B!RTH blogs

CMNH has contributed 9 blogs highlighting global inequalities in childbirth



Global inequality in childbirth


The difference in the number of women who die during and after pregnancy across the world, by Dr Mary McCauley

In 2015, it was estimated that 303,000 women died during or after pregnancy throughout the world. This is an unacceptable number and the saddest fact is that the majority of these women live in low or middle income countries. This represents a massive .

The main complications that result in women dying during or after childbirth are largely preventable if good quality care is available for the women. The five main complications include:

  1. severe bleeding (mostly bleeding after childbirth)
  2. infections (during or after childbirth)
  3. high blood pressure during pregnancy (pre-eclampsia and eclampsia)
  4. complications during delivery (e.g. no access to safe Caesarean section)
  5. complications from miscarriage and abortion.

Therefore recognizing and addressing the complications of pregnancy before they become severe can prevent many maternal deaths.  But this is unfortunately not the case in many low and middle income countries.

In 2015 the  set a total of 17 goals and are working with governments of countries to help them to achieve these goals. One of Sustainable Development Goals (SDGs) concerning health problems, including maternal and newborn health issues is SDG number three, to Ensure healthy lives and promote well-being for all’ and one of the targets is to reduce the global maternal mortality ratio to less than 70 per 100 000 births.

At present the global maternal mortality ratio is 210 per 100 000 births. This means for every 100,000 babies that are delivered, at least 210 women die giving birth to these babies and often if a women dies, there is lack of care for the newborn baby that is then at much higher risk of dying also.

The maternal mortality ratio is a developmental indicator used to compare the health of women in different countries. To date, there is still massive discrepancy between low and high income countries (Table 1).   For example a women giving birth Sierra Leone is more times likely to die than a women giving birth the United Kingdom.

Table 1 shows the differences of the ratio of women who die giving birth according to the income level of the country and in countries featured in the upcoming plays birth website in comparison to other countries.

Type of income country (World Bank) Number of women for every 100,000 babies born (maternal mortality ratio)
High income countries combined 10
Middle income countries combined 181
Low income countries combined 496
Countries where the plays are based Type of income country (World Bank) Number of women for every 100,000 babies born (maternal mortality ratio)
United Kingdom High income 9
Ireland High income 8
Brazil Middle income 44
China Middle income 27
Kenya Low income 540
India Middle income 147
Syria Middle income 68
Other countries
Malawi Low income 634
South Sudan Low income 789
Nigeria Low income 814
Chad Low income 856
Sierra Leone Low income 1360

Table 1: Maternal mortality ratios for different regions and countries.

Figure 1 displays the burden of where women continue to die during and after pregnancy on the world map.  Therefore improving maternal health and reducing global inequality in childbirth must be the priority for many countries in order to improve the survival of mothers and their babies and to decrease their suffering during and after pregnancy.

Figure 1: Countries are sized in proportion to the absolute number of women who died from complications during or after childbirth in one year []



Complications and ill-health during and after pregnancy


Why do millions of women continue to suffer complications and ill-health during and after pregnancy? Asks Dr Mary McCauley.

The United Nations recently published a document ‘’ that complements the  and emphasizes that all women have the right to the highest attainable standard of health and well-being including physical, mental and social aspects. In response to this, the current global maternal health aim is to ensure that every women in every setting has an equal chance to survive, thrive and contribute to the transformative change envisioned by the .   The  strives for a world in which every mother can enjoy a wanted and healthy pregnancy and childbirth and can thrive to realize their full potential.

Fortunately, this Global Strategy is achievable in the United Kingdom (UK). For example in the UK, if a woman has any concern regarding her health (physical, psychological or social) during and after her pregnancy she has direct access to a plethora of highly trained health professions working in a well-functioning, free National Health System (NHS), that aims to ensure that the women benefits from the highest quality of care delivered by an empathic supportive medical team to ensure the best possible experience for her and her newborn baby.

This is however not the case in many of the countries of the world where women continue to suffer significant ill-health during and after pregnancy, which is at present largely unrecognised and not treated. It is estimated that for every woman that dies in low and middle income countries (LMIC), at least 20-30 other women suffer significant ill-health related to pregnancy and childbirth, which has a negative impact on the woman’s well-being.

The problem is that the priority of many countries is to decrease the number of woman who are dying during and after childbirth. Even though this is of utmost importance, the number of women who die however, only represent ‘the tip of the iceberg’ with a massive undocumented mass of maternal ill-health hidden beneath.  Therefore, the scope of global maternal health targets has been expanded moving from a focus on preventing death to formulating targets and emphasizing the importance of health and well-being.

At present, unfortunately available antenatal and postnatal care packages, especially in low resource settings are not adequate to screen for all forms of ill-health and do not address the needs of women in a comprehensive, holistic way. For example there is often not the infrastructure and skilled healthcare professionals available to screen for and treat all types of complications that affect a woman’s health during and after childbirth including other medical conditions, depression, suicidal ideation and domestic violence.

CMNH advocate that care packages are developed and put into clinical practice in low- and middle-income countries to identify the specific health needs of women during and after pregnancy. CMNH we are working in partnerships with governments of low and middle income countries to implement innovative strategies and effective, evidence-based and low-cost methods to assess, improve and monitor maternal health, in the context of low resource settings.



The role of international medical volunteers in other coutnries


What role do international medical volunteers have to play in helping healthcare providers in other countries, asks Dr Mary McCauley.

There is no doubt that many people in the United Kingdom (UK) are very passionate about global inequality in childbirth and are keen to help in any way they can.

Many of these people are often healthcare professionals who become international volunteers, skilled individuals who are motivated to offer their services willingly, without consideration for financial gain, in order to make a contribution to another community in a low or middle-income country (LMIC). It well recognised that there is a huge lack of adequately trained healthcare providers in many LMIC, where they are most needed, as it is in these settings that women and their babies are at highest risk of dying or suffering significant ill-health during and after childbirth.

Against the background of this stark inequality in the availability of healthcare providers, the UK government recognise that they have a responsibility to act and support healthcare development in poorer countries. The UK government support a growing number of highly skilled medical professionals (nurses, midwives, doctors) who work in the National Health System (NHS) to engage in voluntary work in LMIC.

There are many types of healthcare volunteer placements available provided by non-governmental organisations (for example, United Nations volunteers, Oxfam, Save the Children), faith based organisations (for example, Christian Medical Fellowship), twinning of hospitals or partnership programmes (for example, Tropical Health & Education Trust) and government volunteering schemes (for example, International Citizen Service).  Healthcare volunteer placements can be long term (one year or more) with the aim of skilled medical professionals working alongside local colleagues in low resource settings to build capacity, train staff and strengthen health systems (for example Voluntary Service Overseas (VSO)). However, short-term placements (for example, two weeks – two months) are more common with the specific aim of providing emergency disaster relief and medical aid (for example, Médecins Sans Frontières and Red Cross) or teaching and training.

One such short-term volunteer project is the ‘Making It Happen’ programme delivered by the Centre for Maternal and Newborn Health (CMNH) at the Liverpool School of Tropical Medicine (Foto-Cewek) that has reduced the number of women and babies who die and suffer complications during and after childbirth in eleven LMIC. This project was funded by the Department of International Development, from the UK government and over the past ten years as part of the ‘Making it Happen’ programme, a pool of 400 volunteers based in the UK have played an integral role in the delivery of the Essential Obstetric and Newborn Care (EOC & NC) training package to 18,598 healthcare providers in India, Bangladesh, Kenya, Zimbabwe, Sierra Leone, South Africa, Malawi, Pakistan, Ghana, Nigeria and Tanzania.

CMNH are currently conducting a survey to assess the views and experiences of all UK facilitators who have worked as volunteers to understand further how sharing of expertise works, what is needed to support it, and to understand the long term effects of volunteering on the countries involved, the NHS and the volunteers themselves.



What is obstetric fistula and what can be done to stop it?


What is a fistula?

 is a horrific condition. Obstetric fistula is the medical term for a hole that affects over one million in women in many low- and middle-income countries. As the result of complications during childbirth, a hole develops between the tissues of a woman’s vagina and her bladder or rectum. The sad fact is that this awful debilitating condition is totally preventable.

What commonly causes obstetric fistula?

An obstetric fistula results from a long and obstructed labour where there is no access to good quality emergency medical care.  It is estimated that 15% of all pregnant women worldwide will experience complications during labour. In the United Kingdom and other high-income countries, emergency obstetric care is readily available and women will quickly receive a Caesarean section to deliver her baby. In many low-and middle-income countries where health systems are much weaker, obstructed labour is much more common and can result in drastic consequences for the mother, possibly even death. If the mother survives obstructed labour, she may have suffered terrible complications resulting in an obstetric fistula and it is likely that her baby will die.

How does the fistula develop?

Women who suffer obstructed labour often live in rural areas in poor countries and do not have the necessary medical help available (skilled birth attendant). Without the ability to travel to a medical facility for help and the possibility of a Caesarean section, labour is unattended and can last up to six or seven days. The baby will die during the process but the labour will continue to cause contractions that push the baby’s head against the mother’s pelvic bone. The soft tissues between the baby’s head and the pelvic bone are compressed and do not receive adequate blood flow. The lack of blood flow causes this delicate tissue to die, and where it dies, holes are created between the labouring mother’s bladder and vagina and/or between the rectum and vagina. These holes result in permanent incontinence of urine and/or faeces. Many of the women who develop fistulas are abandoned by their husbands and ostracised by their communities because of their constant, foul smell.

How many women does this problem affect?

It is estimated that there are over  women suffering with obstetric fistula and the majority of these women living in low- and middle-income countries. Because many women with fistula sustained their injury as teenagers or young women in their first pregnancy, they are likely to suffer from this dreadful condition for the rest of their lives if it is left untreated. Estimates of new cases vary wildly, but it is likely that an additional  suffer from fistula every year.

Can fistula be cured?

An obstetric fistula can be repaired with  by highly skilled doctors.  For every woman that receives treatment, at least 50 go without.  The difficulty is that the surgery is expensive, there are only a small number of doctors with the necessary skills to perform this complicated surgery and the hospitals are very far away from the women’s home in many of these poor countries.

There are a number of charities (, , and) which play a vital role in helping these women by providing free surgical repair and working to end the suffering caused by fistula worldwide.

What can be done to stop fistula occurring?

Obstetric fistula is both preventable and treatable. It can be prevented if women have access to good quality medical care during pregnancy and childbirth, especially when complications arise. Women in low- and middle-income countries must be educated and supported to be able to make decisions regarding when to access medical care. There must be free transport available to the healthcare facility and the women must receive free immediate excellent quality medical care (Caesarean section) when she reaches the healthcare facility.

The Centre for Maternal and Newborn Health at Foto-Cewek firmly advocate that all women have the . The Centre for Maternal and Newborn Health are leading research and training healthcare providers in emergency obstetric care in over 11 countries, not only to prevent maternal death but to improve women’s overall health and well-being during and after pregnancy.


VSO placement in Ethiopia 2012-2013

Mary McCauley, Clinical Research in Medecine Associate and our lead contact at Liverpool School of Tropical Medicine, recounts her experience of working as full time volunteer Obstetrician and Gynaecologist in Ethiopia. 

It’s was harder than I ever imagined. Six dead mothers and countless dead babies in only four months. Pregnancy in Ethiopia really is a life and death struggle. The statistics – 676 maternal deaths for every 100,000 deliveries –never made me cry but the wasted lives before me deeply touched my soul and stole my sleep.

My frustration was that so many of these deaths could have been prevented with proper education, training, and appropriate medical care.

I know of many simple straightforward strategies that could have saved mothers and babies lives. I was armed to the teeth with methodologies on how to improve the management of the delivery ward. But daily I was faced with cultural obstacles and obstructions I’m was not sure how to navigate.

I often heard my Dad’s voice somewhere in my head, ‘Mary, it’s better to light a candle than to sit and curse the darkness. Mary, you can’t change the whole world all at once. Change it one life at a time.’

I knew my assignment was to continue to implement small but effective changes. To inspire others to improve their clinical care. Despite all the complex difficulties I was committed to the placement and up for the challenge! I did make a difference.

My name is Mary McCauley and I am a medical doctor specializing in Obstetrics and Gynaecology. In 2012, I volunteered with Voluntary Services Overseas (VSO) Ireland to work on the labour ward of the Yirgalem General Hospital in Sidoma, in the Southern Nations Nationalities and Peoples’ Regional State in Southern Ethiopia. The Yirgalem General Hospital is a rural area and serves as a referral hospital for a catchment population of over 3 million people.

In 2011, after I completed my medical specialization postgraduate examinations I decided to act on a long-term desire to work in a low income country. So I simply filled in an online application form on VSO Ireland website and within six months I was preparing for my one-year placement in Ethiopa. VSO has a strong relationship with the Royal College for Obstetricians and Gynaecologists (RCOG) who set the guidelines and regulations for my specialty training. Thus it was relatively straightforward to take a career break. Without this relationship I could not have worked in Ethiopia and I am so grateful for this affiliation.

Over half a million women suffer long-term disabilities due to complications during or after pregnancy. In addition at least 300,000 babies die annually across the country.

Ethiopia, like its people, is beautiful and welcoming. It’s also the second poorest country in the world and has unacceptably high child and maternal morbidity and mortality rates. Ethiopia’s 2011 demographic and health survey estimated that 22,000 women die each year giving birth, while over half a million women suffer long-term disabilities due to complications during or after pregnancy. In addition at least 300,000 babies die annually across the country.


The Government of Ethiopia has worked hard to improve the situation attempting to meet the Millennium Development Goal 4 – Reduce Child Mortality and the Millennium Development Goal 5 – Improve Maternal Health that ended in 2015. However, progress was limited due to lack of skilled birth attendants and the poor quality services for basic and comprehensive emergency obstetric and newborn care in many health facilities.

Yirgalem General Hospital especially experienced a critical shortage of health professionals to respond to the health needs of the surrounding communities. VSO is a leading international development organization that believes that work in progress and positive transformation is only possible in partnership with local communities. VSO only work where local partners request our presence. This means there is best use of local knowledge, and an increase in the provision of skills and training directly to communities in need. My role was to increase the capacity of the local maternal health care providers by facilitating knowledge sharing and skills transfer, thereby working to reduce both maternal and child mortality.

The major causes of maternal death in Ethiopia are bleeding after delivery, obstructed labour, infection, complications from miscarriage and severe pre-eclampsia/eclampsia (a disease specific to pregnancy where the blood pressure is severely elevated). The saddest fact is that a large proportion of maternal deaths are attributable to potentially preventable complications during and after pregnancy.

Working in a specialty involved in the care of the pregnant mother and aiming for a safe delivery for herself and her baby is tough. Working in this specialty in the one of the poorest country in our world is extremely tough. That’s why I volunteered to work there with VSO.



Over medicalisation of childbirth


There are two upcoming plays at the B!RTH festival that highlight issues surrounding  and .

Recently I attended two Positive Birth Conferences. One was in London and the other in Dublin. As a midwife who manages a free-standing midwifery led unit in the North of Ireland, I am passionate about creating a positive birth experience for women regardless of mode of delivery or perceived ‘risk’ statuses of pregnancy. I support women in informed decision making regarding choice of place of birth. In the conference in London most of the delegates were midwives or midwifery students.

The focus was on ‘Informed Choice’. One of the speakers suggested that maternity care was used to ‘screen out women and  deny access’ to certain models of care, that is Midwifery Led Unit care model or home birth. One of the pregnant women, Michelle, who attended was pregnant with her third child and was planning a home birth after 2 previous Caesarean section deliveries. She discussed feeling that she was ‘bullied and harassed’ into planning a birth at an obstetric unit in a hospital.

She also felt that once you got pregnant instead of being treated like an intelligent human who should be involved in the decision making process that you were given a limited range of options one of which you had to choose. Even though women in the UK have the right to refuse treatment or recommended place of birth even if it will result in harm to her or the unborn child the persuasive culture of fear often prevents women from exercising this right. Michelle has since safely given birth to a baby boy in her home.

In Dublin, Ina May Gaskin was the guest speaker. She has been called the ‘Mother of Authentic Midwifery’ . She drew a diverse crowd containing a mix of healthcare professionals, pregnant women and their partners. Throughout the day it became apparent that many of the women there had suffered negative experiences as a result of the maternity system in the South of Ireland. Many women cried when asking Ina May questions. They felt if she had been present at their birth or if a midwife had advocated for them they would not have had the negative experience that they had. They stated they felt like survivors of abuse as they had been refused the option of a birth they had wanted, home birth or water birth.

In Irish law women cannot make any decisions regarding place of birth if it is perceived that it poses a risk to the unborn infant. This has resulted in women travelling to England to have home births as they have been denied access to the in Ireland. In my career I have yet to meet a woman who would ever put the life of her unborn child at risk when it comes to choices regarding birth. Unfortunately the maternity system in the South of Ireland is not focused on providing women centred individualised care. Instead administrators, legal teams, policy makers and indeed health professionals continue to take the power way from women and hand it back to a patriarchal system and indeed society.

Ina May Gaskin states that ‘the way we treat women during birth is a good indicator of their value to society’. We still have much work to do if we are to truly value women, honour their informed choice and work in partnership with them throughout pregnancy.


Experiences from Uganda


It was a beautiful bright morning in a small rural town in Northern Uganda.

It was a beautiful bright morning in a small rural town in Northern Uganda. I was walking to the local referral hospital as I had done most mornings since arriving four weeks before. I was volunteering with Voluntary Services Overseas (VSO) as a maternal health specialist for two years. As part of this process I needed to gain registration as a midwife with the Ugandan Nursing and Midwifery Council and undertake a placement within a local government hospital. I had quickly become part of the team and had even been given a Luo name – Apio by the head of midwifery.

On this particular morning as I walked to the maternity building I noticed a group of people had gathered outside the building. They were all visibly distraught. One of my colleagues quickly filled in me on what had happened overnight. A woman had been referred in from a rural health centre for medical assessment as she was in obstructed labour. The clinical officer who was on duty examined the woman and said that she needed an emergency caesarean section delivery. However he requested money to undertake the operation and also that the family provided money for all the equipment needed for the procedure. The husband then returned to his village and sold all of his goats to raise funds for the operation. By the time he returned to the hospital – some six hours later- his wife and baby had died. As I looked at the situation I was overwhelmed with a sense of helplessness.

Life in this situation had been valued at 300,000 Ugandan shillings, the equivalent of £75.

A woman and baby had died unnecessarily due to a medical officer requesting money for an operation he should have undertaken as part of his role. He had not been paid for three months and was obviously under pressure. Life in this situation had been valued at 300,000 Ugandan shillings, the equivalent of £75. As the hospital administrators tried to defuse the situation and promise justice for this family I walked into the labour ward. Everywhere there were labouring women, on the floor, on the old donated birthing couches and some in the corridor. As I put on my gloves to support my hard working fellow midwives and students I hardly had time to reflect on the situation.

I still had so much to learn.

Twelve hours and 20 births later as myself and the other midwives discussed the events of the previous evening one of the said ‘It’s God’s will’. Indeed it’s not I quickly retorted and started to denigrate the entire Ugandan health system. As silence descended and the conversation stopped I realised I was being a typical Muzungu. I still had so much to learn. As I walked home to the sound of laughter in homes and children being called home for the night I realised that, if you have very little for indeed no control over the everyday events in your life, you will justify it by saying it’s fate or suggesting it is indeed God’s way. That way it’s easier to cope and continue to live another day. It doesn’t have to be this way.

The Ugandan system has a lot of challenges and needs to support health system strengthening and tackle corruption but if the women and midwives I meet during my time there are anything to go by …… change is indeed coming. A time will come in the not too distant future where women and their infants will not die unnecessarily in childbirth and Uganda will emerge as a place where women are one of the most valuable assets the country has and be treated as such throughout their entire lifetimes.



Vaginal birth after caesarean

Lisa McGarrity reflects on her experiences of achieving a  with the support of pioneering healthcare providers in Northern Ireland.

I knew that I would have a fight on my hands to get the birth I wanted.

It is deemed necessary for me to have a Caesarean emergency section in 2007 with my first baby. I then chose an elective or planned Caesarean section in 2011 with my second baby. However, I knew before I was even pregnant for a third time, that I wanted to experience a natural .

In Northern Ireland it was generally considered that ‘Once a Caesarean section, always a Caesarean section’ and so I knew that I would have a fight on my hands to get the birth I wanted. I began reading around the subject of  to educate myself on the risks and benefits of both an elective or planned Caesarean section and a vaginal birth. I came to the decision that I would like to try for a natural vaginal birth. During my research I came across the name of a Consultant Obstetrician in Northern Ireland who was supportive of women choices, so I made sure that I booked at the hospital where she worked and requested to be under her care.

At my booking interview with the midwife in the community I explained what I wanted and was met with statements such as ‘They won’t let you do that’ or ‘You will have to ask if you can go past your due date.’ I felt like my choices were not being listened to and I felt deflated. Then came the time for my first hospital appointment where I met with a Consultant Midwife and the Consultant Obstetrician. My experience here could not have been more different!

This time I felt totally empowered.

My requests were such things as ‘no repeat Caesarean-section, no induction, ability to use telemetry (mobile continuous monitoring of the baby’s heart in labour), and to use the water for labour and birth if I chose. They simply said yes to everything and worked with me to reach decisions about my care that I was happy with. This was such a refreshing experience compared to my previous pregnancies! I felt like in the past I was just a number, I just conformed to hospital policy, was never really given the necessary information to make informed decisions regarding induction or elective Caesarean section and the time was never taken to discuss what I actually wanted.

This time I felt totally empowered, I trusted that the team looking after me would only opt for a Caesarean section if totally medically necessary and not just because a policy said my time was up. I had a wonderful pregnancy with only one appointment at 38 weeks upsetting this blissful journey. At the antenatal clinic, I was not seen by my usual Consultant and this other doctor did not take the time to read my notes which contained my birth plan.

At this point I felt like I was just part of a process, she wanted to book a Caesarean section and do an internal examination to stimulate labour, both of which I did not want. When I explained what I wanted she made me feel as if I was mad for even thinking about a natural birth. I went home that day totally distraught, I felt like all my plans would be for nothing and I was so anxious that if I went into labour and arrived at the hospital nobody would listen to me and I would not be strong enough to fight at this point. Thankfully, I called my midwife who had my own doctor call me and ask me to come back down.

I birthed my baby girl into this world with a feeling of total euphoria and elation.

Both of them spoke with me at length, reassuring me that everything I wanted was still ok and that they would both be there to ensure this happened. I came away with a renewed faith and feeling empowered once again. Effective communication is so important. My due date came and went and I still felt calm and in control. I was seen more often for checks and the team were happy for me to go into labour in my own time.

The midwives were all fantastic and I laboured in the water in the hospital with the use of telemetry (monitoring of baby during labour) choosing to get out of the water for the birth. I had a very long second stage (time from full dilatation to delivery of baby: 3 hours 58 mins) and truly believe that had I been under another Consultant’s care and not this particular doctor, then I most certainly would have had been rushed to theatre for a Caesarean section after one hour of pushing.

Instead two weeks over my due date, I birthed my baby girl into this world with a feeling of total euphoria and elation. Nothing will ever come close to the experience of that day for both my husband and I. The care provided to me was excellent, support and most certainly helped me achieve this birth. I will be eternally grateful to both my Consultant Midwife and Consultant Obstetrician for supporting my choices and enabling me to have a safe vaginal delivery.



Breeding like rabbits or living like pandas?


India was the first country in the world to start a state funded family planning programme.

With concerns about the “population bomb”, public health messages on ideal family size changed from “Two or three are enough” to “We two, our two”. During the mid-1970s, the urgency to control the population led to setting of targets for family planning. Reports of forced sterilizations of men and women during this period were among the factors that led to the defeat of the government and a change in name of the programme to Family Welfare. A rose by any name smells sweet – if only this had been a rose!

Forty years later, is the population bomb still ticking in India? The Economist recently reported that the ideal family size in India, China and Indonesia is now smaller than the ideal family size in Britain or America. Fertility rates are falling to replacement levels in many Indian states. Is it true that Indians today are “more like pandas than rabbits”? And if so, why are there still concerns about coerced sterilizations?

Indeed we were more like rabbits in the early 1970s.  As a medical student in the state of Tamil Nadu in the South of India, kwashiorkor (severe protein–energy malnutrition), tetanus (a dangerous infection that can be prevented by proper immunization) and women with several children were common. Yet as only one woman in five gave birth in facilities, we jostled with midwifery students to get the required number of “normal deliveries” for our training. Infection due to unsafe abortion was an everyday occurrence, even though liberal abortion laws had been made early in that decade.

What I saw in the two years after graduation in the neighbouring state of Kerala in the South of India was different. Most women preferred to give birth in hospitals and have tubal ligations after the second or third baby. Malnutrition was not an issue. The only woman with an infection following abortion that I saw during those two years was someone who had had an abortion in a public hospital. People in Kerala are well known for the achievements in health, and are more like pandas. The high literacy rate over several decades particularly among women is one of the many reasons attributed to the health status in this state. Literacy rates in Tamil Nadu were comparatively lower.

Tamil Nadu however did not lag behind for long. With good governance, greater urbanisation, improved water and sanitation, fall in vaccine preventable diseases and better attention to child nutrition, child survival rates improved rapidly in the 1980s and 1990s. Students in the mid-1990s in my university learned about kwashiorkor, tetanus and problems of women having several children only from text books. With better child survival, women and their families did not see the need to have several children to make sure that the desired numbers survived. Having only two children became the norm.

To ensure that both children were born healthy, women preferred to give birth in facilities, and not at home. Traditional birth attendants practically vanished. Unfortunately, male contraceptive use is still limited. Injectable contraceptives are not available through the public system. Intrauterine devices are used more often for birth spacing but voluntary female sterilization after two children is very common.

Unfortunately, the situation is not the same everywhere. In states with poor governance and dysfunctional systems, there is lack of accountability that adversely impacts on health and development.   Assembly line style laparoscopic tubal ligations still exist. In 2014, 83 women in Chhattisgarh were reportedly operated during a one and a half hour period by one laparoscopic surgeon using the same equipment. Sixteen young women lost their lives in the days following the camp, most likely from infection. Reaching targets seem more important than providing quality care. Low expectations from an undemanding and often illiterate population further contribute to the problem. Improvements will come only when communities become aware of their rights and demand greater accountability. Until then many breeding rabbits may continue to die as flies.