What Do Numbers Tell Us?

Do you all remember this infamous article that circulated the internet in 2010 that said now“it’s more dangerous to give birth in California than it is in Kuwait or Bosnia?” I remember thinking when I read it, “Wait…is that an insult or a compliment?” Maybe the  author was looking for war zones to make a shocking comparison to and could only find a newspaper from the early 1990s. We’ll never know exactly why the author chose to make this seemingly random comparison. But – on International Women’s Day, I think it appropriate to look at the question: - how safe is it for women to give birth in Kuwait?

This is a difficult question to answer, but here is what we do know.  According to the information that is available to us through Kuwait’s Annual Health Report (2010) and the WHO ROEM Report 2009, despite recent increases, maternal mortality rates are still very low (compared to other developed countries), but  little is known about maternal morbidity (injury, infection, or harm related to birth).

• While the Maternal Mortality Rate has increased from 1.9 (2006) to 5.2 (2010) this number is still considered low. If these numbers are accurate, this means that Kuwait is probably a very safe place for a woman to give birth. For a comparison, depending on where you are in the US- rates range from 6 - 15. These numbers have changed dramatically over the last decade around the world as countries have strengthened their reporting policies to get a more accurate view of maternal mortality- which is why you will find that rates in the US have nearly tripled in the last decade - though not all of the increase comes from reporting practices, some of the increase is actually attributable to increased incidence of mortality due to cesareans and other unsafe medical practices.
• Kuwait’s reported Cesarean rate is less than 12% according to the WHO ROEM Report 2009- but it is unclear whether this number reflects private hospitals as well. That is a commendable rate- the US has a rate of nearly 32%
• There is no public data available on maternity care practices (episiotomies, assisted fertility, artificial induction or augmentation, assisted delivery with forceps or vacuum extraction etc.)    
• There is also no public data available reporting iatrogenic morbidity (harm caused by medical intervention in the first place) associated with maternity care practices (maternal infections, placenta accrete or placenta abruption, pre-term babies attributable to elective cesareans or elective inductions etc.)

How about from a baby's perspective? How safe is it to be born in Kuwait?

Despite an ever increasing volume of evidence highlighting the importance of breastfeeding in infancy and later life, and International recommendations promoting exclusive breastfeeding as the optimal method of infant feeding for the first six months of life (WHO: Global strategy for infant and young child feeding. Geneva: WHO; 2003), according to the only recent study on breastfeeding initiation in Kuwait (Dashti et al. “Determinants of Breastfeeding Initiation among Mothers in Kuwait” International Breastfeeding Journal; 2010):

• The rate of exclusive breastfeeding among mothers in Kuwait at the time of discharge and at the three-month follow up is only 10%, with prelacteal (feeding the baby with a bottle before initiating breastfeeding) and partial feeding being the norm.

We don’t have enough evidence to fully understand the cause of low breastfeeding rates, but according to Dashti et al., cultural beliefs and norms and medical practices (such as cesareans) might be contributing. While the authors fail to mention it, hospital and government policies surrounding the promotion and subsidizing of breastmilk substitutes might also be contributing.

Low breastfeeding rates should be a concern for everyone, as they pose serious deleterious short and long-term health effects for the mothers:

• increased risk of breast and ovarian cancer, postpartum weight gain, type-2 diabetes, and myocardial infarction,

And their babies:

• increased risk of infectious morbidity, SIDS, childhood obesity, type-1 and type-2 diabetes, and leukemia.

(Steube, Alison, “The Risks of Not Breastfeeding for Mothers and Infants”,  Obstetrics and Gynecology, 2009.)

Likewise, while the overall perinatal mortality rate has decreased, short-gestation remains the greatest threat to infant mortality in Kuwait

• Perinatal Mortality Rate has decreased from 10.4 (2006) to 9.2 (2010).
• The number of Low Birth Weight Babies per 1000 live births (babies born weighing less than 2500 grams) has remained almost the same (8.4% or 84/1000 in 2007) and (8% or 79.7/1000 in 2010).
• And nearly a quarter (24.4%) of all infant deaths in Kuwait are attributed to short gestation and low birth weight.

The good news is that there are many in Kuwait working to help mothers and babies breastfeed. In the last year alone, the Kuwait Lactation Consultant Society was formed, along with peer breastfeeding support groups like La Leche League Kuwait and The Breastfeeding Support Club. Hopefully, next year we'll have even more progress.

It’s hard to interpret data. Looking at reported maternal mortality rates along, you could say “It’s safer to give birth in Kuwait than it is in California,” but by looking at perinatal mortality rates you could just as easily say "It's safer to be born in California than it is in Kuwait." You might just as easily say that you can’t make any comparisons from one country to another because reporting practices are too variable from place to place and you can’t get a fair comparison. In the end, your own personal practices have a far greater impact on your own health outcomes than general statistics- so don't make your decisions completely based on the numbers. Always evaluate the context of those numbers. You will soon learn that no place in the world will guarantee you the "perfect birth"- but no matter where you are, you can always take advantage of the resources that can support and help you to have the best birth possible- prenatal fitness classes, childbirth education and preparation classes, midwives, doulas, peer-breastfeeding counselors, etc. You now have access to many of these great resources in Kuwait- so be sure to make your health decisions from an empowered position!