Archive for May 4th, 2009

To mark International Day of the Midwife on May 5, Merlin is launching All Mothers Matter a report outlining why, without urgent investment in health workers in fragile states, the Millennium Development Goal for maternal health will not be reached.

50 per cent of women who die in childbirth every year live in countries caught up in or emerging from crisis.

Yet evidence is clear: 75 per cent of lives could be saved if women had access to a skilled birth attendant or emergency obstetric care. With less than one health worker per 1,000 people, fragile states simply do not have the health workforce or services in place.

Carolyn Miller, Merlin’s Chief Executive comments:

‘Midwives are at the heart of maternal survival. Fragile states carry the greatest burden of maternal deaths – and have the lowest numbers of health workers – yet receive insufficient Overseas Development Aid. We cannot hope to meet global maternal health goals if we don’t reallocate our focus, and funding, to countries in crisis.’

In 2007, fragile states received just 38.4 per cent of Overseas Development Aid despite suffering the highest levels of maternal mortality. All Mothers Matter addresses this disparity calling for targeted investment of £2.4bn for health in fragile states, an investment which would ensure countries in crisis are back on track to meet Millennium Development Goal number 5 to reduce death in childbirth by three quarters.

Working out at £2.71 per person per year, this additional funding re-allocated from international budgets and into fragile states, could double the health workforce, including rapid scale up of midwifery training to ensure there is one skilled birth attendant for every 175 women. It would also provide all the medical supplies and drugs needed plus incentives for staff working in underserved and rural areas.

Carolyn Miller also said:

‘It is more important than ever to be effective and targeted with aid. Maternal deaths lead to global productivity losses of $7.5billion each year. Reallocating aid to fragile states will not only save hundreds of thousands of lives, it makes clear financial sense.’

All Mothers Matters advocates for an overhaul of how health is currently funded to ensure maternal mortality is tackled effectively. Currently huge amounts of aid are spent tackling diseases such as malaria and TB in isolation; yet such diseases, which contribute to high levels of maternal mortality, cannot be prevented, treated or cured without sufficient numbers of trained health workers. Also such aid loses 40% of its value thanks to donor conditions.

The report prioritises investment in health systems calling for 50 per cent of all global health funding to be channelled into strengthening health systems, with 25 per cent of that to be used to train and retain health workers. Investing in health systems would help deliver regular staff salaries, training, equipment and incentives for health workers, ultimately building the skills base needed to stop mothers dying needlessly in childbirth.

Mama Zeena, a Training Coordinator at Merlin’s midwifery school in Zwedru, Liberia is in the UK to launch the report. She commented:

‘You cannot tackle maternal mortality in isolation’ you need sustained investment in a functioning workforce. You need more midwives. All women should be able to see a trained midwife and get help when they need it, regardless of where they live. A mother should not have to die.’

Read All Mothers Matter


With China’s rising affluence, increasing numbers of infertile couples have been seeking surrogate mothers to bear them babies.

In recent years, officials have largely turned a blind eye to this underground womb-for-rent industry that defies the country’s strict childbirth laws. Now, there are signs the authorities are starting to crack down by forcing some surrogate mothers to abort their fetuses.

In the southern Chinese city of Guangzhou, three young surrogate first-time mothers were discovered by authorities hiding in a communal flat.

Soon afterwards, district family planning and security officers broke into the flat, bundled them into a van and drove them to a district hospital where they were manhandled into a maternity ward, the mothers recounted to Reuters.

“I was crying ‘I don’t want to do this’,” said a young woman called Xiao Hong, who was pregnant with four-month-old twins. But they still dragged me in and injected my belly with a needle,” the 20-year-old told Reuters of her ordeal which happened in late February.

The woman, who declined to give her full name for fear of reprisals, said the men had forced her thumbprint onto a consent form before carrying out the abortion.

Another of the surrogates, who said she’d come from a village in Sichuan province, recounted how officers made her take pills then surgically removed her three-month-old fetus while she was unconscious. “I was terrified,” the 23-year-old said.

A spokesman for the Guangdong Provincial Family Planning Commission Zhong Qingcai declined to be formally interviewed by Reuters, but said authorities were investigating.

The official Guangzhou Daily newspaper quoted district family planning officials as saying the women were all unmarried and acting as “illegal” surrogates. It added the three had “agreed” to undergo “remedial measures” in accordance with the law.

But the head of the surrogacy agency caring for the mothers, disputes this version of events.

“It’s an absolute crime,” said Lu Jinfeng, the founder of the “China Surrogate Mother” website ( which has run for over five years without encountering any problems like this. By forcefully dragging people away like this to undergo an abortion is a savage illegal act that violates human rights.”

Since the incident, a notable vein of officially sanctioned media reports, including one paper describing the profit margins of the surrogacy business as “greater than the narcotics trade,” has led some observers to expect tighter curbs in future.

“When you see this kind of reporting it’s a kind of public education … a sign the government is going to do something,” said Siu Yat-ming, an expert on China’s family planning issues with Hong Kong’s Baptist University. “They’re becoming more aware of the situation … a lot of the (surrogacy) agencies are making a lot of money just like an organized industry,” Siu added.

Underground networks of surrogacy agents, hospitals, and doctors have spread in recent years as infertile Chinese couples with money hire surrogates to produce babies for them.

The surrogates are often confined to secret flats for most of the duration of their pregnancy to avoid detection, while fertility, obstetrics and childbirth procedures for the mothers are often carried out discreetly by medical staff at public hospitals and health clinics with links to agents.

“Under China’s civil law, this (surrogacy) should be prohibited. Intermediary (surrogacy) services are also essentially illegal,” said Zhang Minan, a law professor at Guangzhou’s Sun Yat-sen University and an expert on the issue. “But these cases exist and they cannot possibly be made public or legalized. You cannot legalize such practices,” he added, referring to China’s tight birth planning rules which have restricted couples to just one child since the late 1970’s.

With around one in six couples in the U.S. now estimated to be infertile and with similar rates seen in China as modern urban lifestyles take hold, surrogacy agencies have been recruiting girls, often from poor villages, to have babies on behalf of prospective parents, in ever greater numbers.

Accurate figures on the size of the industry are hard to come by, but a recent report by the respected Southern Metropolis Weekly estimated around 25,000 surrogate children have been born so far in China, citing research into surrogacy agency websites carried out by family planning authorities.

Hundreds of Chinese surrogacy agencies are openly listed on Chinese search engines like Baidu, luring prospective clients with maternal imagery and pop-up windows offering live chats.

Prospective surrogate mothers are openly recruited and paid between 50,000 to 100,000 yuan ($14,650) per pregnancy on some sites, making it a lucrative profession for poor village girls in a country where the average annual per capital income for rural households is around $600.

While emotional, ethical and legal complications make surrogacy a thorny topic in many countries, the trend has been on the rise globally. India, in particular, has become a “surrogate outsourcing” hub for infertile and gay Western couples.

“There are millions of people out there who want to have kids but can’t,” Robert Klitzman, a bio-ethicist at Columbia University’s Medical Center told Reuters by phone from New York.

India has moved to introduce legislation on surrogacy to safeguard the rights and health of impoverished women from exploitation.

In some U.S. states paid surrogacy is outlawed, while weak regulatory oversight in states such as California has led to clients being duped by unscrupulous surrogacy brokers.

“Whenever you have an underground industry you’re going to have problems because there’s no guarantee that they’re going to follow standards of safety, follow standard medical or ethical practice. There’s a lack of transparency,” Klitzman added.

In China, however, with the number of surrogate births still very small compared to the overall birth rate, the prospect of a safe legal framework remains a distant one, leaving open the risk of arbitrary, violent enforcement.

“They (the authorities) do have the right (to force abortions) but it rarely happens because such surrogacy is extremely secretive. And for the authorities it’s difficult to get evidence,” said Zhang, the legal scholar. “Because this problem hasn’t yet sparked widespread social interest, so from this perspective the Chinese government hasn’t really noticed the matter, nor accepted it,” he said. “If this problem does spark widespread social interest, then authorities might start to do something about it,” Zhang added.

Shabnam had dreamed of owning a home for years, but with few prospects for her husband, she followed the lead of many poor women in her town in western India: she signed up to carry a baby for another couple.

At the clinic of Nayna Patel, perhaps India’s best-known “surrogate doctor” who delivered Anand town’s first surrogate baby, more women are signing up to be surrogates, with even nurses and teachers lining up, as their husbands lose their jobs.

“The women who come here usually want the money to buy a home, pay off loans, or for their childrens’ college education,” said Patel in her small clinic, the walls of which are covered With clippings and pictures of Patel with babies and parents.

A surrogate is generally paid about 250,000-400,000 rupees ($4,000-$8,000), a huge sum of money in a country where many live on less than $2 a day.

Doctors with a western education, top-notch facilities and lower prices have already made India an attractive destination for procedures ranging from bypass surgery to liposuction.

Lax legislation and an entrepreneurial streak in Gujarat state have helped make Anand a last stop for many childless couples at home and abroad, after its first surrogate baby five years ago.

In this bustling town known for India’s best-known brand of butter, Patel has delivered more than 100 surrogate babies, 40 percent for Indians living abroad and 20 percent for foreigners.

It all began with a grandmother surrogate for a UK couple five years ago that pitched Anand and Patel into the spotlight.

Following their lead, locals and foreigners began to flock to Patel’s clinic, drawn by the lower costs, relaxed attitude toward surrogates and lack of legislation.

A draft bill on surrogacy is pending before parliament, and meanwhile, hundreds of clinics have mushroomed across the country, with critics saying touts promoting this “reproductive tourism” care little for the health or rights of the surrogates.

Patel, who was featured on a special show on Oprah Winfrey two years ago, raises her voice in defence.

“My argument is: the surrogate is not killing anyone, not committing an illegal or immoral act. And if a surrogate’s child is able to get an education, if one family is able to buy a home — and help a needy couple in the process, where is the harm?”

Not everyone sees it that way.

Patel and the couples, more than half of whom are either non-resident Indians or foreigners, have come under a barrage of criticism for “exploiting” surrogates and for glossing over the ethical debate.

Many surrogates themselves do not tell their parents or in-laws for fear of being ostracised, and several of Patel’s surrogates live in a Surrogate House to ensure they have a proper diet, and are safe from drunken husbands and nosey neighbours.

Shabnam, 26, has not told her two older daughters or her in-laws that she is a surrogate; she lives with a few other surrogates at the hospital with her youngest child, while her husband, who is out of work, cares for the two others at home.

“I don’t think I can ever tell them; I don’t think they’ll understand,” she said, insisting on using just one name. Her husband used to earn less than $1 a day washing dishes.

Some experts say surrogates, who are often barely literate, do not understand all that the process entails, and are putting themselves at physical and emotional risk but have few rights.

“The primary concern is the physical and mental health of the surrogate: there are several risks, including maternal mortality, associated with assisted reproductive technologies,” said Preeti Nayak at Sama Resource Group for Women and Health.

India’s maternal mortality ratio is 301 in 100,000 births, the highest in south Asia after Bangladesh, the World Bank says.

For Chris McDaniel and his wife Shannon, who came to Anand last April from San Diego after having tried every option in the United States, where hiring a surrogate can take months and cost up to $100,000, the decision to go to Patel was clear.

“It wasn’t in our life plan to fly half-way around the world to a country we barely knew about to have our child,” said Chris, who is writing a book on their experience.

It is hard to come by numbers of surrogates in the country, but Patel has a list of nearly 200 and is seeing more women walk in everyday because they are feeling the pinch of the slowdown.

In the absence of legislation, Patel sticks to guidelines of apex body Indian Council of Medical Research, which say a surrogate may only be implanted with the egg and sperm of the couple or anonymous donors, and that she must be below 45 years.

Patel also insists couples seeking surrogates must have a medical condition that makes child bearing impossible or risky, and draws the line at gay couples and single parents.

The surrogate, who must have her husband’s consent, has no rights over the baby, but feels empowered nevertheless, she said. “Until then, they have felt powerless, helpless; now, they feel like they can be of some use to their family,” she said.

Shabnam’s ambition is far more modest.

“I was very scared thinking of our situation, thinking how will we manage?” said Shabnam, who is eight months pregnant with the baby of an Indian couple living in the United States. Now I feel a bit more confident. At least if we can buy a house, then things will get better.” ($1 = 50 rupees)

With only six years left to achieve its Millennium Development Goals (MDG), [see:] Nepal, like many other Asian countries, is lagging behind and must make further efforts, say local and international health experts.

A top priority is the maternal mortality ratio (MMR), which Nepal’s government hopes to reduce to 134 women per 100,000 live births from its current level of 281 per 100,000 live births, according to the government’s Demographic Health Survey 2006. [see:]

Put another way, this means one woman is dying every four hours (six women a day) due to pregnancy-related complications.

“It will be a big challenge for Nepal to really achieve the maternal health goal,” said reproductive health expert, Ava Darshan Shrestha, vice-president of the Safe Motherhood Network Federation (SMNF). [see:]

Skilled birth attendants are not present at nearly 81 percent of deliveries, something that is putting thousands of women at risk, according to SMNF.

There is a severe shortage of maternal health services, especially in the hills, where most of the maternal deaths occur.

“In rural areas, most women need to walk for hours. If they travel by bus it’s just as bad because the roads are so rough that women in labour end up in a serious condition even before reaching hospital,” said Sabitri Chettri, a female community health volunteer.

Weak administrative, technical and logistical capacity, inadequate investment and lack of skilled health personnel further hamper effective health services, according to UNICEF’s State of the World’s Children – 2009 report [see:]

Experts are concerned that failure to achieve the MMR goal will also adversely affect other MDGs.

Unless you reduce the MMR, it will be difficult to achieve other MDGs, including a reduction in child mortality [goal 4], as well as gender equality and empowerment [goal 3], Saramma Mathai, a maternal health expert with the UN Population Fund (UNFPA) in Bangkok, told IRIN. We know that unless a mother survives [childbirth], the risk of death of a newborn is much higher,” she said.

She said the maternal health goal was also linked to MDG 1, which relates to both poverty reduction and malnutrition.

“Without a mother, a child’s nutrition is going to suffer. And women contribute a lot to the economy, both in terms of working at home and contributing to the economy,” said Mathai.

Local health experts told IRIN the health of mothers and newborns was closely linked, and preventing deaths required implementing measures like antenatal care, skilled attendance at birth, access to emergency obstetric care, adequate nutrition, post-partum care, newborn care and education to improve health, infant feeding and care, and ensuring good hygiene behaviours.

“To be truly effective and sustainable, however, these interventions must take place within a development framework that strives to strengthen and integrate programmes with health systems, and an environment supportive of women’s rights,” said the State of the World’s Children 2009 report.

The Ministry of Health and Population, with the support of the UK Department for International Development (DFID), has started Ama Surakchhya Karyakram, a national programme offering free childbirth and travel costs to women who come and deliver at a maternal health facility.

The programme is available in all government hospitals and health centres.

“This programme is aimed at improving maternal health and newborn survival, and we are committed to its effective implementation,” said senior government official Girija Mani Pokhrel. “We need to remember that Nepal is the 14th poorest nation in the world,” Sushil Baral, DFID maternal health adviser in Kathmandu, told IRIN, adding that the programme was a “bold initiative”.

The number of women dying in childbirth in Liberia has nearly doubled since the 1980s, according to a recent UN report that has policymakers calling for urgent attention to reproductive healthcare.

While the report shows encouraging trends in infant and child survival, it puts maternal mortality at 994 women per 100,000 live births in 2007 compared to 578 in 1987.

“We need to do something immediately and urgently about maternal mortality,” said John Agbor, head of child survival for the UN Children’s Fund.

The increasing proportion of women dying while giving birth is linked to a drop in the proportion of births attended by skilled health personnel, according to the UN report. In 2006 under half of births were attended by trained personnel versus 91 percent in 1986, according to the report on Liberia’s progress on the Millennium Development Goals. Even fewer deliveries – 37 percent – take place in health facilities, the report says.

Part of the problem is a lack of health personnel. Before civil war broke out in 1989, Liberia had 250 qualified licensed doctors, but now just 50 doctors serve 3.5 million people; many have gone overseas to work, according to government statistics.

As a result few women are referred to doctors for obstetric care, according to the same report. Jennie Fallah, who lives in the Monrovia suburb of Paynesville, told IRIN: “When I was about to deliver there was no doctor so I was forced to give birth [without] one…I really did not know what to do as I was in severe pain…there was a health centre near [my home] but there is no doctor or midwife there at night.”

High adolescent pregnancy rates – a third of all babies are born to teenagers – and low literacy rates further compound maternal mortality, said UNICEF’s Agbor.

George Gould, UNDP’s National Policy Analyst in Liberia, told IRIN access to skilled health attendants has declined in rural areas partly because it is so difficult to attract health workers.

“There are no opportunities in the rural areas. There is no piped water or electricity or anything to attract personnel to work in these areas. Rural health workers need higher wages to pull them out of cities.”

Under-five mortality has been cut in half since 1992 to 111 per 1,000 live births, the report says, noting that Liberia is likely to meet the MDG goal to reduce by two thirds the under-five mortality rate by 2015. Infant mortality decreased from 139 per 100,000 live births in 1992 to 72 in 2007.

Infant mortality has dropped partly because vaccination rates vastly improved, according to Agbor. Five diseases – pneumonia, diarrhoea, malaria, measles and AIDS – account for half the deaths among children under five in Liberia, according to the report.

Immunisation rates for measles have risen significantly and Liberia has been polio-free for several years.

Since 1999 vitamin A supplements have also been widely distributed, significantly boosting hundreds of thousands of children’s immunity to common killers such as diarrhoea and measles, UNICEF’s Agbor said.

The UNDP’s Gould said the government must remain vigilant in order to meet the infant mortality MDG. To build on progress already made, the Ministry of Health should continue supporting mass immunisations, providing vitamin supplements and insecticide-treated bed nets, alongside revitalising primary health care, he said.

“Reducing both maternal and infant mortality remain a priority,” Agbor said. “If Liberia continues in this path the infant mortality MDG might be reached.” But he added: “Reaching the maternal mortality MDG would clearly be an uphill task.”

It is a task the government is finally taking on. When maternal death statistics came out in 2007 the Ministry of Health created a reproductive health policy, but it is only now being implemented.

“We have had a sustained period of peace and security,” said Gould. “Health outreach activities can now be regular and planned, which should mean that progress against the MDGs now speeds up.”

Progress will be documented in the country’s next Demographic Health Survey, expected out in 2010.

Pregnancies among girls as young as 12 and women in their early 40s are on the rise in Mali’s rural north, according to health workers, who say cultural mores and economic pressures contribute to the potentially life-threatening pregnancies, which often go untreated due to scant health services.

Bana Nimaga is a midwife at the Bankass health centre – 700km east of the capital Bamako – which sees the most complicated pregnancies from surrounding villages. Most of her patients have never been to a health centre, she told IRIN.

“They arrive to me in a complete state of catastrophe, so tired and worn down at the end of their pregnancy. You find the infant is on the edge of survival. [In these cases], the only legacy women leave for this world are stillborn babies.”

The director of Koulogo health centre almost 40km away, Ousmane Fomba, told IRIN that he has referred “more and more” high-risk pregnancies in these age groups to Bankass. “It is not uncommon to see 35- and 40-year-old women or 12- and 13-year-old girls pregnant.” He said that as more girls travel to work in Bamako or in neighbouring Côte d’Ivoire, early pregnancies have increased.

“And the mature expectant mothers tell us that they do not feel they can say no their husbands who demand intercourse or children,” he said. The medical director said though the centre offers family planning education, “old mentalities endure.”

In 2006 119 babies of every 1,000 live births died by age one, and more than 900 women died for every 100,000 live births in 2005, according to the government. Though the maternal mortality rate decreased by almost half in 2006, lack of access to clean water and health care still put the country in “a state of health emergency” according to the UN Children’s Fund (UNICEF).

According to a government survey, almost one in 10 newborns in 2006 did not live beyond their first year. Half of those deaths occurred during the first week of life. Fewer than half of women who gave birth did so with a trained birthing attendant and 70 percent of infant deaths happened in the home, according to the same survey in 2006.

Even for women who give birth in a health centre the situation is not much better, said the head of the Bankass referral centre, Mamadou Guindo, who told IRIN the health centre does not deserve its designation. “We do not have inpatient facilities or electricity. The only generator we have does not provide enough energy. We do not have enough [medical] materials or anaesthesiologists.”

He said the centre often must refer patients to the hospital in Mopti more than 100km away.

Women ages 17 to 70 sit on vinyl mattresses, drainage bags on the floor next to their hospital beds, catheter tubes stretching from under colourful skirts. Each one has a serene, triumphant look.

The women are recovering from an operation that lasted some two hours and repaired tissue damage that made their urine flow uncontrollably – in one case for 50 years.

“I am beside myself with joy,” one woman told IRIN, talking through an incessant smile. She told IRIN she had lived with the condition for 20 years.

Through a programme run by the UN Population Fund (UNFPA) specialists are training local surgeons and gynaecologists in Korhogo, northern Côte d’Ivoire, in repairing obstetric fistula – a hole in the birth canal caused by complicated labour and a lack of medical intervention, which leaves a woman leaking urine or faeces or both.

When the soft tissues of the pelvis are compressed between the baby’s head and the mother’s pelvic bone, the lack of blood flow causes tissue to die, creating a hole between the vagina and bladder or between the vagina and rectum.

Obstetric fistula is preventable, yet some two million women around the world live with the condition, according to UNFPA. “The persistence of fistula is a signal that health systems are failing to meet the needs of women,” UNFPA says.

For now 16 beds are available for fistula patients at the Korhogo hospital, according to Mansaré Ladji, surgeon, gynaecologist and one of the physicians being trained to perform fistula operations. “There is a waiting list,” he said.

The demand in Korhogo – 630km north of the commercial capital Abidjan – exploded when partner NGOs in surrounding areas began informing communities of the free treatment, Mansaré said. “Women are coming from everywhere.”

Since launching the project in February doctors in Korhogo have performed 25 operations to date.

“We are giving these women a new life,” Mansaré told IRIN, recalling how some women danced as they left the hospital. “It cannot be described, it must be experienced.”

“This operation changed everything,” said Silué Korotoum, a 34-year-old woman who received the treatment. “I can thrive now. I can go where I wish and do as I wish.”

Mansaré said one of the most important goals is long-term training for local health workers to treat obstetric fistula. “We must set up something that will continue after [trainers] are gone.”

In many cases women are not aware a remedy exists, or if they are, cannot afford it, according to UNFPA. Without subsidies the operation cost about US$300, about 10 times what most people in the region earn in a month, residents said.

In the UNFPA centres – in Korhogo, Man and most recently Bouaké – services are free; the programme will continue as long as funding is available through the agency’s Thematic Fund for Maternal Health, UNFPA gynaecologist Abou Pauline told IRIN. UNFPA is urging the Ministry of Health to maintain free care for women with fistulas.

Simeon N’da, Health Ministry spokesperson, told IRIN the government will study whether obstetric fistula is a condition for which the government will ensure free treatment, as it does for some other illnesses such as Buruli ulcer.

In the Korhogo recovery room were three young women ages 17 to 18, whose fistulas were caused by difficult deliveries.

Doctors told IRIN even more important than providing treatment is eliminating the causes of fistula – including poor general health, lack of maternal health care and practices such as early marriage and childbirth, lack of spacing between births and women’s lack of power to make their own health care decisions.

“Obstetric fistula is a condition resulting from complicated childbirth,” gynecologist Abou told IRIN. “If we reduced complications in childbirth we would reduce fistulas.”

It is essential that people have access to properly equipped medical facilities and qualified medical personnel, she said.

But even when facilities are available, cultural practices weigh on women’s health, medical workers told IRIN.

At the Korhogo hospital a health worker recounted a case in which a woman urgently needed a caesarean section but family members would not consent without the approval of her husband. He was travelling and out of reach.

Benin’s government is in its first week of helping women pay for caesarean operations in an effort to reduce the number of women dying during childbirth every year, estimated at 2,000 according to the government.

As of 1 April, the US$200 caesarean subsidy is offered to women seeking care in more than 40 hospitals in mostly urban areas nationwide.

Market vendor in Benin’s business capital Cotonou, Marie Reine Amouzouvi, told IRIN that when her doctor recently told her she needed a caesarean section to safely deliver her child, she was worried. “I did not know it would be free. If there were not this free operation, I would have died along with my child because I would not have had money to pay for the operation.”

The head of the gynaecology clinic at the state-run National Hospital and University Centre in Cotonou, José de Souza, told IRIN that before the subsidy, the hospital had to absorb costs to perform life-saving caesarean operations. “This [subsidy] helps medical practitioners. We are able to cover our costs, which makes our job easier.”

The government has linked the country’s high level of maternal and infant deaths in childbirth to long hospital waits for caesarean operations as underfunded hospitals scrambled to assemble the necessary equipment.

In launching the subsidies last month Minister of Health Issifou Takpara said in a nationally televised address that women will have a shorter wait time for their operations and instructed hospitals “to take the necessary steps to render [gynaecological] services operational 24 yours a day, seven days a week, every day of the year.”

But hospital director Souza told IRIN that for the subsidies to make a difference, hospitals need more cash. The state has pledged more funds to solve staffing shortages, improve operating rooms and purchase equipment.

As of 2004 Benin fell short of the World Health Organization-recommended minimum of one doctor per 10,000 people to ensure basic care.

In December 2006 President Boni Yayi pledged free health care for pregnant women and all children under five years old, which would cost the state $50 million, according to the Ministry of Health.

Governments and health analysts have considered cutting health fees as one way to improve the health of some cash-strapped patients.

A government health inspector who works with midwives in Cotonou, Adékambi Adjovi, told IRIN that even a steeply-subsidised caesarean operation may not be enough for some women. “The circuit [of health care costs] for women who have caesarean operations should be covered entirely because now they pay post-operative costs themselves.”

Medical director Souza told IRIN it is important to make sure hospitals do not increase their operating costs to take advantage of the subsidy at the state’s – and patients’ – expense.

The Ministry of Health reported 14,000 women giving birth through caesarean in 2008 and has estimated an additional 3,000 mothers will need the operation in 2009, based on population estimates.

Thousands of pregnant women caught up in the fighting between government forces and the Liberation Tigers of Tamil Eelam (LTTE) are in urgent need of healthcare, according to aid workers. “I was scared. I didn’t know if we were going to make it,” 23-year-old Thanusiya told IRIN. At eight months pregnant and after weeks of shelling, she and her husband escaped to the northern, government-controlled town of Vavuniya last month. Given the number of civilians who have fled to government-controlled areas, coupled with those still trapped inside the conflict zone, the numbers of women in the same position as Thanusiya could easily be in the thousands. “Women do not stop getting pregnant or giving birth to their babies even when on the move or when living in camps,” Lene Christiansen, country representative for the UN Population Fund (UNFPA) [see:] in Colombo said, expressing concern for the large proportion of high-risk pregnancies among women in displaced persons camps as well as increased teenage pregnancies. According to UNFPA, pregnancy-related disabilities and death often rise in conflict situations when reproductive health services, including pre-natal care, assisted delivery and emergency obstetric care are disrupted and often unavailable. At the same time, many women lose access to family planning services, exposing them to unwanted pregnancies. About 70,000 civilians remain trapped in the conflict area, the government reports, while international agencies place their numbers at up to 150,000.

As of 6 April, some 60,000 Tamil civilians had fled and were now being housed in 29 camps in Vavuniya, Mannar and Jaffna districts, the government reported. Should that influx continue, aid workers addressing the reproductive health needs of women will be stretched. “If 100,000 people come, the number of pregnant women could easily reach 8,000 or more,” Anura Priyaratne, district programme manager of a local NGO, the Family Planning Association of Sri Lanka (FPASL) [see:] in Vavuniya, told IRIN. “We need to be prepared,” Priyaratne said, citing the importance of spreading their coverage to other camps in the area through their mobile clinics. With local and regional authorities, and supported by UNFPA, the local NGO provides reproductive health services to IDPs in the Vavuniya District through its two mobile health clinics, which visit the camps weekly. In addition to prenatal and postnatal care, assistance includes basic reproductive health services as well as the distribution of clean delivery kits and hygiene items for women and girls of reproductive age through its LISA (Life saving emergency reproductive health services) project. Women in labour are taken to Vavuniya Hospital, where UNFPA has provided equipment for emergency obstetric care.

In addition, UNFPA supports the FPASL in expanding health awareness, with a specific emphasis on HIV and sexually transmitted diseases.