Mothers betrayed

Every year half a million women die in childbirth, deaths easily prevented. Here Sarah Brown, wife o

Two weeks ago, at Mulago Hospital in Kampala, I sat down next to a mother called Sylvia, resting in bed with her newborn baby after a successful delivery, nearly ready to return to her husband and five older children.

But I also looked through a window into a room containing eight babies, none more than two days old, their little cots covered in malaria nets. The doctors explained to me that in each of these cases, and hundreds more like them in the same hospital each year, the mother had died in childbirth.

The causes of death varied from bleeding and infection to high blood pressure and failure to survive a Caesarean section - all so easily preventable by modern western standards. In Britain, for the same reasons, the death of a mother in childbirth was once a common hazard, a fixture of Victorian life.

Improvements over the past century in antenatal care, health education, and obstetric and gynaecological care have lowered the risks of childbirth. There may be more to do at home, particularly on the health risks to newborn babies. But nowadays, only seven in 100,000 women die when giving birth in Britain.

In sub-Saharan Africa, the conditions and health care for mothers in childbirth are often no better, and sometimes far worse, than we had in Victorian times. In 1987, more than 500,000 women were dying in pregnancy or childbirth every year across the world, 99 per cent of them in developing countries. More than half of all women were delivering their babies with no skilled birth attendant present.

It was because of this terrible toll that 20 years ago, the Global Safe Motherhood Initiative was launched by the World Health Organisation to try to reduce the rates of maternal death. In 2000, the United Nations recognised the shocking rates of maternal death and made their reduction one of the Millennium Development Goals. The fifth MDG committed the wealthiest nations to cut maternal mortality by three-quarters between 1990 and 2015.

Tragically, 20 years after the Global Safe Motherhood Initiative, seven years after the UN Millennium Summit, no progress has been made. If anything, the figures are worse. Of 211 million pregnancies worldwide in 2005, eight million women experienced life-threatening complications during pregnancy or childbirth.

Those with access to skilled care and services tended to survive. But 536,000 died, the vast majority in developing countries, 80 per cent of them totally avoidable. Millions more have continuing health difficulties following obstetric complications, making life after childbirth difficult and painful.

In sub-Saharan Africa, the number of mothers dying in childbirth is around one in 50: up to 100,000 women die each year, and hundreds of thousands of babies and older children are left without a mother.

Visit hospitals in Africa and it is easy to see why. While the Commonwealth Heads of Government Meeting was going on in Uganda, I visited labour wards and delivery rooms at Muhimbili Hospital in Dar es Salaam and Mulago Hospital in Kampala. They are both huge referral hospitals attracting many women from across each city, and they offer the only real emergency obstetric care in their areas.

Mulago alone sees the delivery of 33,000 babies a year, almost one hundred a day. Compare that to the Edinburgh Royal Infirmary where my children were born, which is considered a big UK facility and where just 6,000 babies are delivered each year.

In all my visits, I saw overstretched services at work, committed teams with too few con sultants, nurses and midwives, and insufficient equipment and technical provision. Shortages included basic supplies such as sutures and painkillers, which run out whenever there is an extra-busy day for Caesarean sections or other emergency procedures.

The governments in Tanzania and Uganda are doing their best to make progress.

The Tanzanian president, Jakaya Kikwete, told me this was a personal passion for him, and that his government had pledged to put dispensaries around the country that could also offer antenatal care. In Uganda, I saw the nearly completed refurbishment of a maternity block in the Mulago Hospital grounds. But still the death toll remains stubbornly high.

And what makes the lack of any progress on maternal mortality so depressing and frustrating is that, on other Millennium Development Goals, some progress - albeit slowly - is being made and things are beginning to improve. Millions more children are surviving infancy, receiving vaccinations and going to primary school than were in 2000, their life chances transformed by better health care and education. Even in the uphill struggle against Aids, great progress is being made. In Uganda, HIV infection has fallen from 16 per cent to 5 per cent in the past decade.

Yet we know that for hundreds of thousands of children each year, the improvements we make to their life chances through better edu cation and health care are cancelled out by the loss of their mother. For every mother who dies in childbirth, the life chances of a new baby - as well as its brothers and sisters - can be damaged beyond repair.

Avoidable deaths

It is obviously harder for a child to survive, grow and have a life with choices if there is no mother to provide care, food, protection and education. The statistics bear this out. A study in Indonesia showed that 14 per cent of children aged six to ten who had lost mothers dropped out of school, compared to only 7 per cent of those who had not. Poverty as an adult was far more likely for the former group.

The same study showed that children without mothers were four times more likely to die in their early years - usually of malnutrition or disease - compared to other children.

Internationally, pressure is growing, through the White Ribbon Alliance, a global campaign group dedicated to highlighting the avoidable tragedy of maternal death, supported by the WHO's Making Pregnancy Safer campaign and the Partnership for Maternal, Newborn and Child Health. In the UK, the White Ribbon Alliance is led by the Royal College of Obstetricians and Gynaecologists (RCOG) and I sit on its international advisory group. This has given me the opportunity to meet some of the world's leading experts in this field. It has opened my eyes to the impact of maternal death on the life chances of infants.

The general causes are well understood: high fertility rates lead to greater pressure on resources, inadequate and inaccessible health care makes childbirth inherently risky, and women's low status economically and culturally affects their access to health services and the priority they are given.

There is also broad agreement on the solutions required: greater resources, better education, better access to emergency care, availability of antenatal care to spot problems in advance and quick referrals for mothers with complications.

The RCOG International Office has designed a course teaching young consultants essential obstetric and newborn care. The course is available in Tanzania and Kenya, and I hope it will soon be extended to Uganda. Accompanied by Tony Falconer, RCOG senior vice-president, I met a young doctor in the antenatal clinic at Muhimbili Hospital who had completed the course two months before, and thought his training had already helped him save lives.

The RCOG is taking this work further. In South Africa, it is working to help obstetric experts develop a training package for all local doctors in their third postgraduate year, generally spent in more remote conditions. Momentum is building. I am hopeful that a special session will be devoted to maternal death at next year's international summit in Davos and the Bill and Melinda Gates Foundation is funding projects around the world to raise awareness.

At home, just over a month ago, the International Development Secretary, Douglas Alexander, announced at a conference in London that the UK would commit an extra £100m towards improvements in reproductive health. To meet any of the Millennium Development Goals, we need the will, the means and the momentum. We have seen this in relation to vaccinations, free education and the fight against Aids. Now we must see it on the issue of maternal death, where no significant progress has been made, not just in the past seven years, but in the past two decades.

Each developing country needs a strategic health plan that takes account of local situations, expanding services so that populated central and remote areas alike acquire trained people and resources. The investment needed to improve maternal health is small, but the gains for the poorest children in the world will be huge. We must make 2008 the first year of progress on this neglected Millennium Development Goal.

Sarah Brown sits on the international advisory board of the Royal College of Obstetricians. As founder of the Jennifer Brown Fund, she has been closely involved for the past six years in the area of infant and maternal health

This article first appeared in the 10 December 2007 issue of the New Statesman, How New Labour turned toxic

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The age of loneliness

Profound changes in technology, work and community are transforming our ultrasocial species into a population of loners.

Our dominant ideology is based on a lie. A series of lies, in fact, but I’ll focus on just one. This is the claim that we are, above all else, self-interested – that we seek to enhance our own wealth and power with little regard for the impact on others.

Some economists use a term to describe this presumed state of being – Homo economicus, or self-maximising man. The concept was formulated, by J S Mill and others, as a thought experiment. Soon it became a modelling tool. Then it became an ideal. Then it evolved into a description of who we really are.

It could not be further from the truth. To study human behaviour is to become aware of how weird we are. Many species will go to great lengths to help and protect their close kin. One or two will show occasional altruism towards unrelated members of their kind. But no species possesses a capacity for general altruism that is anywhere close to our own.

With the possible exception of naked mole-rats, we have the most social minds of all mammals. These minds evolved as an essential means of survival. Slow, weak, armed with rounded teeth and flimsy nails in a world of fangs and claws and horns and tusks, we survived through co-operation, reciprocity and mutual defence, all of which developed to a remarkable degree.

A review paper in the journal Frontiers in Psychology observes that Homo economicus  might be a reasonable description of chimpanzees. “Outsiders . . . would not expect to receive offers of food or solicitude; rather, they would be fiercely attacked . . . food is shared only under harassment; even mothers will not voluntarily offer novel foods to their own infants unless the infants beg for them.” But it is an unreasonable description of human beings.

How many of your friends, colleagues and neighbours behave like chimpanzees? A few, perhaps. If so, are they respected or reviled? Some people do appear to act as if they have no interests but their own – Philip Green and Mike Ashley strike me as possible examples – but their behaviour ­attracts general revulsion. The news is filled with spectacular instances of human viciousness: although psychopaths are rare, their deeds fill the papers. Daily acts of kindness are seldom reported, because they are everywhere.

Every day, I see people helping others with luggage, offering to cede their place in a queue, giving money to the homeless, setting aside time for others, volunteering for causes that offer no material reward. Alongside these quotidian instances are extreme and stunning cases. I think of my Dutch mother-in-law, whose family took in a six-year-old Jewish boy – a stranger – and hid him in their house for two years during the German occupation of the Netherlands. Had he been discovered, they would all have been sent to a concentration camp.

Studies suggest that altruistic tendencies are innate: from the age of 14 months, children try to help each other, attempting to hand over objects another child can’t reach. At the age of two, they start to share valued possessions. By the time they are three, they begin to protest against other people’s violation of moral norms.

Perhaps because we are told by the media, think tanks and politicians that competition and self-interest are the defining norms of human life, we disastrously mischaracterise the way in which other people behave. A survey commissioned by the Common Cause Foundation reported that 78 per cent of respondents believe others to be more selfish than they really are.

I do not wish to suggest that this mythology of selfishness is the sole or even principal cause of the epidemic of loneliness now sweeping the world. But it is likely to contribute to the plague by breeding suspicion and a sense of threat. It also appears to provide a doctrine of justification for those afflicted by isolation, a doctrine that sees individualism as a higher state of existence than community. Perhaps it is hardly surprising that Britain, the European nation in which neoliberalism is most advanced, is, according to government figures, the loneliness capital of Europe.

There are several possible reasons for the atomisation now suffered by the supremely social mammal. Work, which used to bring us together, now disperses us: many people have neither fixed workplaces nor regular colleagues and regular hours. Our leisure time has undergone a similar transformation: cinema replaced by television, sport by computer games, time with friends by time on Facebook.

Social media seems to cut both ways: it brings us together and sets us apart. It helps us to stay in touch, but also cultivates a tendency that surely enhances other people’s sense of isolation: a determination to persuade your followers that you’re having a great time. FOMO – fear of missing out – seems, at least in my mind, to be closely ­associated with loneliness.

Children’s lives in particular have been transformed: since the 1970s, their unaccompanied home range (in other words, the area they roam without adult supervision) has declined in Britain by almost 90 per cent. Not only does this remove them from contact with the natural world, but it limits their contact with other children. When kids played out on the street or in the woods, they quickly formed their own tribes, learning the social skills that would see them through life.

An ageing population, family and community breakdown, the decline of institutions such as churches and trade unions, the switch from public transport to private, inequality, an alienating ethic of consumerism, the loss of common purpose: all these are likely to contribute to one of the most dangerous epidemics of our time.

Yes, I do mean dangerous. The stress response triggered by loneliness raises blood pressure and impairs the immune system. Loneliness enhances the risk of depression, paranoia, addiction, cognitive decline, dem­entia, heart disease, stroke, viral infection, accidents and suicide. It is as potent a cause of early death as smoking 15 cigarettes a day, and can be twice as deadly as obesity.

Perhaps because we are in thrall to the ideology that helps to cause the problem, we turn to the market to try to solve it. Over the past few weeks, the discovery of a new American profession, the people-walker (taking human beings for walks), has caused a small sensation in the media. In Japan there is a fully fledged market for friendship: you can hire friends by the hour with whom to chat and eat and watch TV; or, more disturbingly, to pose for pictures that you can post on social media. They are rented as mourners at funerals and guests at weddings. A recent article describes how a fake friend was used to replace a sister with whom the bride had fallen out. What would the bride’s mother make of it? No problem: she had been rented, too. In September we learned that similar customs have been followed in Britain for some time: an early foray into business for the Home Secretary, Amber Rudd, involved offering to lease her posh friends to underpopulated weddings.



My own experience fits the current pattern: the high incidence of loneliness suffered by people between the ages of 18 and 34. I have sometimes been lonely before and after that period, but it was during those years that I was most afflicted. The worst episode struck when I returned to Britain after six years working in West Papua, Brazil and East Africa. In those parts I sometimes felt like a ghost, drifting through societies to which I did not belong. I was often socially isolated, but I seldom felt lonely, perhaps because the issues I was investigating were so absorbing and the work so frightening that I was swept along by adrenalin and a sense of purpose.

When I came home, however, I fell into a mineshaft. My university friends, with their proper jobs, expensive mortgages and settled, prematurely aged lives, had become incomprehensible to me, and the life I had been leading seemed incomprehensible to everyone. Though feeling like a ghost abroad was in some ways liberating – a psychic decluttering that permitted an intense process of discovery – feeling like a ghost at home was terrifying. I existed, people acknowledged me, greeted me cordially, but I just could not connect. Wherever I went, I heard my own voice bouncing back at me.

Eventually I made new friends. But I still feel scarred by that time, and fearful that such desolation may recur, particularly in old age. These days, my loneliest moments come immediately after I’ve given a talk, when I’m surrounded by people congratulating me or asking questions. I often experience a falling sensation: their voices seem to recede above my head. I think it arises from the nature of the contact: because I can’t speak to anyone for more than a few seconds, it feels like social media brought to life.

The word “sullen” evolved from the Old French solain, which means “lonely”. Loneliness is associated with an enhanced perception of social threat, so one of its paradoxical consequences is a tendency to shut yourself off from strangers. When I was lonely, I felt like lashing out at the society from which I perceived myself excluded, as if the problem lay with other people. To read any comment thread is, I feel, to witness this tendency: you find people who are plainly making efforts to connect, but who do so by insulting and abusing, alienating the rest of the thread with their evident misanthropy. Perhaps some people really are rugged individualists. But others – especially online – appear to use that persona as a rationale for involuntary isolation.

Whatever the reasons might be, it is as if a spell had been cast on us, transforming this ultrasocial species into a population of loners. Like a parasite enhancing the conditions for its own survival, loneliness impedes its own cure by breeding shame and shyness. The work of groups such as Age UK, Mind, Positive Ageing and the Campaign to End Loneliness is life-saving.

When I first wrote about this subject, and the article went viral, several publishers urged me to write a book on the theme. Three years sitting at my desk, studying isolation: what’s the second prize? But I found another way of working on the issue, a way that engages me with others, rather than removing me. With the brilliant musician Ewan McLennan, I have written a concept album (I wrote the first draft of the lyrics; he refined them and wrote the music). Our aim is to use it to help break the spell, with performances of both music and the spoken word designed to bring people together –which, we hope, will end with a party at the nearest pub.

By itself, our work can make only a tiny contribution to addressing the epidemic. But I hope that, both by helping people to acknowledge it and by using the power of music to create common sentiment, we can at least begin to identify the barriers that separate us from others, and to remember that we are not the selfish, ruthless beings we are told we are.

“Breaking the Spell of Loneliness” by Ewan McLennan and George Monbiot is out now. For a full list of forthcoming gigs visit:

This article first appeared in the 20 October 2016 issue of the New Statesman, Brothers in blood