Maternal mortality and morbidity in Mongolia

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Maternal mortality and morbidity in Mongolia
Chuluundorj, Oyuntsetseg
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136 leaves : ; 28 cm


Subjects / Keywords:
Mothers -- Mortality -- Mongolia ( lcsh )
Women -- Social conditions -- Mongolia ( lcsh )
Women -- Economic conditions -- Mongolia ( lcsh )
Mothers -- Mortality ( fast )
Women -- Economic conditions ( fast )
Women -- Social conditions ( fast )
Mongolia ( fast )
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )


Includes bibliographical references (leaves 128-136).
Statement of Responsibility:
by Oyuntsetseg Chuluundorj.

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University of Colorado Denver
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Auraria Library
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All applicable rights reserved by the source institution and holding location.
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47815456 ( OCLC )
LD1190.L43 2001m .C48 ( lcc )

Full Text
Oyuntsetseg Chuluundorj B.S.. Mongolian Medical University, 1996 M.S. Mongolian Medical University, 1998
A thesis submitted to the University of Colorado at Denver in partial fulfillment of the requirements for the degree of Master of Arts Anthropology 2001

This thesis for the Master of Arts degree by
Oyuntsetseg Chuluundorj has been approved by
V- ^ v/

Chuluundorj, Oyuntsetseg (M.A., Anthropology) Maternal Mortality and Morbidity in Mongolia Thesis directed by Associate Professor Craig R. Janes
The maternal mortality rate in Mongolia is high and has increased in the last ten years. This increase can partly be explained by the adoption of the WHO definition of maternal mortality by the Ministry of Health and Social Welfare in 1992, but the larger part is due to political, social and economic changes as the result of the transition of Mongolia to a free-market economy. Tow levels of socioeconomic development, deepened by current economic crisis, the low social status of women in the society, underdevelopment of hospital resources on the community level, and poor training of medical professionals, are the major factors contributing to the high rate of maternal deaths in Mongolia. Because the policy of health care-providers to reduce maternal mortality in Mongolia has been focused on the provision of adequate number of health professionals and technology, with the neglect to their quality of service and to many changes occurring in the social, cultural, economic and political lives of the people, nothing has changed in terms of reduction of maternal mortality. The increase of maternal mortality in the last decade is a clear example of how socioeconomic and political factors may affect the health status of a people, especially of women, and health policy, which ignores the contribution of these factors, may not be the solution to the problem.
The purpose of this thesis is to identify the socioeconomic and political factors that contribute to the high rate of maternal mortality in Mongolia, and to discuss the development of successful health policy to reduce maternal mortality in Mongolia.
This abstract accurately represents the content of the ca recommend its publication. H
ng R. Janes

I dedicate this thesis to the memory of my grandfather, whose wisdom has always been a beacon in my life.

My thanks to my advisor, Craig R. Janes, for his direction, advice and patience during the past three years.

1. INTRODUCTION..............................................1
2. REVIEW OF THE LITERATURE..................................8
What is Maternal Mortality.............................8
Statistics Worldwide...................................8
What Causes Maternal Mortality........................13
What is Known as the Main Determinants of Maternal
Phase 1 Delays.................................19
Phase 2 Delays.................................47
Phase 3 Delays.................................48
What Has Been Done....................................51
Traditional Birth Attendants...................52
Antenatal Care.................................54
Maternity Waiting Shelters.....................56
Family Planning................................58
Summary of the Most Relevant Questions................59

4. DATA...............................................80
Quantitative Analysis...........................80
Interviews with Women and Health Care Providers.95
Phase 1 Delays............................96
Phase 2 Delays...........................113
Phase 3 Delays...........................115
5. CONCLUSION....................................122
MAP OF MONGOLIA...............................126

2.1 Three Delays Framework................................16
3.1 Population Birth Rate, Mortality Rate and Growth Rate...75
.2 Maternal Mortality Ratio, 1988-1999....................77

2.1 Maternal Mortality Ratio of Some Countries (1990).......10
2.2 Top Five Causes For DALYs Lost........................12
3.1 Levels of Health Services in Mongolia (1998)............71
4.1 Age Categories of Maternal Mortality Cases..............81
4.2 Pregnancy Numbers.......................................82
4.3 Birth Numbers...........................................82
4.4 Pregnancy Term..........................................82
4.5 Educational Level.......................................83
4.6 Marital Status..........................................83
4.7 Life Quality............................................84
4.8 Occupational Status.....................................84
4.9 Morbidity Prevalence....................................86
4.10 Pregnancy Complications................................86
4.11 Maternal Mortality Causes..............................88
4.12 Place of Maternal Mortality............................90
4.13 Hospitalization Days...................................91
4.14 Involvement in Antenatal Care..........................91

4.15 Antenatal Care............................................92
4.16 Use of Maternity Waiting Homes...........................92
4.17 Phases of Delays.........................................93
4.18 Maternity Waiting Homes (1999)...........................98
4.19 Fertility Pattern Across the Country.....................105

The story I want to introduce here was the most tragic outcome of childbirth I saw during my work as an ob/gyn in a maternity house in Ulaanbaatar. A woman in her mid 30s died from hemorrhage after birth. She was hospitalized on Friday evening, two days before her death, with weak contractions and diarrhea. She was taken into prepartum department, since the labor had not yet begun. The doctor who did the first exam did not consider her condition to be serious, and did not warn the next on-duty doctor to pay more attention to her, although she weighed only 50 kg (her height was 165 cm), and anemic. It was her second delivery. She gave preterm birth to twins only two years ago but neither of them survived. The woman was seen by an on-duty obstetrician on Friday evening, but he prescribed only the basic medications for her entercolitis. Nobody examined her on Saturday, even though she had several episodes of vomiting and could not eat. No test was available to evaluate the inflammatory process and to diagnose her level of anemia on weekends. She gave birth the next morning, on Sunday, at around 11:00. The total blood loss was 250 ml, which would have been considered normal for a healthy woman.
The newborn weighed approximately 2300-2400 g, although she was at full term.

She fell into hemorrhagic shock soon after birth, but it was not diagnosed until 3:00 in the afternoon, when the new team arrived and evaluated her condition as life threatening. Appropriate measures were taken at that time, but she died two hours later from hemorrhagic shock. The laboratory assistant had been called Sunday morning to take blood tests. However, because there were many patients in serious conditions in intensive care unit, and even though the name of the woman was given to the assistant for blood test, the assistant decided not to take her blood, because, as she reported, the woman had already given birth. On the autopsy, which was done on next morning, the main cause of death was cited as hemorrhagic anemia, with the notation that every organ was white as a paper!
The newborn's condition was also critical at birth. He had respiratory failure, was severely undernourished, and was taken into intensive care. He died six hours after his birth, only five minutes later than from his mothers death.
The doctors tried to reach her husband, and even sent an ambulance after him, but the address had been changed. Upon admission, the woman had not given any phone number, or any reference to family/relatives. The husband was thus completely unaware of his wifes and sons deaths, whom he never saw. He had visited Saturday evening, but was told that his wife would not give birth for 1-2 days. He appeared Monday morning with some food to give her. He was met by the head of the maternity hospital and told that his wife and son had died the

day before. Upon hearing this news his grief and sorrow were profound and terrible to witness.
Upon later conversation with the husband, it was discovered that they were homeless, spending some nights in her relatives ger (Mongolian yurt), but mostly in underground places beneath the city1. Because they moved constantly from one place to another, the woman had had no antenatal care. The poor woman had no work. She became pregnant again only one year after her previous birth. Her husband was working, but only temporarily, and there were many nights they would go to bed hungry. They did not have many relatives, and the ones they had were unable to support them.
Many factors combined together and contributed to maternal mortality in this case. The overwhelming poverty of this family prevented them from eating properly, housing conditions were poor, and they had little access to health care services. Low socioeconomic status had a negative impact on this individuals behavior, limiting attention to health, access to antenatal care, and access to contraceptives that might have increased the time between pregnancies. The low self-esteem of this woman resulted in poor interactions with health care
1 In UB heating sewer pipes run underneath city streets. In recent years these underground areas have become a popular refuge for homeless families and children.

providers; inadequate knowledge about her health condition and pregnancy caused delays in seeking help from the professionals.
Health system factors were also important in this case: the poor quality of health care, the limited responsibility and knowledge of medical staff (doctors, midwives and laboratory assistants), poor communication skills with clients, neglectful attitudes toward the patients, and negligence of socioeconomic conditions of patients. These resulted in significant delays in providing appropriate treatment measures.
There are many cases of maternal deaths in Mongolia similar to the above one. But unfortunately health policy-makers mostly focus on the second set of factors, dealing with the poor quality of care, leaving the first set of factors socioeconomic and politicalout of concern. This may be a clue as to why Safe Motherhood Projects implemented in many developing countries in the world, including Mongolia have had a limited impact in maternal mortality. This thesis addresses in a more holistic fashion the major factors contributing to maternal mortality in Mongolia, including this case I had experienced by working in the maternity house.
Maternal mortality is a sensitive indicator of human development, equity, security, the socioeconomic status of women, and of the availability of health care services. It is one of the central health problems in the world today. The

disparity between maternal mortality rates (MMR) in developed and developing countries is great. Many factors shape the pattern of maternal health. Improvements only in education or spreading the network of health care centers cannot be the solution to the problem. Every society has a unique combination of factors, contributing to maternal death, only recognition of these and adequate policy, taking into account their peculiarities, may be successful. This situation is similar to the case of maternal mortality in Mongolia, which is among the countries with high maternal mortality. Many economic, sociocultural and political changes have occurred in the country in the last ten years, and these have affected the populations health status, particularly womens health status.
My thesis is devoted to the discussion of how these factors relate to or determine maternal mortality in Mongolia. The study of this issue becomes increasingly important, since MMR in Mongolia has been increasing dramatically in last ten years, and it does not show any signs of declining.
The thesis consists of four chapters, excluding introduction: a review of the relevant literature, the health system/situation in Mongolia, the presentation of descriptive statistics and interviews with women and health-care providers, and a conclusion. The literature review explores the main issues concerning maternal health worldwide and presents the findings of many studies regarding the important factors contributing to maternal mortality. The next chapter gives

the background on health care system in Mongolia and existing health situation, including maternal health. The presentation of descriptive statistics is based on the records of 157 maternal mortality cases collected by the author from rural areas in the years 1996 and 1997. These are the records sent from the hospitals in rural areas to the Ministry of Health and Social Welfare. The histories of births on mortality cases are kept at each aimag hospital and were not available for review. The data include information about age, pregnancy and birth number, place of death, cause of death, attendance of antenatal care, use of maternity waiting homes, occupation, education, life quality, and number of family members. These were coded and run on the SPSS 10.0 program for the PC.
The interviews were conducted in 2000 with eleven women from rural areas who were diagnosed with complications of pregnancy and had come to Ulaanbaatars Maternal and Child Research Center for treatment and delivery. These women did not have serious problems related to pregnancy, but came to the central maternity houses in Ulaanbaatar because it was safe. Not all women from rural areas can come to the central hospitals to give a birth. Only those women who can afford it, who have relatives living in Ulaanbaatar to support them, who have relatives taking care of their children and livestock at home (except referral cases) come to the central maternity houses located at the capital cityUlaanbaatar. The average time spent in interviews was 30-40 minutes.

This chapter also includes the interviews conducted with the health care-providers at the Ministry of Health and Social Welfare, with professors at the department of obstetrics/gynecology of Mongolian National Medical University, with obstetricians/gynecologists at the Arkhangai aimags central hospital, with health professionals of soum and bhag hospitals in Arkhangai aimag.
In the conclusion I summarize the main findings and note my thoughts about the needs for future research.

What is Maternal Mortality
Every year about half a million women die from complications associated with pregnancy and childbirth throughout the world. Most of these deaths are avoidable where accessible and appropriate technologies are available (Thaddeus & Maine, 1994, p. 1091). Maternal mortality is defined by the all cases of a womans death occurring during the pregnancy, irrespective of the duration, and within 42 days termination of pregnancy from any cause related to or aggravated by the pregnancy other than accidental or incidental causes (AbouZahr,
Wardlaw, Stanton, & Hill, 1996:77).
Statistics Worldwide
Maternal mortality was neglected by international health policy-makers until 1985 (Okojie, 1994, p. 1237). Since 1985 maternal mortality has received more attention. The Safe Motherhood Initiative was enacted at an international conference in Nairobi. Kenya, in 1987. The initiative promotes family planning, antenatal care, basic maternity care, essential obstetric care, safe delivery, prevention of infertility, primary health care and equity for women (Maine &

Rosenfield, 1999, p. 480). All of these elements are certainly important to womens health. However, some elements adopted by the initiative have been ignored in the decade passed since this initiative, and the maternal mortality rates remain unaffected. According to WHO, 585,000 women died in the year 1996 due to pregnancy-related problems (Koblinsky, 1995, p. s21). Sixty five percent of them could have been easily prevented." an additional 26 percent could have been "probably prevented (Garenne. Mabaye, Bah, & Correa, 1997, p. 22).
The disparity between the maternal mortality rates of the developed and developing world is striking (Stokoe, 1991, p. 9; Okojie, 1994, p. 1238). The probability of a poor woman in a developing country dying during pregnancy and childbirth is 80-200 times greater than that of a middle-class woman in the developed world. Women in South Asia, and Africa, representing 41 percent of the worlds total female population in the reproductive age group, account for 60 percent of all births, and 90 percent of all maternal mortality (Rosenfield & Maine, 1985, p. 83; Shen & Williamson, 1999, p. 197). Table 2.1 below provides figures in maternal mortality from some developing countries.

Countries Maternal mortality ratio (maternal deaths per 100 000 live births) Countries Maternal mortality ratio (maternal deaths per 100 000 live births)
Afghanistan 1 700 Mauritania 930
Angola 1 500 Mexico 110
Argentina 100 Mongolia 65
Australia 9 Morocco 610
Austria 10 Mozambique 1 500
Bangladesh 850 Namibia 370
Belgium 10 Nepal 1 500
Benin 950 Netherlands 12
Bhutan 1 600 Niger 1 200
Bolivia 650 Nigeria 1 000
Botswana 250 Norway 6
Brazil 220 Pakistan 340
Bulgaria 27 Papua New Guinea 930
Burundi 1 300 Peru 280
Cambodia 900 Philippines 280
Cameroon 550 Poland 19
Canada 6 Portugal 15
Chad 1 500 Republic of Korea 130
Chile 65 Romania 130
China 95 Russian Federation 75
Cuba 95 Rwanda 1 300
Czech Republic 15 Samoa 35
Denmark 9 Senegal 1 200
Ethiopia 1 400 Sierra Leone 1 800
Gambia 1 100 Singapore 10
Ghana 740 Somalia 1 600
Guinea 1 600 South Africa 230
India 570 Sweden 7
Indonesia 650 Switzerland 6
Japan 18 Thailand 200
Kenya 650 Turkey 180
Lao Peoples Democratic Republic 650 United Kingdom of Great Britain and Northern Ireland 9
Luxembourg 0 United States of America 12
Source: AbouZahr et al., 1994
Table 2.1. Maternal Mortality Ratio of Some Countries (1990).

Although women in countries with high maternal deaths also die more often from other causes, maternal deaths are one of the 'major contributors to deaths of women of reproductive age. Maternal deaths account for 25 percent of the deaths of women between the ages of 20 to 30 (Walsh et al. 1994). For example, in India, maternal death rates accounted for 13 percent of all deaths of women in reproductive age in 1997 (Ganatra, Coyaji, & Rao, 1998, p. 591).
But maternal mortality is only the tip of the iceberg:
For every one maternal death, acute obstetric complications cause suffering in nearly 100 women. 250 women contract a sexually transmitted disease, and 1000 women suffer stunting and/or anemia (Koblinsky, 1995, p. s21).
Over 54 million women in developing countries suffer from acute pregnancy-related complications every year, with over 20 million being serious. Direct obstetric morbidity results from the complications of pregnancy, labor and puerperium, and from interventions made during this period. The suffering of women from other disorders, not related to pregnancy and childbirth outcome, is equally high. In sub-Saharan Africa, malaria infects some 60 percent of primiparous and 30 percent of multiparous women. In 1985, among the 1.13 billion women in developing countries of age 15 and older, over 500 million were considered to be malnourished and about the same number were thought to

be anemic (Koblinsky, 1995, p. s22). Because morbidity data typically underrepresent the actual prevalence of diseases in the community, real rates are undoubtfully much higher.
Maternal conditions are responsible in developing countries for five out of ten and worldwide for three out of ten leading causes of the disease burden in women aged 15 to 44 (Murray & Lopez, 1996:25). According to the World Development Report, maternal disorders are at the top among the causes for Disability-Adjusted Life Years (DALYs) lost (Nowak. 1995:781). Table 2.2 shows the common causes of DALYs lost.
Detailed epidemiological information on maternal morbidity is mostly unavailable due to inaccurate diagnosis and subjective evaluation of the severity of complications. This lack is a problem primarily of developing countries.
Rank Females (millions of DALYs lost) Males (millions of DALYs lost)
1 Maternal 27.9 HIV 14.7
2 STDs 13.8 TB 13.3
-> TB 10.9 Motor vehicle injuries 13.0
4 HIV 10.2 Homicide and violence 9.6
5 Depressive disorders 9.0 War 6.6
Source: Nowak, 1995, p. 781.
Table 2.2. Top Five Causes for DALYs Lost.
(Developing Countries, Ages 15-44).

What Causes Maternal Mortality
The major proximate causes of maternal mortality are well understood and generally consistent from place to place. Rosenfield and Maine (1985) estimated that worldwide, maternal deaths occur as a result of these five problems (direct causes): hemorrhage (28 percent), infection (11 percent), eclampsia (17 percent), obstructed labor (11 percent) resulting in uterine rupture, and the consequences of illegal abortion (p. 84). These cause together account for 67 percent of all maternal deaths around the world. Extragenital diseases, also called indirect causes, including anemia, malaria, cardiovascular diseases, hepatitis and diabetes, are responsible for another 20 percent of cases of maternal mortality (AbouZahr et ah, 1996, p. 77).
Sixty-one percent of all maternal deaths in developing countries occur after delivery; almost half of them take place within one day after delivery, and 70 percent within the first week (WHO, 1998, pp. 1-2). All of these pathologies are considered to be preventable and/or curable if managed in an effective, timely manner.
Maternal death is not only the result of poor medical management of existing diseases and the birth process. It is also related to a combination of social, cultural, economic and physiologic factors. Every community has its own unique geographical or environmental obstacles, cultural peculiarities, economic

constraints and medical bureaucracy. A number of studies done in developing countries on maternal mortality showed a high correlation of maternal age, parity, socioeconomic status, marital status, health status with a high risk of poor pregnancy outcome (Rao, 1981, p. 78).
What is Known as the Main Determinants of Maternal Mortality
Thaddeus and Maines (1994) three delays framework has thus proven to be a very useful model for evaluating possible cultural, socio-economic and political factors that lead to the delays that cost womens lives. The period between the onset of obstetric complications and the provision of appropriate medical aid is very important to the effectiveness of medical intervention, thus, to pregnancy outcome. Under the three delays model, different factors become obstacles to provision of help in a timely manner.
Phase 1 delays concern the processes occurring in the period before and up to the point that a woman or her family decide to seek care. Many factors, such as the status of women, financial abilities of families, cultural understanding of illness, childbirth and childbirth complications, perception of the quality of the health care provider, previous experiences with health care personnel, and distance from the facility, affect the decision-making of a woman and her family

and may delay womens and family members decision to seek adequate care. The factors leading to delays in this phase are of a great anthropological significance.
Phase 2 delays concern physical accessibility, such as the distance to a medical facility, traveling time, availability of transportation, cost of traveling and the condition of roads and communications infrastructure.
Phase 3 delays reflect the appropriateness of the way a health care facility deals with emergency situations: on-time referrals, shortages of drugs, equipment and experienced personnel, and the latter's interaction or relationship with clients.
The definition of different types of possible delays makes possible the analysis of the factors contributing to maternal death as one complex structure, the elements of which interact with each other in many different ways. It provides an opportunity to study various factors, including the social, cultural, economic and developmental, all together, without leaving any of them out of the discourse. It becomes important in the development of adequate policy and in assurance of its effectiveness. The interaction between different factors of this approach is shown in Figure 2.1.

Factors Affecting
Utilization and Phases of Delay
Perceived Accessibility of Facilities
Phase I: Deciding to Seek Care
Phase II:
Identifying and
Reaching Medical
Phase III:
Receiving Adequate and Appropriate Treatment
Source: Thaddeus & Maine, 1994, pp. 1101-1105. Figure 2.1. Three Delays Framework.

Socioeconomic/Cultural Factors
Illness Factors
Recognition of complications
Perceived severity
Perceived etiology Sociolegal Issues
Illegal abortion
Sanctions of infidelity Womens status
Access to money
Restricted mobility
Value of womens health Economic Status
Educational Status
Positive/negative association
Perceived Accessibility Actual Accessibility
Distance Distribution and Location of Health Facilities
Disincentive Distance
Transportation Travel time
Animal/motorized Outcomes occur in transit
Season (rain/dry) Transportation
Road condition Publicly available
Cost Costs
Transportation Costs exceed expectations or ability
Physicians/facility fees Medications Other supplies Opportunity costs Accompanying people Bribes to pay
Perceived Quality of Care
Reputation/Previous Experience Satisfaction with Outcomes
Effectiveness of treatment and prescribed remedies
Satisfaction with Service
Staff attitudes
Hospital procedures
Availability of supplies
Waiting time
Consistent with local beliefs
Violation rules limiting
Social/family support
Actual Quality of Care
Poorly Staffed Facilities
Staff numbers
Competence of personnel Poorly Equipped Facilities
Unavailability of blood
Unavailability of drugs
Unavailability of other equipment
Hard currency problem
Inadequate Management
Incorrect diagnosis and action

The three delays approach has been used by several researchers in the assessment of maternal mortality in different countries. For example, work done in Zimbabwe has concluded that avoidable factors were identified in 90 percent of rural deaths and 85 percent of urban deaths. Delay in the decision to seek care contributed to 32 percent and 28 percent of rural and urban deaths, respectively. Delays in reaching the facility contributed to another 28 percent of deaths in rural areas. Inadequate clinical management was identified in 67 percent and 70 percent of rural and urban deaths, respectively (Fawcus, Mbizvo, Lindmark, & Nystrom, 1996, p. 319).
A large number of deaths occur at home or on the way from home to a health facility: in work conducted in India, 26.4 percent of women died at home, 6.6 percent in transit from home to a health facility, and 11.5 percent on the way from one health facility to another. Only 37.1 percent reached a hospital with an adequate level of care in emergency situations (Ganatra, Coyagi, & Rao, 1998, p. 593). In a study conducted in China, 15 percent of all maternal deaths occurred on the way to the hospital (Timyan, Brechin, Measham, & Ogunleye, 1993, p. 218).
Often these three levels of delay combine, resulting in many hours of waiting without assistance. In the next part of the discussion I am going to

explain how the above-mentioned different factors contribute to delays, and thus, to tragic outcome of pregnancy and childbirth.
Phase 1 Delays
Phase 1 delays result from poverty and income inequality, gender discrimination, structural adjustment, poor morale of health care providers, and distance from health facility.
Poverty and Income Inequality. The relationship of maternal mortality to socioeconomic development is different from other causes of death in the developing world. Rapid industrialization and socioeconomic development have generally resulted in an enhancement of public health: better nutrition, higher living standards and improved water supply have had a positive impact on decrease of morbidity and mortality from infectious diseases. Infant mortality rates and deaths from infectious diseases were dramatically reduced in Europe and North America as the result of improved living standards in the 19th century. But at the same time maternal mortality did not decline until the 1930s when there were the achievements in medical technology, including antibiotics, improved surgical techniques and blood transfusion (Maine & Rosenfield, 1999, p. 481).

The fact that 99 percent of all maternal deaths occur in developing countries in Africa, Asia, and Latin America may be seen as having a common
underlying factor-poor socioeconomic development and the accompanying poverty. And there are different explanations why poverty is related to poor health: living and working conditions, limits of income resources, social relationships, smoking, poor diet, and little exercise (Stansfeld. 1999, p. 215). Briefly, the mechanism of how material deprivation affects health may be presented in the following way:
1) material deprivation affects health outcomes directly via social and psychological environment (for example, poor working and living conditions, poor nutrition, environmental hazards, stress, depression),
2) material deprivation operates indirectly, through individual's behavior (for example, difficulties in traveling to seek help, inadequate health care),
3) material deprivation results in behaviors with negative effect (for example, smoking, taking drugs, lack of exercise, isolation from others) (Rutter & Quine, 1990, p. 563).
Deprivation begins, we suggest, by having two principal effects, one an increase in negative life events, often with an absence of social support, the other a reduction in the level of education and

access to information. Life events and lack of support lead in turn to emotional problems, including stress, anxiety, lowered selfesteem and depression, while poor education and information produce a corresponding range of cognitive problems, including a lack of knowledge and a set of beliefs and attitudes which lead the women to see herself as vulnerable to illness and complications but helpless to prevent them (Rutter & Quine, 1990, p. 563).
But material deprivation cannot explain completely the differences in health status, maternal mortality between developed and developing countries. Maternal mortality can vary in different communities within a country. A study conducted in two rural provinces in China concluded that annual family per capita income was a sensitive indicator of maternal mortality only where per capita income was very low. In another province, where the annual per capita income was higher, it was not a sensitive indicator of the maternal death rate (Jacobson, 1993, p. 8). Poverty contributes to maternal death, but this relationship does not seem to be a simple one: poverty interacts with other social factors, the combination of which decides a womans destiny. These other factors will be discussed later.
Modernization, which leads to higher standards of living and advanced medical technology, may contribute to both lower mortality and lower fertility. But this correlation is not evident across the world. In fact, the maternal mortality ratios of those countries where GNP per capita was below US$ 1,000 in 1993,

ranged from 22 to 1,600 per 100,000 live births, which is a very great variation, and cannot be explained alone by economic development, urbanization, educational level and health care services (Brouwere, Tonglet, & Lerberghe, 1998. p. 771).
Modernization theory, arguing that economic development leads to both lower mortality and fertility, does not give attention to inequality within societies, gender stratification and cultural peculiarities. Material deprivation or poverty can only partly explain the high mortality rates in poor countries. Not every pregnant or delivering woman in the developing world suffers from poor health. It is poor, uneducated, unemployed, often unmarried women, and the heads of large families. It is only the poor woman, who in order to get medical aid. is often left to deal with the time lost in domestic labor and child care, the costs of transportation and services, medical fees, food, emotional stresses of all these problems, and, at the end with inadequate care and unsuccessful outcome.
Many studies have concluded that mortality is related to the relative income within counties, rather than in the differences of absolute income. Even life expectancy does not relate to economic growth rate (Wilkinson, 1997, p. 591). Socioeconomic development does not equally affect all the members of society. Income inequality and discrimination exist in every society. The rise of GNP does not equally apply for all the individuals in the same society: there is a

wider gap (from eight-fold to 30-fold) in GNP between the middle class and the poor. According to Harrisons estimation (1997), GNP for the middle class individuals increased by 1.5 times, while it has not increased for the poor (p. 7). And where is more income inequality, there is poorer health outcome and the consequences are dramatic: a 66-fold difference in GDP per capita contributes to 400-fold reduction in maternal deaths (Harrison, 1997, p. 8).
Thus, improvements in nutrition, housing, safe water, and primary health care facilities cannot be the solutions for preventing maternal mortality. But it is likewise dangerous to ignore the important roles such improvements play in improving maternal health. Malnutrition and a high rate of infectious diseases still affect millions of people in developing world. A small amount of blood loss which would not seriously affect a healthy, adequately-nourished mothers condition can be fatal for severely-anemic mother. Low-virulence bacterial infections can be fatal for a mother with poor immune resistance resulting from infectious diseases and anemia. Small pelvic bones resulting from malnutrition in a childhood leads to the high probability of obstructed labor, thus to high risk for uterine rupture. These conditions caused by poverty may not be seen as direct causes of maternal deaths, but they certainly increase the risk of mortality when combined with other proximate causes.

Material deprivation is not the only mechanism through which poverty affects women's lives. The higher the income, the greater the knowledge about health-related situations, and the greater the tendency to seek preventive and curative help. But income does not alone affect the access to health care. And the existing inequality in health cannot be explained by inequality in the obtainment of health care. The removal of financial problems as barriers to seek for health services cannot seriously affect existing health behavior of the poor. Health beliefs and many other social factors are equally important to health-seeking behavior.
An increasing socioeconomic inequality in a society concerns not only income, but also opportunities to have a good education and a suitable occupation. Although income, education, and occupation are considered to be the most important factors determining a persons socioeconomic status, they are not sufficient to be studied separately in relation to health. Educational level creates differences between people in terms of access to information, and of benefiting from that knowledge, whereas income creates differences in access to material resources. Higher income and education are associated with larger networks, greater contact, higher social support, and higher positive emotional support. Occupational status includes both of these aspects and also job benefits, such as prestige, privileges, power, and social and technical skills. A poor woman may

not have permanent employment, which is the most effective guarantee against both poverty and ill health. Mechanisms through which unemployment affects health are considered to be poverty, stress, and changes in health-related behavior. Adaptation to unemployment is accompanied by lowered self-esteem, loneliness and cynicism (Bartley. 1999. p. 85). If the employment grade is lower, close relationships tend to have a negative, stressful impact on the unemployed (Stansfeld, 1999, p. 171). Some lower-paid unsatisfactory jobs can be as depressing as unemployment. But there is little an individual can do: the labor market selects workers into lower and higher status occupations with different income and prestige. It may result in different working environment with different exposure to physical hazards and with different levels of control and social support.
The relationship of SES measured by income, education, or occupational grade and inequalities in health requires explanations for different levels of society: the individual and the social structural levels. The individual level concerns lifestyle factors and the access to health care. Social structural levels include family environment (social networks, social support), work environment (job strain) and community factors (income distribution, social capital, and culture) (Kawachi, 1998, pp. 3, 44).

A mothers educational level, occupation, self-esteem, social network and support are very important factors that influence her health, pregnancy and childbirth outcome. All of these economic and social factors are connected with each other by dense ties: a woman without money cannot easily attain a good education and employment, cannot cope with difficult situations in life (including disease) without falling into stress and depression, may not have high selfesteem, have limited social network and support, can easily be abused, can marry earlier and suffer from ill health, can have a limited chance to seek appropriate care for her own health, may not use contraceptives to avoid unwanted pregnancy, may give birth several times, passing these links to her children, who also will not have good health. Further, her childrens ill health in childhood will lead to lower SES. social exclusion, having jobs with less opportunity, control, job insecurity, unemployment, fewer social networks, poor nutrition, addictive behavior, and poor housing (Marmot, 1999, p. 12).
An individuals social capital and social network have a significant impact on womens health.
Social capital is defined as those features of social structures-such as levels of interpersonal trust and norms of reciprocity and mutual aid-which act as resources for individuals and facilitate collective action. Social cohesion is a broader concept and includes the absence of latent conflict and the presence of strong social bonds. Social capital and social cohesion are dimensions of

society and the results of social relationships, while social support and social networks can be measured at the individual level (Kawachi & Berkman, 2000, p. 175).
Social capital has multiple benefits to a society: on an individual's behavior, on education, on work and organizations, on socioeconomic development, on democracy, criminology, and on health. The possible mechanisms of social capital influencing an individual's health are:
1) influencing health-related behaviors (rapid implementation of health knowledge or healthy behaviors, controlling harmful behaviors),
2) influencing access to health services (creating social organizations ensuring access to easy transportation, community health clinics, recreational facilities), and
3) affecting psychosocial processes (providing support and increasing selfesteem)
(Kawachi & Berkman, 2000, pp. 184-185).
The ways in which having a social network can affect health include:
1) provision of social support (emotional, material, cognitive),
2) social influence,
3) social engagement and attachment, and
4) access to resources and material goods (Berkman & Glass, 2000, p. 144; Kawachi, 1998, p. 7).

Thus, mechanisms linking income inequality to health cannot be only explained by inequality in income distribution within society. This relationship consists of different factors, including direct psychological pathways, underinvestment in human capital (education, occupation) and poor social capital (network, cohesion). A study of army wives in U.S. noted that 91 percent of women with high stress and low social support had obstetric complications, when only 33 percent of women with high stress but high social support had obstetric complications shows the importance of these social factors in maternal health. Having somebody close at the birth results in shorter duration of labor, fewer complications, strong mother-infant bond, better infant condition. Stress and the absence of a supportive person may contribute to less frequent attendance at antenatal care classes (Rutter & Quine, 1990, pp. 557-558).
To feel depressed, cheated, bitter, desperate, vulnerable, frightened, angry, worried about debts or job and housing insecurity; to feel devalued, useless, helpless, uncared for, hopeless, isolated, anxious and a failure: these feelings can dominate peoples whole experience of life.... The material environment is merely the indelible mark and constant reminder of the oppressive fact of ones failure, of the atrophy of any sense of having place in a community, and of ones social exclusion and devaluation as a human being (Wilkinson, 1996, cited in Shaw, 1999, p. 223).

Globalization and Structural Adjustment. Wallerstein and Bernstein (1994) has argued that the capitalist economy has shaped the world into two poles: advanced North American and European industrialized countries who regulate the world economy and gain the profit by exploiting so-called developing countries. These countries are dependent on the industrialized countries for jobs, and aid, but become poorer in the process of accepting this dependent position.
The interdependence of countries and the involvement of local systems in the global system is not a new phenomenon. The expansion of capitalism and the intervention of the capitalist mode of production basically have changed the existing structure and modes of production in previously non-capitalist, poor countries. These countries have no other choice than to be involved in the world global system: they have become the main resource base for developed countries by providing raw materials and cheap labor to the core economies. Agricultural lands, pastures, and forests are often taken from people and turned into plantations. Left without any resources to provide for themselves and without any power and means to defend their own land, these poor people are turned into the wage laborers for minimal wages to secure their basic subsistence. They do not produce anything for their own subsistence; any profit will be given to the owner of the means of production. Everything they need will have to be bought

from the market. They will be forced to work hard and for longer hours to make a quick profit for the owners of the means of production; they will not have the protective measures for their health. Competition for jobs and economic security threatens social relationships between people and thus weakens social solidarity and cohesion.
Once male household heads are unable to feed their families, women and children may be forced into the wage labor market. If the idea of women working was previously unacceptable, economic factors may make womens work necessary and thus socially acceptable. But it adds a burden to women's labor. People may become sick from the hard labor, live in environment degraded by industrial wastes, may not have appropriate medical services and spend all their wages for expensive ineffective drugs (Scheper-Hughes, 1992, pp. 12-20). The real situation is often neglected or misunderstood; authorities assume that it is only the victims fault to live poorly: they may think that he/she could work harder, live better, but does not have a will to improve the condition of their lives (Morsy, 1996, pp.21-25). This victim-blaming attitude continues to dominate this discourse.
More than half of the grain produced worldwide is harvested in Asia, Africa, and Latin America, but one billion people live in hunger, and another one billion with the chronic risk of hunger. Poor people mostly live in rural areas:

over 80 percent of the total number of poor people in the world is in rural areas (Desjarlais, Eisenberg, Good, & Kleinman. 1996, p. 19). They do not have permanent employment, are highly vulnerable to natural disasters and famine. Real food prices have increased in those countries, while the prices of raw materialsa main source of exporthave fallen. In fact, between 1980 and 1987 the prices of 33 raw materials decreased by 40 percent (Desjarlais et ah, 1996. p. 17).
Therefore, the economic growth of developing countries and the integration of these countries into the world economy may not contribute to the reduction of poverty and income inequality; indeed it worsens the lives of millions of people. A clear example of this are the Structural Adjustment Programs (SAPs) introduced by development lenders in the early 1980s in 75 developing countries in Africa, Latin America, and Asia (Gershman & Irwin, 2000, p. 23). It was the aim of U.S, United Kingdom, and Germany to resolve the debt crises in those countries, in the poor countries by introducing macroeconomic restructuring so as to insure debt repayment. The rise of US interest rates during the 1970s increased the debts and the decline of commodity price for oil in world market made many countries unable to pay the interest. Along with this, the pressure from the poor and middle classes for equal distribution of economic growth benefits led these countries to take huge loans

from commercial banks. In order to deal with this deep debt crisis, the poor countries became subject to SAPs. whose main goal was the reduction of state role in the economy, the enhancement of economic efficiency and the integration of the national economy into the world economy. In short, it was about the privatization of state enterprises, liberalization of prices, and the establishment of market economy mechanisms.
As the result of this, government spending on health and education in many countries was cut, the quality and availability of health care was reduced, inequality between rich and poor was increased, with a large part of population becoming impoverished, and violence, corruption and alcoholism threatening to go out of control. Thus, SAPs added to the burden for many poor people who were already on the edge of survival (Gershman & Irwin, 2000, pp. 23-25).
The transition to a free-market economy aggravates the gap between rich and poor nations while at the same time contributing to inequality within nations:
Of the $23 trillion global gross domestic products in 1993, $18 trillion accrued to industrialized countries, and only $5 trillion to the developing countries, home to 80% of the worlds people. The poorest 20% of the worlds population saw their share of global income decline from 2.3% to 1.4% in the past 30 years. Meanwhile the share of the richest 20% increased from 70% to 85%. That doubled the ratio of the shares of the richest to the poorest, from 30:1 to 61:1 (Kawachi, 1998, p. 11).

Thus, SAPs, which affect many poor countries, led to many negative consequences: poverty, socioeconomic inequality, increased external debt, brain drain, underdevelopment of infrastructure and social services, unemployment, escalated crime rate, undernutrition, declined agriculture, environmental degradation, and corruption and political instability. This experience would suggest that foreign investment does not necessarily improve womens status. In fact, these investments may lead to many undesirable results, and seriously impede women's access to education and health services (Shen & Williamson. 1999, p. 210).
Gender Discrimination. The issue of gender inequality has been hidden for a long time under poverty and underdevelopment, putting both men and women at the same disadvantage with respect to health status (Thaddeus & Maine, 1994, p. 1098). Sex discrimination in general has not been given much attention as a contributing factor to maternal mortality.
The maternal mortality rate is a sensitive indicator of human development, equity, security, socioeconomic status of women and of an availability of health care services. But it shows only the most tragic end of womens lives, leaving their generally poor health, frequent morbidity episodes, and suffering hidden (Okojie, 1994, p. 1238). Gender inequalities in health, as

the consequence of gender inequalities in many societies, become a critical issue in the discourse on maternal mortality. The concepts of gender inequality include inequality in prestige, power and access to or control over resources (Okojie. 1994, p. 1237).
The socioeconomic status of women contributes to maternal mortality through its effect on health behavior, health status, access to health services, and many other unknown pathways (Okonofua. Abejide. & Makanjuola, 1992. p. 319). Womens low socioeconomic status, expressed in terms of educational level, occupation and income, increases an already high mortality rate, not only in the developing world, but also in urban areas of wealthy industrialized countries. T his is a universal problem. Women's status affects womens access to health care services, affecting the decision of women or other household members to go to the clinic, for example, in areas where leaving the home without a husbands permission is forbidden.
Discrimination in nutrition based on the low economic value of women and high expenses at marriage of daughters and sisters leads to a high rate of malnutrition and poor general health among women of childbearing age. The cultural belief that women are naturally inferior to men, that women are inherently less important to the household, and the undervalue of their labor and role in the household, reduce the opportunity for women to share already scarce

resources equally with men. Factors such as the preference for boys as the keepers of family ties and the supporters of parents, girls and women's lack of access to resources and excessive energy demands in household labor rewarded by the smallest portion of food, premature pregnancies, and closely spaced births contribute to womens malnutrition, anemia, poor general health, reduced quality of life, and lower capacity for economic contribution to the household (Okojie, 1994, p. 1239). Poverty causes malnutrition and aggravates it by making women vulnerable to infectious diseases. Poor nutrition results in poor maternal health, and in more complications during pregnancy and childbirth. This discrimination continues throughout their lives, resulting in lower education, lower-paid jobs, higher workloads, and reduced access to health care facilities.
Gender discrimination does exist in other areas of social life, including educational and occupational opportunities, opportunities to use health services, and limits the possibilities for women to gain the equal socioeconomic status with men.
In many developing countries women do not have formal employment; they are mostly involved in the informal economy or household production. If they have employment it is typically in low-wage and low-status occupations. Womens attachment to domestic labor limits their free time, and their lower

education does not give them much of a chance to compete with higher-educated men for better occupations (Browner & Leslie, 1996. p. 262).
Employment indirectly or directly can have a huge impact on the health outcomes of women. It develops physical strength and vitality, cognitive function, education, work skills, social capital, and psychological capacities such as self-esteem, coping skills, and secure identity. It gives the opportunity for cash income, which women can use to seek care without necessary waiting for spouses or male relatives permission.
Women are involved in domestic work on average 12-18 hours per day as opposed to 10-12 hours workload for men. mostly taking care of children, family and working on family farms (Jacobson, 1993, p. 12). It is mostly heavy physical work: washing, preparing firewood for cooking, carrying big containers of water, working in the field and processing food. Women have multiple work responsibilities: childcare, household maintenance, agricultural work, and wage employment in the labor force. Environmental degradation and agricultural marginalization limit the resources of women to handle all these family responsibilities and increase the work burden for women, negatively affecting their health status.

The work done by women is undervalued, although at least one-fourth of male-headed households rely on female earnings for more than 50 percent of the total household income (Koblinsky, 1995, p. 30).
The workload expected of women in the field, at home and in child rearing is so heavy that the threshold of illness recognized by society for women is very high on the health-illness continuum in order to ensure their availability for their work. For this reason women will endure a lot of pain and discomfort before they admit that they are ill. This partly explains the delay in seeking medical care by women (Okojie, 1994, p. 1242).
Education is an important determinant of population health. Higher levels of education increase the chances for better jobs, higher incomes, better living conditions, and extended social networks. But the number of years spent in education does not necessarily reflect the quality of education (Lynch & Kaplan,
2000, p. 22).
In many developing countries women do not have access to education. Today, only 15 percent of all women in Africa are literate in comparison with 33 percent of all men. In Asia the situation is the same: only one-third of women can read, but more than one-half of men are literate (Jacobson, 1993, p. 11). The situation is similar for college education.
Education increases the access of women to information, enhances their self-esteem, increases their knowledge of new health practices, tightens their

relationship with a doctor, and, ultimately, it enhances a womans optimism to seek care (Timyan. 1993, p. 228).
Many studies repeatedly identify the high positive correlation between mothers education and child survival (Thaddeus & Maine, 1994, p. 1099; Olsen & Madsen, 1999, p. 135). A study in Mexico noted that women with more than six years of education are 62 percent less likely to favor the midwife in comparison with less educated neighbors from the same village (Parra, 1993, p.
1325). The educational and social status of women was the major predictor of maternal and infant mortality and life expectancy. Illiteracy becomes an important factor for not using family planning (Hertz, Hebert, & Landon, 1994,
p. 110).
A study done in India concluded that the husband's education was significantly associated with maternal survival, and there was no association between women's education and maternal death (Ganatra et ah, 1998, p. 593). This may be explained by the dominance of the husband in decision-making and the low socioeconomic status of women.
But the education of women does not guarantee the better utilization of health care services. The large investments in education and achievements of high literacy may not have a positive impact on maternal health. The examples are Paraguay and Tanzania, where maternal mortality is high even though the

female literacy rate is 80-85 percent. Women with higher education may depend on self-care and delay the visits to professionals (Thaddeus & Maine. 1994. pp. 1099-1100). So, the correlation between higher education of mothers and lower maternal mortality is not always evident.
Where women's status is low, they may not have reproductive freedom: they cannot control the number of births and the space between births. In many patriarchal societies, men do not allow women to practice family planning. According to some researchers, if women were able to control their pregnancy and avoid unwanted pregnancy, each year maternal deaths could be reduced by 150,000 lives (Shen & Williamson, 1999, p. 200). It is estimated that 25-50 percent of pregnancy-related deaths are due to the fully preventable complications of unsafe abortions (Winikoff & Sullivan, 1987).
Worldwide it is estimated that 35-50 million induced abortions occur every year. About 32 percent of women in developing countries live where abortion is not liberalized. Illegal abortion may prevent women from going to hospital for help. But liberalization does not guarantee a safe and legal abortion. In India, where abortion is not restricted, only 250,000 legal abortions occur as opposed to four million illegal ones (Heise, 1993, pp. 172-183)! The main causes of death from abortions are sepsis and hemorrhage.

It is tragic that behind a womans death due to unsafe abortion, many children are left without mothers. More than half of the married women suffering from septic abortions already had more than two children. Unsafe abortion becomes another pressure on hospitals already lacking resources: the treatment of abortion complications may consume 50 percent of hospital budgets in developing countries (Coeytaux. Leonard. & Bloomer, 1993, p. 134). These numbers show the importance for both mother's and child's health of providing safe family planning methods.
Family planning is an important contributor to the reduction of maternal deaths due to the reduction of unwanted pregnancies and unsafe abortions. The prevalence of contraceptive use is generally increasing, but 13-40 percent of women who say they do not want more children do not use family planning (Koblinsky, 1995, p. s30). Poor access to or use of contraceptives leaves women no other choice than to carry an unwanted pregnancy to term, which may expose them to the risk of complicated pregnancy and labor, or to undergo induced abortion, which may cost them their lives. If women have a choice to prolong the space between births, they are one step further towards decision-making in other areas of life (Wallace & Giri, 1990, p. xix).
Unfortunately, in many societies those who make decisions on how many children to have, on what family planning methods to use, are men, not women.

Women have little involvement in this decision. In Papua New Guinea and Niger, for example, women need their husbands permission to buy contraceptives. In Turkey, women are required to have their husbands consent to undergo a medical abortion (Eshen & Whittaker, 1993, pp. 109-110). The situation is the same in Nigeria: husbands decide about pregnancy and childbirth, including the choice of antenatal and delivery services.
Low socioeconomic status and poverty can lead women to another tragedy of the Third Worldprostitution, and thus, to a heightened risk for HIV and STDs. Tragically, prostitution becomes the only source of income for those who are rejected by their families (because of the belief that girls bring too many expenses and little contribution to the household) or single-mothers. The position of adolescent girls becoming the lovers of older married man in order to be supported is, from a health standpoint, no better. One study done among prostitutes revealed that the HIV seroactivity among prostitutes in Kenya has risen from zero in 1980 to 3.4 percent in 1981, to 61 percent in 1985, and to 88 percent in 1988 (Ngugi, 1991 cited in McDermott, Bansger, Ngugi, &
Sandvold, 1993, p. 93). These numbers are truly frightening, and reflect clearly the violence perpetrated on women by poverty and gender discrimination.
About 40 percent of women in the developing world give birth before reaching age 20, putting themselves at between 20-200 percent higher risk of

dying from pregnancy related causes than older women (Shen & Williamson, 1999, p. 199). Wall (1998) argues that young mothers don't have adequate knowledge of pregnancy and childbirth, they may not be courageous enough to ask these questions from older women, they do not go to seek antenatal care or to a hospital, and they are not freed from hard domestic labor (p. 350). In a study done in Nigeria, it was found that young women had a higher incidence of delay in Phases 1 and 2 (decision to seek care and reaching the hospital). Young mothers usually have a lower socioeconomic status, are more likely to be unmarried, are less educated, and are less likely to report complications (Okonofua, Abejide. & Makanjuola, 1992, pp. 321-323). Adolescent fertility becomes a social problem not only because the rates have declined much more slowly than overall rates, but also because it often occurs outside of marriage, leading to single motherhood and children with no fathers (Buvinic, 1998, p.
Women are subject to domestic violence. Violence against women is perhaps the most pervasive yet least recognized human rights abuse in the world (Heise, 1993, p. 171). The studies done on domestic abuse show a high percentage of wife abuse in different societies: from one third to three-fourth of wives are beaten by husbands or partners (Heise, 1993, p. 171). Dowry deaths, rape, and female circumcision are other examples of gender violence. Women do

not escape violence during their pregnancies. Violence may be responsible for some portion of maternal deaths, especially among young, unwed women. Beatings and forced illegal abortions of unwed mothers can result in a tragic outcome. One study done in Bangladesh revealed that homicide and suicide motivated by stigma over unwed pregnancy accounted for six percent of all maternal deaths between 1976 and 1986. The threat of violence may also result in the isolation of women and may also prevent women from seeking care.
Womens suffering doesn't begin with the pregnancy and childbearing. They are born to poor families, often to womenheads of households, they are fed inadequately, raised in unhealthy environments, forced into harsh domestic labor very early in their childhood, do not attend schools, do not have permanent employment, marry at a very young age and experience several pregnancies and births, often complicated, and are without adequate health services during and between pregnancies and births. The cycle is thus repeated and poverty passes to the next generation.
Cultural Factors. Unfortunately, many cultural factors, besides financial problems, poor development of infrastructure, long distance to travel, and poor quality of medical aid keep women from deciding to seek professional help. The recognition of the seriousness of a problem and the explanations given to causal

factors may vary across cultures and even among different social groups in a particular culture. Complications may be perceived as normal, or easily treatable situations may be considered as not amenable to treatment, or depending on the causes as treatable only by healers, shamans, etc., by other than medical personnel. For example, in some African cultures obstetric complications, such as obstructed labor, hemorrhage, and edema, may be viewed as not amenable to special medical care and are the consequence of disrespect to husband, woman's insubordination" and needs for apologies or confession, cleansing rites and traditional healers and diviners, rather than medical aid (Thaddeus & Maine,
1994, p. 1097).
A study done in a semi-urban community in Southern Nigeria observed that even though people know that hemorrhage can cause death, they do not go for help until the condition is critical, because they believe that hemorrhage is the cleansing of the body from bad blood (Okolocha et al., 1998, p. 293). Edema is explained as bad water or bad blood and does not require attention as a serious symptom, convulsions are explained as the result of witchcraft or infidelity and treated by herbal juices dropped into a womans nostrils and mouth (Okafor & Rizzuto, 1994, p. 356).
Another reason to delay the seeking of medical help might be a fear of being operated on. Women who have an obstructed labor do not want to go to

hospital because of fear that they will be operated on. Delivery by operation is viewed as a failure of womans reproductive role. Even the woman may prefer to deliver the baby all by herself to show her courage and gain respect (The Prevention of Maternal Mortality Network. 1992, pp. 283-284).
The dominance of male doctors in developing countries becomes another burden for poor women in cultures where examination by male physicians is considered inappropriate. The typical example is Egypt, where the majority of available doctors are male. The custom is, however, that women should not be seen by any male person, other than relatives, after puberty. Here, a woman needs her husbands or male guardian's permission to seek care, even in emergency situations, otherwise she and her family will be accused and shamed. In Islamic countries women prefer to die rather than be touched by male physicians (Timyan et al., 1993, p. 222).
A study in Nigeria showed how cultural traits and customs contribute to maternal morbidity and mortality. For example, the practice of wife-seclusion was argued to limit personal autonomy, taking away even the chance to seek medical care without the husbands permission. The day after marriage she is confined to her husbands compound, cut off from her family, and often subjected to abuse by her new relatives, particularly if she is the second wife of a man whose senior wife is now starting to feel displaced. And women, the young

wives, can feel dominated rather than supported by extended families of their husbands (Paltiel, 1993, p. 198). Wife-seclusion practices do not even allow women to engage in any form of marketing, to have own source of income. Only a husband can earn for the family. If he lacks funds, money must be borrowed from relatives (The Prevention of Maternal Mortality Network. 1992, p. 284).
Women in Islamic countries do not receive an equal share of inheritance, thus have less value, and are confined by virtue of their gender to particular tasks and places. This limits their ability to communicate with others outside the home. The main duty of women becomes bearing, delivering and raising children, because it is the only way to receive respect and honor (Wall, 1998, p. 342). There is evidence that 82 percent of pregnant women who died in Zaire lived within two kilometers of hospital with easy access to transportation and a good road. But they did not come to the hospital and died at home. This is direct evidence of ignorance of males who make the decision over female reproductive health (Wall, 1998, pp. 348-353). Women in those countries delay their first antenatal care visit until the second half of the pregnancy, because they may be ashamed of the will to deny their pregnancy (Timyan et al., 1993, p. 226).
There are beliefs that certain foods can harm both mother and fetus. To prevent miscarriage in many societies in Africa, Asia and Latin America, taboos are established on protective foods, containing vitamins and minerals. During

the final months of pregnancy foods for growth, containing protein, and energy producing foods, containing carbohydrates and fats, are forbidden. It has been argued that these taboos may prevent infant growth, and thus reduce risk for obstructed labor. It is believed that consuming those energy efficient foods will enlarge the fetus and make the labor difficult (Lefeber & Voorhoever, 1997, pp. 1177-1178). But in fact, taboos of energy efficient food may make the labor even more difficult.
Phase 2 Delays
If a woman finally decides to seek care, she must decide how to reach the facility, which may take several hours of traveling, or transportation may not be available at all. These are referred to as phase 2 delays. The scarcity of vehicles and poor road conditions together with bad weather can make traveling extremely difficult. Lack of cash for fuel or bus fares may mean not making a needed trip. Phase 2 delays are very common in remote rural areas. Besides becoming an obstacle to reaching the medical facility on time, these factors (long distance, high cost, scarce transportation) may keep women or their families from making a timely decision to seek care.
Most medical institutions in developing countries are located in urban areas. The lack of resources leads to the underdevelopment of regional hospitals

or health centers' networks in rural areas. For example, in a study done in the Syrian Arab Republic, 30 percent of all government and 19 percent of all private hospitals are located in the capital city, 65 percent of all health centers are located in urban areas, and one third of all national obstetricians practice in the capital city, too (Thaddeus & Maine, 1994, p. 1100). The centralization of facilities increases the travel distances for rural women.
The unavailability of transportation and poor roads are another major obstacle in developing countries. Women often reach health centers by walking and or being carried, and this may seriously impair their condition by the time of reaching a treatment facility. If the situation is not manageable at the closest health center, women must travel even farther, and the chance of dying along the way becomes even greater. The cost for transportation can be so high that a woman cannot afford it. If she or one of her family members finds somebody to give a ride, the gas may not be available.
Phase 3 Delays
Even if a woman reaches a health facility, economic constraints such as shortages of drugs and blood products, or the shortage of well-trained emergency medical personnel, not to mention the poor interaction of medical personnel with their patients, may be related to morbidity or mortality. The poor quality of care

becomes not only an obstacle to effective management of emergency situations, but also leads to dissatisfaction with care and the poor outcome of treatment may further influence to the refusal to come to the health facility the next time (may contribute to Phase 1 delays) (Thaddeus & Maine, 1994, p. 1095). Women communicate this information to their kin and peers. People would not bother themselves to go to hospital when they know that the problem will not be cured or that they may die on the way or in the hospital.
Unfamiliar environments, clothes, food, position at delivery, and use of a different language may make women feel uncomfortable, neglected and, therefore, influence treatment outcome. In some countries, patients are often required to pay the donor for blood, find infusion sets, sutures and drugs by themselves, and wait hours even for emergency operations (The Prevention of Maternal Mortality Network. 1992, pp. 288-289). Often women have to bring drugs, IV solutions and sets, soap, and gloves with them into the hospital (Okafor & Rizzuto, 1994, p. 357).
And adequately trained professional may be not available at the time a woman arrives at the hospital. The shortage of doctors or midwives who can handle emergency situations is very common in developing countries, particularly in remote areas. A great deal of time may be spent trying to find a doctor or to wait until a doctor comes from another emergency call. Or if they are

available, misdiagnosis and incorrect actions may reduce the chances for survival. Phase 3 delays have been identified as the cause of a majority of mortality cases in several countries. For example, a study done in Mexico of 240 maternal deaths concluded that poor management of situations was responsible for 70 percent of deaths (Barnes-Josiah. Myntti, & Augustin, 1998, pp. 987, 991).
Centralization of services, or poor service quality of health facilities in remote areas, make women travel from one facility to another, spending much time and increasing the chance of mortality twelve times (Ganatra et al., 1998, p. 597). The situation that women often face is characterized by the four toos too far from home, too few trained birth-attendants, too poorly equipped to handle complications, and too deficient in quality care (Jacobson, 1993, p. 21).
The interaction between health care givers and pregnant and delivering women is equally important to taking timely, prompt, and adequate measures. Often the rude, negligent attitude and poor interpersonal relations of care providers to mothers leads to poor information exchange, noncompliance of women to their advice, dissatisfaction with the services and discontinuity of care. All of these factors will affect the quality of care.
The organization of maternal care facilities and the efficient management of emergency situations at the facility is the most important factor in reducing

3rd level delays (Thaddeus & Maine, 1994, p. 1091; Bames-Josiah et al., 1998,
p. 981).
What Has Been Done
Many different factors, both sociocultural and economic/developmental, cause delays in different levels of decision-making and health care. Changes in these factors should contribute significantly to the reduction of maternal mortality in developing countries. Some changes may be difficult to achieve because they demand large investments of resources and time, for example, the enhancement of women's socioeconomic status, the improvement of roads and decentralization of services, and improving the quality of first-level obstetric care. But some inexpensive measures can be taken. Several policies have been applied to reduce the traveling difficulties women face to seek medical help and to bring adequate medical aid closer to women. Some of these attempts have been the involvement of traditional birth attendants (TBAs) in the management of obstetric complications and referral, involvement of women in antenatal care, and the organization of maternity waiting homes.

Traditional Birth Attendants
In the last two decades there was a policy of using TBAs in developing countries to reduce maternal mortality. In terms of information exchange and interpersonal relations, the service of TBAs is considered to be most traditional and therefore more comfortable for women. However, TBAs are also criticized by women as having inadequate knowledge and training, using unsterile equipment, and delaying referral to hospitals. Still, TBAs may be preferred because, as discussed, maternity centers and hospitals have trained personnel and can give an efficient service, but may lack supplies, are too expensive, negligent and hostile to women (Okafor & Rizzuto, 1994, p. 358).
Thus, training of TBAs to deliver essential obstetric care seemed to be the solution to the problem of high maternal mortality in developing countries. It was believed that because TBAs share the same cultural understandings of pregnancy and childbirth as their clients, they thus have the respect and belief of the indigenous people, and are nearly always available. And the training of TBAs in the better handling of emergency situations may contribute significantly to the reduction of MMR, especially in rural areas where cultural values and poor infrastructure keep women away from seeking care in heath facilities. But the conflict between TBAs and Western-trained midwives has been an obstacle to efficient referrals and better outcomes (Okafor & Rizzuto, 1994, p. 359).

Many studies done on this topic reveal a competition between traditional and biomedical care providers. Medically trained midwives in Nigeria find the use of TBAs services beneficial because the latter are accessible, can be the most important source of women's cognitive knowledge and can reduce midwives' work, but are critical of the poor sanitary conditions of TBAs' practice, poor training and knowledge, unwillingness to refer high-risk cases and spreading negative rumors about hospitals and midwives' work. In the contrast. TBAs evaluate midwives as rude to women, not always available and disrespectful to TBAs. They also believe that hospitals are too far away, expensive, have no drugs and supplies, delay treatment and only perform surgeries, although they positively evaluate hospitals ability to take measures in critical, advanced situations (Okafor & Rizzuto, 1994, p. 359).
Clearly, TBAs should be taught what to do in emergency situations, and when to refer women to hospitals. However, their experiences vary from one place to another, from one person to another; all of them have different views on pregnancy and childbirth based on the differences of the local culture. It is difficult to teach them modern obstetrics because, according to one group, "we do not know what TBAs ought to be taught (Brouwere, Tonglet. & Lerberghe, 1998, p. 778). Because of these problems, it has been argued that it would be most useful if the money spent on TBAs would go into the training of young new

midwives, who are more willing to follow what they have been taught (Brouwere. Tonglet, & Lerberghe, 1998. p. 778. Jordan & Davis-Floyd. 1993).
Antenatal Care
Opinions about the role of antenatal care in the reducing of maternal mortality is mixed. Bernis et al. (2000) argue that antenatal care has no effect on maternal mortality; it is the effective management of obstetric situations by qualified personnel during the delivery that is important (p. 68). Antenatal screening is reported as having low predictive value for mortality: in this study its sensitivity is 30 percent and specificity is 90 percent (Brouwere et al., 1998, p. 777). Routine measurements of blood pressure, weight, anemia and proteinuria appear to have low predictive power with regard to life-threatening complications: -blood pressure screening found that 30 percent of cases were not detected and 13.5 percent of women falling into the high-risk group for pre-eclampsia were false positives;
-80 percent of women with edema can be normotensive;
-the testing for proteinuria found 25 percent false positives and six percent false negatives (proteinuria is indicative in the later period of preeclampsia); such a low predictive power of screening may produce more stress and costs to women than is necessary;

-screening of risk factors associated with obstructed labor and hemorrhage is sensitive for only 29-41 percent of cases; and,
-none of these measures can predict deaths associated with sepsis and abortion (McDonagh, 1996, pp. 4-8).
However, there is also evidence that suggests the effectiveness of antenatal care in the reduction of maternal deaths. Research done in Zaire found a 17-fold reduction of MMR as the result of antenatal care. The same positive effect was found in a project done in Vietnam (McDonagh. 1996, p. 8). In a study conducted in Hausaland, Nigeria, it was concluded that 92 percent of 238 deaths occurred among women who had not been involved in antenatal care (Wall,
1998, p. 342). Garenne et al. (1997) noted that even a single visit to an antenatal clinic made a difference (p. 19). Unfortunately, women who definitely need antenatal care are less likely to use such services. They are often blamed for non-compliance with prenatal care without considering the underlying socioeconomic circumstances (Krieger et al., 1993, p. 89).
Rutter and Quine (1990) report that antenatal care introduced in earlier stages of pregnancy has a definite impact on the reduction of pre-eclampsia and eclamplsia. anemia, nutritional deficiencies, treatment of infections of reproductive organs, and in the treatment of malaria and helminths. These treatments have been shown to increase the chance for survival from

hemorrhage, sepsis and obstructed labor. Early routine procedures can predict the chance of developing preeclampsia and eclampsia in the majority of cases, which makes the outcome positive. Furthermore, maternal education during antenatal classes reduces the stress and increases the effectiveness of mother's coping behavior (p. 559).
Obviously the impact of antenatal care in the reduction of maternal deaths depends on its role. The antenatal clinics should be the place where women can get necessary information about pregnancy and childbirth, can learn about potentially dangerous symptoms, can be treated for existing diseases, and can learn about family planning. The functions of antenatal care may become very important for women in developing countries, where antenatal visits may possibly be the only source of gaining knowledge, relieving stress and accepting healthy behaviors.
Maternity Waiting Shelters
From 60 to 90 percent of the population in developing countries live in rural remote areas. Most medical institutions are concentrated in urban areas (Stokoe, 1991, p. 12). In this situation maternity waiting homes can be an effective method to reduce delays occurring at all levels. These are the places where women with high risks or those who live in remote areas spend their last two to

four weeks before their term under the supervision of medical personnel. Maternity waiting homes are found in some parts of developing countries: Uganda, Nigeria, Malawi, Ethiopia, but because of the economic abilities of those countries, they have not spread throughout the areas. And there is no study so far to evaluate the role of maternity waiting homes on maternal mortality from complications (Thaddeus & Maine, 1994, p. 1106).
The effectiveness of these homes much depends on management, community involvement, the presence of trained staff, accessibility, educational and other support programs. The homes become the bridge between the primary caregivers who refer women of the risk groups to maternity waiting homes and the hospital to which women are referred on time. The correlation of work between medical staff and TBAs is crucial in the areas with an inadequate number of community midwives and where TBAs are the most available professionals. The organization of waiting homes does not require an advanced technology, only tools measuring blood pressure, height, and weight, mats, books, posters and something for women to spend time on, like sewing machines (Figa-Talamanca, 1996, pp. 1383-1387).
But maternity waiting homes (MWHs) are not the solution to the centralization of obstetric care in developing countries. They are not the places where pregnancy and childbirth complications could be taken care of. Still the

availability of reliable transportation by waiting homes, the experience and quality of professionals working there, and the distance to the hospital are important factors in the effectiveness of MWHs.
Family Planning
The use of family planning can contribute enormously to the reduction of maternal mortality in developing countries. Family planning can reduce maternal mortality in three ways:
1. Women can avoid pregnancy, thus the pregnancy and childbirth complications.
2. They will not have to choose between induced abortion and an unwanted birth.
3. Women can reduce their overall fertility though spacing births and avoiding pregnancy in high risk (teenagers and post-3 5-years periods).
Twenty five to fifty percent of all maternal deaths occur as the result of unsafe abortions worldwide, besides those abortions indirectly may influence the risk of dying from pregnancy and childbirth complications. They increase the risk of placenta praevia, unawareness of which leads to massive hemorrhage; they increase the risk of miscarriage, which also can cause hemorrhage; they increase

the risk of hemorrhage from delayed placenta birth and weakened contraction of uterus muscles. So. the impact of family planning, by preventing abortions, may be greater than 25-50 percent. The indirect role of abortions in maternal deaths in later pregnancies cannot be clearly estimated.
But the introduction of family planning methods should be sensitive to the need of women in a particular society, where cultural norms do not allow the practice of family planning entirely or particularly. Otherwise, its effectiveness may be reduced. For example, in some cultures where young brides are supposed to produce the first born by the first anniversary of the marriage, the risk of these young women of dying during pregnancy or childbirth will not be reduced, unless this cultural norm is changed (Stokoe, 1991, p. 14).
Summary of the Most Relevant Questions
A womens health is her total well-being, not determined solely by biological factors and reproduction, but also the effects of work load, nutrition, stress, war and migration, among others (van der Kwaak cited in Koblinsky et al., 1993, p. 33).
Safe motherhood [encompasses] more than ...the causes and consequences of maternal illness and death... improvements [are also needed] in womens overall status and improvements in the health services that are key

component of primary health care and that womenparticularly pregnant womenneed. (Starrs, 1987, p.22; cited in Koblinsky, Campbell. & Harlow, 1993, p. 35).
The issue of maternal health is very broad and does not only concern the specific risks for mortality and poor health outcomes. It is more generally an issue of human development, gender equality and intrinsic human rights, not to mention the overall socioeconomic development of a country. This thesis focuses primarily on maternal deaths in relation to many different socioeconomic and cultural factors, but women's health deserves much broader scholarly discourse and attention and concern from every community, or from every organization, including both governmental and non-governmental. It is not an issue relevant to a single woman, it is relevant for the future well-being of her siblings, of her family and of her community.
Half a million women die per year worldwide from pregnancy and childbirth complications, 99 percent of whom in developing countries. They die at home without the attendance of professional help, they die on the way from home to the health provider, and they die at the hospital without adequate treatment and care. In order to get medical help, families must balance the time lost in domestic labor and child care, the costs of transportation, services, meals, bribes and fees, and the emotional stresses of travel, with [what they see as] the

dubious benefits of unproven care in order to seek medical aid (Barnes-Josiah et al.. 1998, p. 987). They are mostly poor women from families on the edge of survival, mothers of many children, secluded from the outside world and abused by their husbands/partners. Unless a woman's low status is changed, they will not consider their own health as sufficiently important to bother with antenatal care and unnecessary treatments (Stokoe, 1991, p. 13). In this situation, blaming these poor women for their delays seeking help, or for their late arrival at the hospital, or for their noncompliance with given advice and treatment, is too cruel and unfair. Late referrals to professionals' aid are a major contributing factor. Unfortunately, the deaths of women in a high-risk group are often referred to as women's noncompliance (Sundari, 1992, p. 514).
The family, the community, the government, and the global world economic system all play a role in the health of these women. The victim-blaming model, which in many circles remains dominant, does not offer any alternatives and has thus been proven to be ineffective (Hilderbrandt, 1994, p. 248). It neglects economic, social, and cultural determinants of health and illness. The ecological model that views health as affected by several factors such as access to health care services, human biology, social and physical environment and personal life-styles and behavior is more beneficial (Wright, 1993, p. 2546).

Today we have a lot of experience from different communities and countries in the developing world, successfully implementing new policies to reduce maternal mortality. But each community needs a sensitive approach, taking into account its particular combination of factors that contribute to maternal mortality.
In recent years the community approach to maternal health has been given more attention by international health policy-makers. It promises a more successful outcome, since an individuals efforts to modify her own health practices or beliefs are often inhibited by social, cultural and economic constraints. Because the bonds linking individuals or families in a small community are strong, any changes made at this level have a great potential to make a difference. When people listen to each other, identify their commonalities, and together construct new policies of change and evaluate services so that they respond to local needs, it increases the community members' solidarity, responsibility for each others health, and the effectiveness of the change. The empowerment of community is important: control, capacity, coherence, connectedness and critical thinking of conscientization, and not a commodity are the key elements to make a change in a group (Labonte, 1994, pp. 260-261). Without community participation in decision-making around the problem, policy changes cannot contribute to community empowerment.

Community empowerment should focus on both community and individual change (Wallerstein & Bernstein. 1994. p. 142).
Communities possess both a physical and a social environment (poverty, social inequality, gender inequality, social cohesion, cultural norms). Both of these environments are under the influence of cultural and political system, and economic development. Community responses to a problem solution reflect the changes in both of these environments (Patrick & Wickizer. 1995. p. 67).
Both the government's and the communitys role is important in health promotion. Community education about pregnancy-and childbirth-related complications, training of health volunteers, reduction of women's disproportionate poverty and enhancement of womens status, creation of a communal fund for emergency situations, establishment of access to family planning servicesthese are the interventions easily done at the community level. For example, the effective organization of the Bamako project allows women to have essential drugs all the time for a less expensive price. Empowerment of women by providing them with a small amount of resources, so that they could increase them and have their own funds can also bring positive results. Inexpensive measures to reduce travel distance to health services also could be done: organizing MWH and provision of basic services at the community level

by midwife or by trained TBA if the former is not available (Thaddeus & Maine, 1994, p. 1106).
On the other hand, the role of government in the distribution and financing of medical care may be dominant (Thaddeus & Maine, 1994. p. 1105). Poverty can be reduced, if not eliminated, only through well thought-out government policy. Success in reducing poverty requires two equally important strategies: promoting the use of the most important asset of the poortheir labor--and increasing their human capital through access to basic health care, education and nutrition (World Bank, 1993, pp. 54-55).
The implementation of national health insurance, covering pregnancy and childbirth can be implemented only by government policy. Or the supplying of hospitals with essential drugs, equipment and personnel is also an issue concerning governments funding and ability. Free education including sex education, legalization of abortion, and distribution of family planning materials and information can be implemented successfully if the governments role is dominant. It is the government that must be willing and able. It is the governments policy to choose the most appropriate model of health care for the country.
Koblinsky, Campbell and Heichelheim (1999) review four models of maternal care existing worldwide:

Model 1: Home deliveries with the assistance of family member or traditional birth attendants take place in developing countries with high MMR (e.g. China, Brazil).
Model 2: Home deliveries that take place with the assistance of professionals (trained midwives and nurses), who provide antenatal and postnatal care, risk screening, referral, family planning and child care services, and result in an MMR that is significantly lower (e.g., Malaysia (in the 1970s). the Netherlands).
Model 3: Delivery by a professional in a basic essential obstetric care facility, requiring free transportation and services, resulting in an MMR is lower (e.g.. Malaysia (mid 1980's to 1990's), Sri Lanka). Under this model, emergency obstetric care units are organized throughout the country and are provided with surgical facilities.
Model 4: Delivery by a professional in comprehensive essential obstetric care facilities, not necessarily a guarantee of high quality of service and low MMR (pp.400-401) (e.g., UK, USA, Mexico City).
Model 1 is argued to be the least effective way to reduce the occurrence of maternal deaths, but it is the only model available to many developing countries. For this model to succeed it is important to initiate cooperation between TBAs and medical personnel in order to increase the numbers of

referrals from TBAs to medical professionals and reduce possible delays, which can cost the womans life, to promote the quality of TBAs care, and to increase the quality of care by medical workers. TBAs deliver at least two thirds of all babies in Africa, Asia and Latin America (Lefeber & Voorhoever, 1997, p.
1175). Work done in Mexico revealed that more than half of all rural women rely on traditional midwives, basically those who live in remote areas and have lower education. In such a context, use of traditional midwives' resources, giving them training and support, becomes very important and realistic where there are no resources to build modern facilities or to support them with medical professionals (Parra, 1993, p. 1326).
Model 2 is an effective system to provide the population with medical assistance. Here again, the potential conflict between traditional and biomedical care providers needs to be addressed. This system requires an intensive network of care in rural areas, referral support, provision of essential drugs, and reliable transport factors out of reach for most developing countries.
The transition to the more advanced Models 3 and 4 requires substantial financial investments and broad community participation. The most advanced model (Model 4) does not necessarily guarantee a low MMR (e.g., Mexico City). Most countries have or are in the process of developing a mixed model of obstetric care, depending on the cultural factors, economy, infrastructure,

community participation, level of development or preference of medical care system. Effectively organized Model 2 care can reduce MMR to the lowest level, while ineffective, too expensive, uncomfortably organized Model 4 cannot always promise beneficial results (Koblinsky et al., 1999). The implementation of a model sensitive to the existing circumstances is important in increasing the access of women to medical aid and in enhancing its quality. But the role of primary health care should not be neglected. If the public policy in health is effective, it leads to better health outcomes, greater equity, more consumer satisfaction, and lower cost.

After seven decades of socialism Mongolia ten years ago chose the path of sudden political and economic changes, resulting in a painful and difficult period on the way to democracy and a market-based economy. The socialist system emphasized three idealsequality, brotherhood, and cooperationwhich had many positive impacts on Mongolians' lives, but many felt that it repressed creative thinking and democracy, and created huge bureaucracy, that controlled every aspect of human life. Freedom of speech and of political and social life was limited. The rapid transition to a market economy has brought many benefits to freedom and human rights, but led to rapid declines in the standard of living and of social services such as education and health care. This reduced many Mongolians to poverty and future insecurity.
Following the break of socialist system in Eastern Europe, aid from former Soviet Union and other socialist countries dropped suddenly, which contributed to 30 percent decrease of GDP in Mongolia. Because they relied on imported energy supplies, the poorly-developed industries were shut down. The same condition was faced in agriculture. In order to respond to this extremely

difficult situation, industries and farms were privatized, but they were not well-
prepared for privatization. Industries and farms were divided into many small parts, which were financially untenable. Between 1990 and 1993, the industrial production dropped by one-fifth and in agriculture by one-third (Human Development Report, 2000, p. 9). Closed industries and farms left a large number of unemployed, increasing the unemployment rate to 8.7 percent by 1994. Before 1990 unemployment was almost unheard of. At the same time crime, violence, and alcohol consumption increased noticeably. The government, which was close to exhausting its budget, was unable to intervene. The informal economy was the only way for people to survive (small-scale trade between Russia, China and Mongolia, small private shops, restaurants, hair salon, cleaners, hospitals for outpatient exams and treatment, trade of animal products from rural areas to cities).
As a consequence of reduced GDP, the budget for public services was cut. This had a huge impact in health care services and education. The expenditure for health care was cut to 3.3 percent of GDP in comparison with 5.8 percent in 1991.With few available drugs and supplies, with little tolerance to work in unheated hospital buildings, and with no more patience to wait for delayed salary, many doctors and nurses left the state-run hospitals to work in private hospitals.

Investment in education fell twice during the 1990-98 period. Schools did not have enough teachers, because they had left their jobs for opportunities in the informal economy. Children dropped out of school in order to help their parents with living expenses. Enrollment of children aged 8-15 in schools fell from 98 percent in 1990 to 87 percent in 1998. Lacking encouragement and government financing, the quality of training in schools and colleges has become extremely poor.
For many people the changes opened new economic opportunities, but for others they have caused huge and painful consequences.
Mongolia has an extensive health care system based on the Russian model. There are approximately 750 hospital beds and 240 physicians per 100,000 population (120 midwives/feldshers and 300 nurses). Although the number of physicians and the number of beds are high, their distribution is unequal, with many facilities concentrated in Ulaanbaatar (the capital city).
Health services are provided in four levels and shown in Table 3.1 (Janes, 2000, p. 44).

Level of care Type of care Number
Level 1 Bhag Feldsher posts 875
Level 2 Soum Soum hospitals 345
Level 3 Aimag and City Aimag and City hospitals 33
Level 4 Central Specialized centers in Ulaanbaatar 11
Table 3.1. Levels of Health Services in Mongolia (1998).
At the first level are family doctors in urban areas and bhag feldshers in rural areas, who are responsible for approximately 1200-1500 and 500-1000 people respectively. Their main duties are periodic screening of families, especially those who have children under 5 years and older people, treatment of simple disorders, immunization, health education, referral of serious illness episodes to appropriate level facilities, and identification of pregnant women, who they refer to second level service.
The second level of health services are held by soum hospitals in rural areas and public health centers in cities and 'aimag centers. Each soum has one to three family doctors, one feldsher and/or one midwife, a few nurses, and occasionally one obstetrician and one pediatrician. Each soum hospital provides care for 2500-6000 people within an 80 to 120 km radius, and has 15-30 beds and a delivery room. The services include inpatient and outpatient diagnosis and treatment of common diseases, prenatal and postnatal care, normal deliveries, family planning, health education, and transport of referral cases to aimag

hospitals. Public health services in cities and aimag centers have both family doctors and specialists, such as ob/gyns, pediatricians, surgeons, ophthalmologists, and otolaryngologists, who are assisted by nurses and supported by basic laboratory equipment. They provide only outpatient care and refer the necessary cases to the next level facilities.
The third level of health services includes general hospitals in aimag centers and district hospitals. The fourth level of health services is general and specialized hospitals or centers in Ulaanbaatar.
The health system before 1992 was mostly maintained for curative purposes, and emphasized the training of clinical doctors and nurses, and the implementation of technology. Little attention was given to public health. Since 1992 the government has increasingly emphasized preventive care over curative services and has promoted a shift from hospital-centered medicine to primary care by general practitioners. Infectious disease control health measures have become very important since poor people in difficult living conditions have increased risk of morbidity and mortality from infectious diseases.
The Ministry of Health and Social Welfare accepted the idea of primary health care in 1992 as the major scheme for the health system development in Mongolia, but its implementation is weak and presently has little effect at the community level. The programs and projects of the Ministry of Health and Social

Welfare are not sensitive to the socio-cultural and economic needs of communities, and this could be partially explained by the lack of trained specialists and experience. The government also supports private sector health services, which can lighten its own burden, at least for those who can afford it. But for maternal health care the private sector does not offer much: many private hospitals were established in the last five to six years mostly in urban areas and focus on treatment of gynecological diseases and on abortions, while the main role for prenatal care, delivery and postnatal service are left to state hospitals and facilities.
The implementation of national health insurance policy that ostensibly covers all members of the society without differentiation in their incomes has in fact resulted in a number of people who cannot pay the insurance fee and are often refused treatment. Many of those who can easily afford private hospital services or comparatively high fees benefit from the plan. However, poor families, unemployed, and migrants are at especially high risk of losing or not having coverage. Currently around 90 percent of the total population is enrolled in the national health insurance scheme. The government is supposed to pay for children under age 16, pregnant women, and elderly.
There have been some achievements in the general health of the population during the last ten years. The life expectancy increased from 63.7 in

1990 to 65.1 in 1998; the infant mortality rate (IMR) was significantly reduced as a result of the tendency of women to have fewer children (on average 2.3 children for a single woman) and a greater effort to ensure children's survival, and a high rate of immunization and breastfeeding. UNICEF- and WHO-sponsored programs to prevent and treat diarrhea and acute respiratory infections have had a large impact, reducing IMR almost two times during the period from 1990 to 1998 (Health Indicators, 1999).
Since 1992 the method of estimating MMR in Mongolia has been changed to the same method followed worldwide. Before this time deaths due to abortion, miscarriage and ectopic pregnancy were not considered as maternal mortality cases.
Mongolia, with only 2.5 million total population, has been pursuing the policy to encourage birth during the socialist regime. But in the last decade the birth rate has been significantly decreased as a consequence of the current economic crisis and resulting social instability. Lacking the high allowances and support for mothers of large families from the old government and facing financial difficulties, it has become difficult for households to support many children. The wider use of family planning methods and the liberalization of abortion have also contributed to a decrease in the birth rate (Figure 3.1.). The prevalence of induced abortion is high: 17.4 percent of pregnancies end in

medical abortion (Health Indicators, 1999, p. 67). Thus, the birth rate has
decreased almost two times in the last ten years, whereas maternal mortality ratio has increased. Because it is a sensitive indicator of womens well-being, social status and equity, this high rate of avoidable deaths cannot be ignored, since 27 percent of the total population of Mongolia is women of reproductive age (Figure 3.1).
Source: Health Indicators, 1999.
Figure 3.1. Population Birth Rate, Mortality Rate and Growth Rate.
With the support of WHO, UNICEF, and UNDP, some projects on nutritionsuch as iodine and iron supplements, family planning methods, supply

of essential drugs and traveling facilities, and training of midwives and doctors to emergency obstetric situationswere launched under the country-wide Safe Motherhood initiations (following the worldwide initiation of Safe Motherhood Project), but the results are not satisfactory, and MMR has increased over the last two years.
Risk factors for maternal mortality in Mongolia are well understood, and maternal age, parity, space between births, and the general health status of women are considered to be the most common risk factors of maternal deaths. Also financial capability, educational level, occupation and status of women in the family are mentioned to be the social factors contributing to maternal health, since it is usually poor herdswomen or blue-collar workers, mothers of big families or often heads of households, women with low educational levels, wives of abusive and alcohol-addicted men, who die during pregnancy and childbirth. But how these social factors contribute to maternal deaths in Mongolia have not been studied at all. In addition, the social, cultural, psychological and economic consequences of maternal death in Mongolia are not understood.

What is the structure of maternal mortality in Mongolia?
~ The MMR rose sharply after 1992 and has not decreased significantly (Fig. 3.2.).
Source: The l^iriistry"Heath aTid Social Welfare"
Figure 3.2. Maternal Mortality Ratio, 1988-1999 (per 100,000LB).
~ The MMR is consistently high in the Western aimags such as Bayan-Ulgii, Khovd. Zavkhan and in one central aimagArkhangai.
~ The majority of births take place in hospitals (98.8 percent or 50,708 births in 1999), and the rate of home births is relatively low (1.2 percent

or 615 births in 1999), but half of the latter were not attended by medical professionals.
~ From all home births 82.3 percent ended in a tragic outcome due to the long distances and the inability to get medical help during delivery (Demberelsuren & Dorjpurev, 2000, p. 16). (Those giving birth at home are often women who go into pre-term labor, and are at high risk of complications.)
~ In the previous years hemorrhage was the major cause of maternal death, but in the last few years the prevalence of indirect causes presented by extragenital diseases is increasing. Direct obstetric complications during pregnancy (30 percent), during labor (17.7 percent) and after the childbirth (10 percent) are responsible for 57.7 percent of all deaths that occurred in 1999, whereas in 42.2 percent of the extragenital diseases led to mortality (Health Indicators, 1999, p. 4).
~ From the analysis done on all maternal mortality cases in the period 1996-1998, 82.5 percent of women were living in remote areas, 40 percent gave birth at soum hospitals and 9.8 percent gave birth at home (Demberelsuren & Dorjpurev, 2000, p. 20).
~ The possible causes of maternal death were reported by the Ministry of Health and Social Welfare as due to poor antenatal care (in 39.4 percent),

poor quality of medical aid (21.5 percent), and late referral to medical help (13.3 percent) (Demberelsuren & Dorjpurev, 2000, p. 29).
~ The risk of dying due to pregnancy and childbirth is high for primigravids and for women who have had multiple episodes of pregnancy and birth: 26.2 percent of the women who died in the period 1996-1998 died during or after their first pregnancy, and 37 percent had four or more pregnancies (together these contribute to more than half of all maternal mortality) (Demberelsuren & Dorjpurev, 2000. p. 46).
The general health of women of reproductive age in Mongolia is considered to be poor. However, there are no data at the community level estimating general health indicators among women of reproductive age. But the fact that 42.2 percent of all maternal mortality cases in 1999 occurred due to extragenital diseases implies that the general level of health in women is very poor (Health Indicators, 1999, p. 85). According to the statistics, half of all pregnancies have complications before, during and after delivery. The prevalence of anemia and urinary tract infections is quite high: 46.6 percent of all pregnant women have anemia and 32 percent of them have urinary tract infections (Udval,
2000, p.6).

Quantitative analysis
The following descriptive analysis was done on 157 cases of maternal mortality in the years 1996 and 1997 across the country, excluding Ulaanbaatar. The available information consisted of data including age of a woman, number of pregnancies and births, number of family members, family income, womans occupation, educational level, involvement in antenatal care, existing diseases, pregnancy complications, place of death, reasons of death, pregnancy term at death and days spent in a hospital.
The basic descriptive analysis of this data allows to understand the general picture of maternal deaths occurring in rural areas: Who are at the high risk of dying during the pregnancy and childbirth? Does the socioeconomic status of women affect pregnancy outcome? What is the general health status of women? And what is the role of the phases of the three delays framework, developed by Thaddeus and Maine (1992), in maternal death (p. 1091)? Since the records are kept in aimag hospitals and only the above-mentioned short records

are sent to Ulaanbaatar, the accurate follow-up of the process is not available in all cases, and the distinction of three phases of delays becomes blurred.
The young mothers experiencing their first pregnancies at their early twenties or even before their twenties and mothers over 35 years old, who have had several episodes of pregnancy and childbirth are at greater risk of dying during the pregnancy and childbirth. This situation is sometimes called the "bell curve. Twenty-eight percent of women out of the 157 were experiencing their first pregnancies and first births. Approximately 30 percent of women, who died, aged 35 and over and had more than four births. The numbers are shown in the Tables 4.1 and 4.3.
Age categories Frequency Percent
Valid under 20 21 13.4
21-25 44 28.0
26-30 32 20.4
31-35 17 10.8
36-40 33 21.0
41-45 8 5.1
Total 155 98.7
Missing 2 1.3
Total 157 100.0
Table 4.1. Age Categories of Maternal Mortality Cases.

Number of pregnancies Frequency Percent
Valid 1-3 86 54.8
4-6 57 36.3
7-9 11 7.0
10 and over 2 1.3
Total 156 99.4
Missing 1 0.6
Total 157 100.0
Table 4.2. Pregnancy Numbers.
Number of births Frequency Percent
Valid 1-3 107 68.2
4-6 39 24.8
7-9 7 4.5
10 and over 1 .6
Total 154 98.1
Missing 3 1.9
Total 157 100.0
Table 4.3. Birth Numbers.
Weeks of pregnancies Frequency Percent
Valid 37-43 74 47.1
29-36 43 27.4
13-28 25 15.9
1-12 4 2.6
Missing 1 1 7.0
Total 157 100.0
Table 4.4. Pregnancy Term.
The majority of women had elementary or secondary education (82.8 percent), were married (82.8 percent) and had an average living standard (49 percent). The number of women with college education among the cases is few

(Tables 4.5, 4.6, 4.7). The criteria of life quality may be subjective, since there is no standardized measurement of living standards in Mongolia, and the given results are based on the womens comparison of their lives w ith others.
Educational level Frequency Percent
Valid college 6 3.8
secondary 85 54.8
elementary 44 28.0
no education 15 9.6
Missing 7 4.5
Total 157 100.0
Table 4.5. Educational Level.
Frequency Percent
Valid married 130 82.8
unwed 14 9.6
divorced 6 3.8
Missing 6 3.8
Total 157 100.0
Table 4.6. Marital Status.

Frequency Percent
Valid average 77 49.0
poor 26 16.6
below average 24 15.3
rich 4 2.5
very poor 2 1.3
Missing 24 15.3
Total 157 100.0
Table 4.7. Life Quality.
Herdswomen and housewives together count for 76.1 percent of deaths in comparison to less than 10 percent of deaths for office workers (Table 4.8).
Frequency Percent
Valid herdswomen 84 53.2
housewife 36 22.9
blue-collar 20 12.7
office worker 10 6.4
student 2 1.3
Missing 5 3.2
Total 157 100.0
Table 4.8. Occupational Status.
The general health status of women appears to be poor. The majority of women had chronic diseases and pregnancy complications both related to and not related to previously existing diseases. Only 21.65 percent of all women were considered to be healthy, did not have the history of chronic disorders and did not have complaints during the pregnancy. In 11 cases (7 percent) there was no data on morbidity. In 71 percent of cases women had some kind of disorders: organ

and system diseases or pregnancy complications, in some cases several disorders of organs and systems and pregnancy pathologies were combined in a single woman. Table 4.9 shows the prevalence of organ and system diseases, and Table 4.10 gives the prevalence of pregnancy complications. The prevalence of pyelonephritis and anemia is the highest, but the rate of anemia is lower than the estimated prevalence among women in reproductive age, which is approximately 40 percent. It can be possibly explained by the lack of laboratory tests in the most of maternal mortality cases to prove the existence of anemia. The organ and system diseases increase the risk of certain obstetric complications and in some cases can become the direct cause of maternal mortality. For example, hypertonic disease, chronic liver diseases, chronic coagulopatia may increase the chance of hemorrhage, and anemia reduces the ability of bodys compensatory mechanisms against severe hemorrhage. Another example might be kidney diseases, such as pyelonephritis, nephritis, hydronephrosis, which make pre-eclampsia cases severe and intolerant to treatment, resulting in eclampsia and death from stroke.

Diseases Frequency Percent
Pyelonephritis 44 28.03
Anemia 19 12.10
Pneumonia 7 4.45
Reumocarditis 6 3.82
Hypertonic disease 5 3.18
Tuberculosis 5 3.18
Acute viral hepatitis 4 2.55
Liver cirrhosis 4 2.55
ARVI 3 1.91
Gastroentherocolitis 'j J) 1.91
Nephritis -> 1.91
Ulcer of intestines 'y 1.91
Chronic bronchitis 2 1.27
Chronic coagulopatia 2 1.27
Cholecystitis 2 1.27
Mental disorders 2 1.27
Asthma 1 0.64
Brain vassal pathology 1 0.64
Chronic hepatitis 1 0.64
Goitre 1 0.64
Hepatosis gravidarum 1 0.64
Hydronephrosis 1 0.64
Leucemia 1 0.64
Miocarditis 1 0.64
Obstruction of intestines 1 0.64
Osteomyelitis 1 0.64
Vit. C deficiency 1 0.64
No morbidity 35 22.0
Table 4.9. Morbidity Prevalence.
Pregnancy complications Frequency Percent
Preeclampsia 64 40.76
Miscarriage 5 3.19
Weakened labor force 6 3.18
Placenta praevia 4 2.55
Real fixation of placenta 2 1.27
Toxicosis gravidarum 1 0.64
Table 4.10. Pregnancy Complications.

The direct causes of maternal mortality are shown in Table 4.11. Hemorrhage is the leading cause of maternal death, accounting for 35.03 percent of the cases. The majority of hemorrhaging takes place after birth, in earlier postpartum period (within two hours after birth). The second leading cause of maternal mortality becomes extragenital diseases, which count for 28 percent of cases. It is mostly the diseases of cardiovascular and respiratory systems, acute and chronic hepatitis, acute surgical pathologies of organs of abdominal cavity, and tuberculosis, the prevalence of which has been increasing in recent years among the causes of maternal mortality. Pre-eclampsia and eclampsia, the third leading cause of maternal death, is responsible for 23.57 percent of deaths, the majority of which takes place prior to the labor.

Causes Frequency Percent
Hemorrhage Prepartum 14 8.92
Placenta abruptio 12
Placenta praevia 2
Interpartum 6 3.82
Uterus rupture 6
Postpartum 30 19.11
Hypotonic hemorrhage 21
Delay of placenta birth 4
Perineum rupture 1
Remains of placental 4
Ectopic pregnancy 5 3.18
total 55 35.03
Eclampsia preeclampsia 6 3.82
prepartum 21 13.38
interpartum 2 1.27
postpartum 8 5.10
total 37 23.57
Sepsis after birth 4 2.55
after miscarriage 5 3.18
after abortion 4 2.55
total 13 8.28
Complications hemorrhage 3 1.91
of CS sepsis 2 1.27
total 5 3.18
Liver diseases acute viral hepatitis 6 3.82
hepatosis gravidarum 1 0.64
chronic acute hepatitis 1 0.64
liver cirrhosis 1 0.64
total 9 5.73
Table 4.11. Maternal Mortality Causes.

Table 4.11 (Cont.)
Cardiovascular diseases complications of reumocarditis 4 2.55
cardiorespiratory failure 2 1.27
cardiogenic failure 1 0.64
brain vassal pathology 1 0.64
hypertonic disease 1 0.64
stroke 1 0.64
trombembolia 1 0.64
total 11 7.02
Diseases of respiratory organs pneumonia 8 5.09
bronchial asthma 1 0.64
total 9 5.73
Acute surgical conditions appendicitis 5 1.91
ulcer of intestines 2 1.27
obstruction of intestines 1 0.64
total 6 3.82
Tuberculosis 3 1.91
Anaphylactic shock 3 1.91
Embolia by amnion water 2 1.27
Nephritis 2 1.27
Leucemia 1 0.64
Missing Value 1 0.64
Total 157 100.00
More than half of the women died in remote areasat home, in bhag, soum and intersoum hospitals before reaching specialized facilities (57.4%). Thirty-seven percent of women died in aimag central hospitals, 88 percent of which were transferred from soum hospitals or from bhag departments. The rate of home births in overall births is low1.5 percent on average (women prefer to give a birth in hospitals)but they are responsible for approximately 10 percent

of maternal deaths (Table 4.12). The main cause of women who died at home were hemorrhage after birth (in half of the cases), eclampsia prepartum (in three out of 15 cases), pneumonia (in two cases), sepsis (in one case), stroke (in one case), and in one case the cause was unclear.
Frequency Percent
Valid soum hospital 65 41.4
aimag hospital 58 36.9
at home 15 9.6
intersoum hospital 8 5.1
maternity house 8 5.1
bhag department 2 1.3
Missing 1 0.6
Total 157 100.0
Table 4.12. Place of Maternal Mortality.
Thirty-six percent of hospitalized women spent less than one day at the hospital, eighty percent of whom died after a few hours since the hospitalization. Table 4.13 gives more detailed information.