The daily lottery of life and death

By Mukesh Kapila

The act of giving birth is still very much a lottery with the dice loaded according to who you are and where you live.

There are about 7.4 billion people on the planet. Left to nature alone, there would be approximately the same numbers of males and females: women tend to live longer but that is compensated by more boys being born.  But, overall, there are 60 million fewer females in the world than should be the case largely because they have not been allowed to be born or to live due to strong gender preferences in countries such as China and India.

If 60 million people were suddenly disappeared, you may scream blue bloody murder or even “genocide”. But we don’t do so because selective female abortions and infanticide happen insidiously. But indeed, it is still a form of genocide or “femicide”: the targeting of a section of the population on account of its identity as females.

So inequality and injustice are structured-in even before some of us are allowed to take our first breath. Of the 7.4 billion population, nearly a billion live in the least developed regions of the world.  If you are a woman in a rich country, you may expect to live 82 years and bear 1.7 children along the way. But if you are poor in a very poor country, you would bear 4.3 children and will be lucky to get past your 66th birthday. Being poor in the wrong place robs the average woman of 16 years of life.

Some 300,000 women worldwide die each year due to the complications of pregnancy and childbirth. That is more than 800 a day. Of this more than 700 live and die in sub Saharan Africa and South Asia and nearly all the others perish in other poor countries. Only 5 of these 800 luckless women die in the developed world. The vast majority of these deaths – perhaps 9 out of 10 – are entirely preventable.

Put another way, the lifetime chance of a woman dying from maternity in the poorest and most fragile countries is some 2% or hundred-fold the 0.02% chance of so dying in the richest parts of the world.

Furthermore, deceased mothers continue to cause negative impact beyond their untimely graves. A million children are left motherless each year. Their start in highly precarious. A child whose mother dies during childbirth is 3-10 times more likely to die before his or her second birthday.

To add to the insult are the injuries the world deliberately inflicts upon women with a direct impact on their birthing experience.

I saw that for myself for the first time as a medical student in the 1970s visiting a village in India where a young pregnant woman had an at-term baby dead inside her – the victim of domestic violence by her alcoholic husband. The only way to save her was to deliver the baby through a destructive operation that you only see described in old surgical text books – by decapitating its head and cutting other body parts off to get them out piece by piece.

An extreme illustration perhaps of a daily reality: 1 in 3 of all women worldwide have experienced either physical and/or sexual intimate partner violence or non-partner sexual violence in their lifetime. And domestic violence appears to increase during pregnancy. Worldwide studies have indicated that around 10% – and in places up to 30% – of pregnant mothers report being violently abused with self-evident consequences.

As I began my medical career, one of my first experiences – here in England – was helping a more senior obstetric colleague to deal with obstructed labour in a young Somali woman in labour who had suffered from female genital cutting at the age of 12. There are more than 200 million girls and women like her who have undergone female genital mutilation with some 3 million additional girls at risk every year. In some countries such as Sudan, the prevalence of female genital cutting is 80-90%.

In the UK, we have more than 130,000 women living with female genital mutilation.  The most serious form of genital cutting affects at least 8 million women worldwide. The severe consequences of this are seen in virtually 100% of the cases, in terms of infections, complicated deliveries and postnatal complications for the mother such as fistula and the subsequent ostracism of the unfortunate women by their husbands and communities.

There are many other familiar forms of violence against women with a direct bearing on the birth experience. Rape is well-established as a weapon of war and the forced impregnation of women is recognised as a characteristic of genocide. I saw this for myself in Rwanda in 1994 where over the course of 100 days between 250,000 and 500,000 women were raped. Two-thirds of whom got infected with HIV and up to 20,000 children were born as a result of rape, thousands of whom were also HIV infected.

Ten years later in 2003/04, as the head of the United Nations in Sudan, I saw mass rape in effect all over again in Darfur – the pregnant victims of which were systematically denied medical help let alone justice. The birth experience has a whole different and traumatic meaning for them – leaving a legacy for life and transmitted across generations.

A few weeks ago, I visited Calais where 5000 people live under terrible ramshackle conditions in the so-called “jungle camp”, many of them aspiring to somehow and eventually reach the UK. Coming from Sudan, Syria, Somalia, Iraq, Eritrea, Afghanistan, and elsewhere they are a microcosm of the world at war. Each mother – baby in tow or pregnant – had a unique story to tell. Of fear. Of violence. Of separation. But also of courage and resilience. For them too birth also means something very different. At the least, what will be the status of their babies? Sans-papiers, would they be stateless? And therefore legally not exist. What chances then for their future?

As this lottery of life and death plays out between and within countries, we may remember that we live in an era where never before have we known so much or accumulated so many capacities and resources to apply that knowledge in the service of humanity. We know, for example, that spacing births two or more years apart significantly reduces the risk of maternal and newborn death. But still some 222 million women who want to delay or avoid pregnancy don’t access contraception. We know that skilled professional birth attendants can make a difference to the health and survival chances of both mother and child.  But still only around half of all births in Sub-Saharan Africa take place with the help of a skilled birth attendant.

Of course behind these numerous statistics are real faces and we remember them from their unique experiences – from Rwanda to Syria, from India to Darfur, from Afghanistan to Calais and right here in England.

To an extent living and dying will always be a chancy business. But does the dice have to be so unfairly loaded for so many women? The birth debate is eventually about shining a light on the world we live in, how and why it is disordered the way it is, and what we must do as individuals to re-shape it.

The statistics quoted here are taken from a range of United Nations, World Health Organization, and World Bank sources.

This post already appeared on and is reposted here with permission.