By Nino Gvedashvili - Caucasus
Maternal mortality rates remain stubbornly high in Georgia, a result of failing healthcare systems and low levels of awareness, experts say.
The government has pledged to reduce the number of deaths among new mothers by two-thirds by 2015.
Maternal mortality is often highlighted in the Georgia media. In recent months, TV reports have carried news of seven women dying in childbirth or as a result of complications in labour.
According to the United Nations, which bases its Maternal Mortality Ratio on the number of deaths arising from pregnancy or childbirth within 42 days of the birth, the rate rose by 20 per cent in the decade after 1990, from 41 to 70 deaths per 100,000 births. The figure has improved a little since - the UN put it at 66 per 100,000 in 2005. But it is still a long way behind European Union states and former Soviet countries like Russia, where the figure is 34 for every 100,000 births, and Armenia, with 30 deaths per 100,000.
"While there have been encouraging downward trends in maternal mortality, these are difficult to measure," Maya Kurtsikidze, spokeswoman for the UN children's agency UNICEF in Georgia, told IWPR. "Studies have shown that even when death reporting systems are relatively complete, maternal deaths are under-recorded due to misclassification of the cause of death".
Kurtsikidze said effective prevention of maternal death required a high calibre of professionals providing antenatal and maternity care, and a good medical referral system.
"The level to which women are educated about care and delivery is also very important," she added. "Those pregnant women who are under risk need more support and supervision, and this isn't being taken into account. The referral programme is accessible to all pregnant women but it is in need of serious improvement."
Ivane Poskhverishvili, acting head of the health ministry agency that monitors the medical profession, says efforts are being made to investigate possible cases of negligence.
Following investigations into five cases where women died in or after childbirth in the last two years, he said, ten doctors were subject to sanctions.
"Three lost their state registration for six months, one for three months, and six received written warnings," he said.
Women who have experienced maternity clinics say concerns about professional standards go much deeper than just a handful of doctors.
Nestan Londaridze says that when she had a caesarean section in the capital Tbilisi, staff members were extremely unprofessional.
"When my child was born, the doctor went to members of my family and said the mother was fine, but the child had breathing problems and his lungs hadn't opened, even though I myself saw how he cried when he was born. It turned out they'd forgotten to clear his nasal passage," she said.
"The doctors called it a ‘minor oversight', but I opted to leave the clinic as we weren't being cared for properly and there was no point staying. And that's not to mention the hygiene standards and the indifference of the staff there. No one even noted that I was leaving with a high temperature."
According to a study by the Centre for Disease Control and Prevention, Georgia could reduce maternal deaths by better informing women about risks associated with pregnancy - what the early signs of complications are, why they should see a doctor immediately if this happens, and the danger of exacerbating other health conditions.
The Georgian health ministry declined to give a detailed response to questions about maternal mortality, but said it had "a whole range of programmes in operation for the early detection, treatment and prevention of disease".
Nevertheless, in Kurtsikidze's view, "Lack of access to services contributes to most maternal deaths, as does the providers' lack of capacity to identify and manage complications and provide the right support to women and their newborn babies. Haemorrhage, puerperal infection, and pregnancy-induced hypertension accounts for most directly obstetric maternal deaths."
Georgia has shifted from free healthcare provision to a system of based on private insurance. People can either take out private policies or else join a state-funded free insurance scheme for the less well-off, which still requires a contribution to the cost of care and medicines. The extent to which services are free or paid for is determined by which "state programme" they fall under. The mother and child health programme, for example, envisages free state care except for certain higher-risk scenarios, where the patient has to find 25 per cent of costs.
As Nino Moroshkina, a health specialist at the World Bank's Georgia office, told IWPR in a letter, "out-of-pocket spending is very high in Georgia and thus the poorest are affected".
Nino Tlashadze, who is expecting her second child, found antenatal care expensive, and then had to pay 1,450 laris, equivalent to 875 US dollars, for a caesarean section.
"Each examination costs at least 200 laris, and the first visit is even more expensive. And anyone with a problematic pregnancies has to pay even more," she said.
She said her insurance covered three doctors' appointments in the 13th, 24th and 38th weeks of pregnancy, plus some basic tests.
"That's very little, especially if a pregnant woman has a few problems. I was worried about my blood pressure, for example, and if I'd waited until the 13th week to go to the doctor, there could have been risks both to me and my baby," she said. "The state programme offers nothing to women at risk."
Nino Gvedashvili works for Human Rights House - Tbilisi.
The article is published by the Institute for War and Peace Reporting (http://iwpr.net)