ANKILIBORY, 28 May 2010 – In a tiny shack in Ankilibory village, southern Madagascar, Herintsoa, just 16 years old, recently gave birth to her second child, but it was easy compared to the first one, which she had when she was 14. “That was a lot more painful. I did it at home myself – my husband cut the [umbilical] cord.”
Unfazed, she said, “We want 10 children.”
According to government figures, 70 percent of 16-year-old girls in some parts of Madagascar have given birth to their first child, but the fact that early pregnancy is common on the huge Indian Ocean Island does not make it less dangerous.
The 2009 national Demographic and Health Survey noted that every day eight women die as a result of complications during pregnancy or delivery, often at a very young age.
Jocelyne Rasoanirina, head of the UN Population Fund (UNFPA) in southern Madagascar, pointed out that besides the immediate risks there were also longer-term implications.
Large families are an important contributor to household poverty – the average Malagasy family has five children but the number rises dramatically in rural areas, where it is not uncommon for women to have 10 children by their mid-thirties.
Rasoanirina said the biggest obstacle to reducing maternal and neonatal mortality was access to quality healthcare. “People live very far from health centres and don’t have any transport options.”
Herintsoa has never seen a hospital, a doctor or a nurse – the nearest health centre is 30km from her village, and the only way to get there is an expensive ride in a “chariot” – an ox-drawn cart – or walking through the desert-like terrain. “The death rate is high for mother and child,” said Aro Rajoelina, Regional Medical Inspector of Ampanihy district, where Herintsoa’s village is located.
Although some 70 percent of pregnant women in the south of the island have access to prenatal services, only about 10 percent of births are attended by skilled health personnel. Government figures put maternal mortality at 469 deaths per 100,000 live births.
“We try to ensure that a health centre can cover several villages, and that the maximum distance to travel is 80 kilometres, but it is still difficult for people to cover such distances,” Rajoelina told IRIN.
Women and girls often seek medical attention very late in the pregnancy, and sometimes only when the situation has reached a critical stage. “It’s the culture to stay at home and see a traditional doctor or midwife, but they are not qualified to [handle complications]. When that does not work, they might go to the clinic but it’s often too late,” Rajoelina said.
The poorest Malagasy get free treatment at the health centres, but traditionally the entire family goes along when one of them needs medical attention, making the trip too expensive. “They have to pay for food and accommodation for everyone; it’s a financial problem,” Rajoelina commented.
Sambetire, 16, has come to the Health Centre in Amphany, a town in southwestern Madagascar, because she is four months pregnant but has started bleeding vaginally. Luckily her family owns a chariot and the six of them could all come with her on the 20km journey to the centre.
“This is my third child, and I already lost one,” she said from her bed. The midwife at the centre, Henriette Baofeno, said there was a real risk that Sambetire could lose the baby.
“I get sad when I see cases like that,” she said. In her 23 years as a midwife at centre there has been “no big change – I still see young girls like this very often.”
Postpartum haemorrhage, or bleeding after delivery, in girls giving birth at home in their communities, far from qualified help, is a major contributor to the maternal death rate.
Another serious cause of maternal death – the second most common in Madagascar, according to the demographic survey – is obstetric fistula, or a hole in the birth canal caused by prolonged and obstructed labour.
Rajoelina said he had seen girls as young as 10 give birth, and “taking out the baby can damage the organs [of the mother]. They are too small and not developed yet.”
Obstetric fistula is often the result of early childbirth, when the birth canal is too narrow and there are no qualified medical personnel to perform a caesarean operation.
The condition often leaves young women incontinent, causing their husbands, families and communities to shun them. “In those cases you need surgical intervention, but that is impossible here,” Rajoelina said.
In Ankazoabo, a coastal village in the southeast of the island, Avivelo, 34, encourages her 17-year-old daughter, who already has two children, to have as many as possible. “I gave birth to eight children and now it is her turn to do the same, but it is difficult.”
Southern Madagascar, where aid agencies struggle to feed thousands, is a hostile place even in a good year, and the past four have been particularly harsh, but more mouths to feed has not been a deterrent.
The 10 children huddled around Avivelo are a poster for malnutrition in the region: swollen bellies, visible emaciation, and their mouths stained by red raketa – a local cactus fruit used only in desperate times that Rajoelina said was “unfit for human consumption”.
“Having many children is a blessing for people here, and that’s why family planning programmes are so important … but it’s very difficult to change the way people think,” UNFPA’s Rasoanirina commented.
“Its part of the culture,” she said, referring to the traditional Malagasy wedding blessing, “May you have seven sons and seven daughters”.
[This report does not necessarily reflect the views of the United Nations]