection is relatively uncommon, less than one per cent of women attending antenatal clinics are HIV-positive. The figure rises to over 20 per cent in urban areas in several countries in sub-Saharan Africa, and as high as 30 to 40 per cent in some studies.

Decreased immunity due to HIV infection increases women's risks of experiencing clinical consequences of malaria, including anaemia. Several studies have shown that women who are HIV- positive have delayed wound healing after caesarean sections and induced abortion. Infections are more common. Women and health professionals need information about how to support pregnant women with HIV and improve their health outcomes.

Infants are also at risk of contracting HIV from their mothers. Without preventive treatment, up to 40 per cent of children born to HIV - positive mothers will be infected - about two thirds during pregnancy and delivery and one third through breast feeding.

Withholding breast feeding however, can lead to increased risks of ill health and death for a child if clean water for breastmilk substitutes is unavailable.

Social injustice

A single dose of the drug Nevirapine given to a woman during labour and to the newborn baby halves the likelihood of HIV infection being passed on to the child.

In many countries, practices which inhibit women's chances of surviving pregnancy and childbirth are enshrined in law and culture. The result is chain of disadvantage, ultimately leading to death.

Early marriage can lead to childbearing before physical development is complete.

Girls aged 15 to 19 are twice as likely to die in childbirth as women in their 20s both because thy are younger and their bodies not fully developed and because first births are more risky. Yet more than 50 countries allow marriage at age 16 or younger, and seven allow marriage as early as age 12.

In many countries even the youngest brides face immediate pressure to prove that they are fertile. In sub-Saharan Africa, more than half of women give birth before age 20. On average, women with seven or more years of education marry four years later than those with no education.

The pressure to bear children early increases risks of obstructed labour, resulting in death or severe injury. A young woman who is malnourished is at greater risk. She may be physically stunted with a contracted pelvis, smaller even than that normal for her young years.

Outside marriage too, young women suffer risks of unplanned pregnancy where contraceptive services are unavailable. Laws that deny adolescents reproductive health information and services without parental consent may appear superficially neutral but have a disproportionately harmful impact on women's health interests.

Safe motherhood is not just about surviving pregnancy but about women having choices. Says Ingar Brueggemann, director General of the International Planned Parenthood Federation (IPPF): "I do not think we have a right to speak about safe motherhood only When a woman survives the birth. To me, it is not a safe motherhood if I have to see, as I saw recently, a 12-year-old girl cradling her baby. Is that what we mean by safe motherhood - that this kid survived the birth of her child?"

Violence is another risk factor for women associated with both unplanned pregnancy and adverse obstetric outcomes. Studies in some countries reported high levels of coercion and force at first intercourse. Even when pregnant, violence does not necessarily abate. Surveys in the US and Europe, conducted in a variety of obstetric or gynaecological settings, revealed that the prevalence of domestic violence reported by women varied from 0.9 pre cent to 46 per cent.

Researchers at the University Hospital in Geneva, Switzerland, have concluded that the prevalence of violence against pregnant women is high and severely underestimated by their health care providers.

Maternal mortality is a stark reminder of the non-fulfilment of women's rights and reducing it cannot be separated from broader structural issues of gender equality. When women are valued, resources will be made available to ensure their well-being. Says James Wolfensohn, President of the World Bank: "I do not believe for one minute, that if men were dying in their prime in these numbers, so little would be being done".

Undesired fertility

"A woman's health prospects are transformed if she can decide whether and when she wants to have children," says Margaret Catley-Carlson, president of the Population Council. Many women and men rely on traditional methods of birth control such as withdrawal. They have no access to more reliable methods of family planning.

In Ghana, 37 per cent of women have an unmet need for family planning and say they would like to stop having children or space their next birth, according to national demographic and health surveys. In Bolivia this figure is 35 per cent, in Tanzania 27 per cent and in the Philippines 26 per cent. If these women or their partners had access to contraception - and were free to use it maternal deaths could be reduced by nearly the same amount.

The same is true for access to safe, legal abortion. In Romania, when a restrictive abortion law was implemented in 1966, maternal mortality rates due to unsafe, illegal abortion increased more than fivefold. A less restrictive law introduced in 1989 caused deaths to fall quickly again by the same armount.

Access to safe, legal abortion and advice has recently become harder in many parts of the world as a result of the so called 'gag' rule which applies to organisations that receive aid funds from the US for family planning. The rule requires recipients of US funds to refrain from advocating for changes in abortion laws, or except in limited circumstances, providing abortion information, counselling or services, even with their own funds.

The law was first introduced by President Ronald Reagan in 1984 and was in force intermittently through the 1980s and 1990s. It was reinstated by George W Bush on his first full day in office.

The impact in many developing countries has been immediate. In Nepal, a country where 1 in 10 women die from pregnancy-related causes - approximately half from unsafe abortion - the Family Planning Association of Nepal (FPAN) has had to relinquish a relationship with USAID which had lasted 26 years.

Its director general, Dr. Nirmal K. Bista, has testified before the United States Senate Foreign Relations Committee on how the global gag rule has threatened the lives of poor women in his country. "If I were to accept the restricted US funds I would be prevented from speaking in my own country to my own government about a health care crisis I know first hand," he said.

Officials at the Ministry of health have concluded that legalising abortion could be a first step towards reducing maternal mortality. In October this year Nepal's lower house passed a bill allowing abortion upon request within the first 12 weeks and in cases of rape and incest or if the lives of the mother of child are in danger. The new law must also be approved by the upper house and the king.

A coalition of medical experts and women's and development organisations had long been seeking a change in Nepal's harsh laws which imprison women convicted of attempting to obtain an abortion. International attention was drawn to the issue four years ago by the case of Min Min, a 13-year-old girl who was raped by a relative. Her family managed to secure her an illegal abortion but she was reported and subsequently jailed - her sentence 20 years.

A campaign by FPAN and others led first to the reduction of her sentence to 12 years and subsequently to her release after two years of imprisonment. One in five women in jail in Nepal are there for the same reason. Min Min now works for FPAN.

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