It's A...The excitement and wonder of seeing a picture of their baby in the womb was singular to the moms in the Americas. In Chicago, Quintana also was delighted to see that she was having a girl. Her son and first child, Alex, studied the image and declared his excitement at having a sister. Quintana had already settled on a name, ShaLawn, which she used in her byline, her nom de plume.
In Guatemala, ultrasounds were rarer. Most of the women in the Palajunoj Valley went to Primeros Pasos every two months for their prenatal checkups. That was more convenient and less expensive than making a trip to the city, but at the time there was no ultrasound machine at the clinic. Only when they went to the regional government hospital in Quetzaltenango did they get an ultrasound, which did not happen often, and sometimes not until they were ready to deliver. Once during her pregnancy Dianet Coyoy did take the thirty-minute bus ride into the city for a checkup. She received an ultrasound, which revealed she was carrying a girl. Dianet rejoiced, but her celebration was tempered when she returned home to find her joyous news greeted with skepticism. “No, no, not a girl,” she was told more than once by family members. “No, your belly is low. It will be a boy.” The ultrasound was wrong, they told her.
In both Ongica and Shivgarh, there were no pictures, no wonders, no excitement, no ultrasounds. “No power, no power.” That was the constant refrain Harriet in Uganda heard when she went to the regional hospital in Lira for a checkup several weeks before her due date. She had suddenly been feeling listless and dizzy; a nurse at the Ongica clinic, where there is no ultrasound machine, suspected she had high blood pressure and referred her to the hospital for a routine fetal scan to make sure the baby was well. But as Harriet learned, the mere presence of a machine didn’t necessarily benefit her. The facility needed electricity to run the ultrasound and a technician to fi x it when it broke down, which was often. Neither was available the day Harriet showed up. She returned home, no wiser or healthier.
Harriet’s malaise deepened. Try as she might, she couldn’t work in the fields without getting tired and needing a rest, even though the sweet-potato harvest had just begun. This wasn’t like her; she was always a hard worker. Now she was weak and had lost her appetite. She had battled malaria a few months earlier; maybe, she worried, she was having a relapse. Her legs were swelling and the headaches were becoming more persistent. She went to the clinic and was again referred to the regional hospital in Lira. She hitched a ride on the back of a motorcycle and rode sidesaddle for the twenty-minute journey. There, a doctor told her she was anemic and had high blood pressure; noting a risk of preeclampsia, the doctor checked her in for bed rest. It was now three weeks before Harriet was due. The doctor and nurses expected her to have a normal delivery. Still, they offered her the opportunity to have an ultrasound. This time, the power was fine. But there was another problem. The cost was 15,000 Ugandan shillings, or about $7. It would take several days of work crushing stones at the quarry to cover that. Harriet and her husband agreed it was too expensive. Again, poverty played the trump card. Harriet pleaded with a nurse, but she was told they would do a scan for free only if there was an emergency. “No money, no scan,” she was told. Instead, the nurse listened through an old-fashioned fetal scope and heard a heartbeat. She believed neither Harriet nor the baby were in any imminent danger.
In the rural areas of India, it was rare that an ultrasound would even be offered. When I asked a gathering of moms and moms-to-be in Shivgarh if any of them had received an ultrasound, or would expect to, there was initial silence. Then muffled laughter. And then animated chatter. For them, it was a silly question. “It’s generally prohibited,” one woman coldly explained. The information, particularly if it showed a girl, could be used for an abortion, she said. “No, no ultrasounds.”
Rather than bringing the joy that Jessica and Quintana and Dianet experienced, an image of a girl in the womb here could lead to great tragedy. Official statistics put the annual number of abortions in India at several hundred thousand, but maternal and child health advocates believed the actual number was far higher, for many of the abortions happened in unauthorized facilities. National census figures had revealed a steady decline over the previous decade in the number of girls compared to boys up to age six. Domestic and international organizations advocating access to safe abortions estimated that a woman died every two hours from an unsafe abortion in India.
Beyond the experience of seeing an image of your child, ultrasounds are also valuable in assessing the health of babies and mothers. Quintana, already at risk of preeclampsia from high blood pressure, worried that the stress from her job—during her pregnancy, she was the only teacher in her office visiting classes on Chicago’s South Side—was also affecting her baby. So Quintana saw her doctor nearly every week, especially in the third trimester, to make sure everything was okay with her and the child. Jessica, too, would head to her doctor at any sign of worry. She complained that one teacher at her high school wouldn’t make a special allowance for her to bring a water bottle into class, so she battled dehydration at times. One time she feared that the baby had stopped moving; an ultrasound eased her concern.
In Uganda, India, and Guatemala, the women mainly worried alone, and their maladies remained a mystery. In India, Sanju’s doctor sent her to a city hospital an hour away from her home for an ultrasound, but she didn’t understand why it was necessary. She returned home still wondering. She later told me that no one had explained to her whether they had spotted any complications—or if they did, this woman with no education had not comprehended what they had said. Sanju doubted that the machine even worked. She certainly wasn’t given an image.
Few of the moms in India and Uganda complied with the World Health Organization (WHO) recommendation of going to at least four prenatal-care visits with trained health workers. The distances to a clinic or hospital were too far, the travel too time consuming and costly, the medicines too expensive, the trained health workers too rare. The WHO had determined that four visits were the minimum needed to get a tetanus vaccination and proper screening and treatment for infections and any other potential problems. But, according to the WHO’s own research during the period 2006–2013, barely half of all pregnant women in the world made the minimum four visits; in low-income countries, it was only slightly more than a third. In Uttar Pradesh, one of India’s poorest states, just one-quarter of pregnant women went to any prenatal checkups. In Uganda, a government study revealed that although 95 percent of pregnant women attended their first prenatal visit, to confirm a pregnancy, only 48 percent completed the four visits—and most of those who did lived in urban areas. This meant they also missed out on the distribution of iron and folic-acid tablets and malaria pills. Only one in two women who visited a clinic were warned about pregnancy complications. (Even in the United States, not all pregnant women met the WHO standards; one study revealed that 6 percent of women received no or late prenatal care, and that most of the women who fell into this category were African American or Latina.)
Once they did reach a clinic or hospital for a prenatal checkup, mothers in the developing world would often find scarce staffing and appalling infrastructure conditions. Officials at the WHO and the United Nations Children’s Fund themselves seemed shocked at the overall wretchedness of conditions revealed in their first multi-country review of water, sanitation, and hygiene services in health-care facilities. They called the findings “alarming.” Reviewing data from 54 low- and middle-income countries representing more than 66,000 health-care facilities, the report concluded that 38 percent of these facilities lacked access to an improved water source, 19 percent didn’t provide sanitation, and 35 percent didn’t have soap and water for handwashing. It is hardly surprising then that functioning ultrasound equipment wasn’t high on many priority lists.
The consequences of these deficiencies can be fatal, as infections can quickly spread in such conditions. The report said sepsis and other severe infections are major killers, one of the leading causes of maternal and infant deaths. The risks associated with sepsis are thirty-four times greater in low-resource settings. The impact is particularly pronounced for newborns. Poor hygiene during and after umbilical cord cutting—unclean hands, a dirty blade, filthy cloth—produce untold numbers of cord site infections. In many places, moms must bring their own blades, soap, and cloth—if they can afford them or even access them—and sometimes their own water. In facilities without toilets, women in labor need to walk outside to relieve themselves.
“The health consequences of poor water, sanitation and hygiene services are enormous. I can think of no other environmental determinant that causes such profound, debilitating and dehumanizing misery,” said Margaret Chan, WHO director general, at the release of the damning report.
These conditions compromised the ability to provide basic, routine services such as child delivery and hindered the effort to prevent and control infections. As did a lack of staffing: more than 50 countries had fewer than the minimum 23 doctors, nurses, or midwives per 10,000 people deemed necessary by the WHO and other international organizations to achieve an 80 percent coverage rate for prenatal care and deliveries by skilled birth attendants. A report by Save the Children, Surviving the First Day, noted that sub-Saharan Africa had only 11 doctors, nurses, or midwives per 10,000 people, and that South Asia had only about 14.
All these deficiencies add up to one of the world’s great inequalities. According to the World Bank, child mortality is about fifteen times greater in lower-income countries than in rich-world countries, and maternal mortality is nearly thirty times higher. Almost all of those deaths are preventable.
The First 1,000 Days: A Crucial Time for Mothers and Children—And the World is now available for purchase on Amazon. Learn more about the book in this exclusive preview video: