Gulnura Toralieva in London (RCA No. 597, 09-Dec-09)
Figures showing a rise in the number of women dying in childbirth have only confirmed the multiple challenges facing maternity provision in Kyrgyzstan, which is short of qualified hospital staff, medical supplies and equipment.
From January to the end of August, the latest period for which national data are available, 58 deaths were recorded among mothers during pregnancy, childbirth and the post-delivery period. The figure for eight months was ten more than for the whole of 2008.
The figures were announced at a national congress of Kyrgyzstan midwives, paediatricians and paediatric surgeons held in the capital Bishkek on October 29-30.
As the meeting took place, investigations were continuing into the deaths of four women at Bishkek's perinatal centre between July 1 and August 18.
According to a statement published on the health ministry website, the women, aged between 29 and 36, died as a result of "gross procedural mistakes made while they were under supervision in the pregnancy and delivery stages, or when they experienced complications after delivery".
The statement said the four fatalities - out of a total of six at the hospital over this period - were avoidable, and prosecutions were brought against suspects charged with "inappropriate conduct of professional duties". The chief doctor of the perinatal centre and his deputy were sacked.
The deaths were the subject of two separate inquiries - one by a special team set up by the health ministry, and the other by a commission consisting of ministry specialists, representatives of the human rights ombudsman, and members of parliament.
On December 7, the AKIpress news agency quoted deputy health minister Abdimanap Muratov as saying a third commission, set up by the Kyrgyz parliament, would convene in February to look at the issue of maternal maternity across the country.
The results of the ministry's own investigation, which were made known on September 16, showed that the first death, on July 1, occurred because staff did not have enough plasma to replace blood lost during bleeding. A second woman died on July 31 when she was given a drug to which she was allergic. A poorly conducted medical intervention led to another fatality on August 4, while the fourth fatality occurred on August 18, once again due to flawed procedures at the emergency unit to which she had been admitted.
The investigative team also highlighted the main problem areas, in particular in cases involving emergency treatment, when decision-making was dilatory, communication between staff was poor, and standard procedures were not followed.
Nor was there any systematic analysis of the medical histories of cases involving complications during childbirth, the commission said.
What is clear is that maternity care is deficient across Kyrgyzstan rather than just in this one hospital. Deputy health minister Muratov told AKIpress that teams from the ministry had inspected medical facilities in Naryn, Issykkul and Osh regions and found high rates of maternal mortality.
Dr. Ernest Akramov, a leading surgeon and also a member of parliament, told IWPR the situation was unacceptable.
"Dozens of cases of fatalities among expectant mothers amounts to criminal negligence on the part of society," he said. "It comes down to the state paying inadequate attention to medical staff - there are no schools for upgrading medics' skills, and no schools for midwives or gynaecologists."
Another member of parliament, Zulkhabira Bekenova, agreed that Kyrgyzstan's medical training was deficient.
"Punishing doctors who are found responsible [for deaths] is not ultimately going to fix the problem; it requires a deeper analysis," she concluded.
Many doctors, both recent graduates and mid-career professionals, have joined the brain drain from the underfunded and poorly-paid state sector.
Some go into private medicine, others abroad. Either way they can earn much more, but that leaves the state hospitals with a severe shortage of experienced staff, which is hard to make up given the length of time it takes to train a doctor.
As Dinara Sagynbaeva, head of the health ministry's medical provision department, points out, things are even worse in the countryside, where she describes the shortage of midwives and other staff as "catastrophic".
"Young people don't want to work for 3,000 soms [under 70 US dollars] a month, so the only doctors who stay on are those who are close to retirement," she said.
Maternity hospitals have to cope with shortages of pharmaceuticals, obsolete infrastructure, inadequate numbers of ambulances and intermittent supplies of electricity, heating and even water.
"We've been forced to provide generators - paid for by donors - to all the maternity units in the country, for when the electricity goes off," she said.
While the current cases involve professional negligence, Sagynbaeva said that when complications arose in pregnancy and birth, another contributory factor was the attitude displayed by mothers-to-be.
Around 45 per cent of women who gave birth last year had not previously registered with the health authorities, she said, adding that "even when they do sign up, they miss appointments and don't follow doctors' orders".
Pregnant women among the large number of female labour migrants in Russia and Kazakstan present a particular problem, as they often delay returning home to give birth until the last minute, the health official said.
Member of parliament Dinara Moldosheva, agreed that "lack of awareness among women about pregnancy, as well as families being ill-prepared for the pregnancy, are factors in childbirth mortality".
She added, "It is no secret that female mortality is a phenomenon caused by social problems. A higher mortality rate reflects a country's low level of social and economic development."
The maternity death scandal seems to be prompting some expectant women in Kyrgyzstan to look for other options - if they can afford it.
Ayjan Mambetalieva, an aspiring PhD student in the capital Bishkek, is due to have her baby in a couple of months' time. Now she has decided to go to Almaty, Kazakstan's biggest city, which is not far from the Kyrgyz border.
"Childbirth is a scary enough experience as it is, but after the recent TV and newspaper coverage, it's become even more alarming," she said. "Of course it'll be difficult to give birth in a different country, as I'll have to go there ahead of time and then come back with my new baby amid the cold of winter. But I still feel more reassured this way - I don't have confidence in the doctors here."
She added, "I can't imagine what other women can do. Not everyone has the money to get out of giving birth in a state hospital."
Gulnura Toralieva is an IWPR-trained journalist.