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The future - and present - of maternal health care

One of our families favorite things to do is check out old cemetaries - my kids love to read gravestones and talk about the stories that came behind them. I love cemetaries - I find them comforting in an odd way, although I'm not fully sure I can explain why, and I'm glad that my children have the same passion for historical records and also the same pleasure in knowing something about lives before ours.

Walking in old graveyards is also always a reminder of how fortunate I am. Most graveyards have a "children's" section, or family stones record the brief and incredibly short lives of children - and a world where losing at least one child was a norm. Add in the high risks of childbirth and a walk through a cemetary can be a laudable reminder of things one doesn't want to lose in a lower energy society - childhood vaccination, clean water supplies and good reproductive medicine - low technology whenever possible, but high when truly needed.

Moreover, for those concerned about population, counter-intuitively, demographers generally find that the conditions necessary for people to choose fewer children include radically lower child, infant and maternal mortality. Because childbearing decisions are often built on economic necessities, the less certain you are your children will live to adulthood, the more likely you are to have more of them. A longer term stability depends on keeping child, infant and maternal mortality low, even as we struggle with health care costs and the creation of a lower-energy infrastructure.

Over the last thirty years, infant and maternal death rates in childbirth in the US have crept up - in 1987 the death rate in childbirth was 6.6 deaths per 100,000 live births while by 2006 it was 13.3 - it had doubled. Some of this was probably attributable to better record keeping and reportage, but there's no question that the infant and maternal death rate in the US has climbed quite dramatically - even though it remains low compared to the Global South. In the same approximate period, however, enormous gains were made (although there is still much more to be done) in reducing child and infant mortality in the Global South - only in the US were we headed backwards.

For women of color, the rates of maternal and infant death, or serious and long-term health care consequences from childbirth are four times what they are for white women in the US. Two African-American women die in childbirth every day in the US - a rate that is truly scandalous. And compared to most of the rest of the Global North, the rates are extraordinarily high.

It would be easy to say that by necessity a lower energy and poorer world must result in worse outcomes for women and children - but there's some real reasons to question this. One way to look at this (and I do this in much more detail in my book _Depletion and Abundance_) is to ask whether it is possible to keep maternal and infant mortality rates low while using low-cost, lower energy interventions much of the time. We already know that many nations that have higher rates of home and midwife attended births have as good and better outcomes than the US. We also know that the Old Order Amish, who have what most of us would describe as high risk factors for perinatal death and injury - most women have many children, often continuing to have babies into their mid-forties or later, physician medical care is usually involved only if an emergency occurs, while most prenatal care is provided by Amish lay midwives at home in houses without electricity or often, running water, and most households do not have easy car access to transport women to the hospital. Despite this, studies suggest that rates of infant and mother mortality for Amish women are similar to white rural women in more modern settings.

This, and the experience of less wealthy nations with low infant mortality like Cuba might be used as a model to create a low-energy infrastructure that could further reduce infant and child mortality, a functional "shadow" health care system that could both reduce loss of life now, and also serve families in a world that may struggle even further to provide adequate health care access.

Amnesty International points out rightly that maternal and infant health care are a human rights issue - none of us want to live in the bad old days, when women made their wills before childbirth and cemeteries were filled with the memories of babies and children and women's lives cut short. None of us want to live in a world where preventable consequences of childbirth disable women and children and make it impossible for them to live a functional life. What's most disturbing about the growing rate of women struggling with health care issues is that it is so obviously possible to prevent most of those problem, most of them at low cost and with comparatively simple interventions.

What do you think? Leave a comment below.

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