Maternal Mortality in Africa

Upon learning they are pregnant, most women do not immediately wonder if it’s a fatal diagnosis. However, that is the stark reality for many women in developing countries, particularly in sub-Saharan Africa. Maternal mortality in Africa is a pervasive and devastating issue. Far hospitals, scarce doctors and poor healthcare systems all contribute to maternal mortality. Most maternal deaths are preventable and caused by complications treatable in developed nations. It is important to recognize the causes of maternal death and solutions already in place to further reduce maternal mortality in Africa.

Causes of Maternal Mortality

The most common causes of maternal mortality are severe bleeding, infections, high blood pressure during pregnancy, delivery complications and unsafe abortions. In most cases, these are treatable with access to trained medical staff and proper medication. Access to maternal health care varies around the world. “A 5-year-old girl living in sub-Saharan Africa faces a 1 in 40 risk of dying during pregnancy and childbirth during her lifetime. A girl of the same age living in Europe has a lifetime risk of 1 in 3,300,” according to Dr. Greeta Rao Gupta, deputy executive director of UNICEF. Factors such as “poverty, distance, lack of information, inadequate services, [and] cultural practices” prevent women from having access to the proper medical services they need.

Additionally, warfare in developing countries causes the breakdown of healthcare systems. This further prevents women from accessing life-saving medical care. For example, when the 11-year civil war in Sierra Leone ended in 2002, it left less than 300 trained doctors and three obstetricians to treat the country’s 6 million people.

Solutions to Reduce Maternal Mortality

Many NGOs work throughout the region to combat maternal mortality in Africa. In fact, the United Nations initiated the Global Strategy for Women’s, Children’s and Adolescents’ Health, 2016-2030. Their goal is to “reduce the global maternal mortality ratio to less than 70 per 100,000 live births” by 2030.

According to a study by the World Health Organization, there needs to be better documentation of maternal mortality in Africa to create more effective policy solutions. Currently, less than 40 percent of countries have a registration system documenting the causes of maternal mortality. Hence, this lack of information makes it difficult for the U.N. and NGOs to create effective solutions.

An unexpected yet effective way maternal mortality in Africa has been combated is through photography. Pulitzer-prize winning war correspondent Lynsey Addario took her camera to the region to document maternal mortality. Addario documented the experiences of many women, including 18-year-old Mamma Sessay in Sierra Leone. Sessay traveled for hours by canoe and ambulance while in excruciating labor to reach her nearest hospital. Addario stayed with Sessay for the entire experience, from the birth of her child to her subsequent hemorrhage and death. Addario even traveled with Sessay’s family back to their village to document Sessay’s funeral and her family’s grief.

Ultimately, TIME published Addario’s photographs. And as a result, Merck launched Merck for Mothers, giving $500 million to reduce maternal mortality rates worldwide. Addario stated, “I just couldn’t believe how unnecessary her death seemed, and it inspired me to continue documenting maternal health and death to try to turn these statistics around.”

The Bottom Line

The international community must continue to address maternal mortality, a preventable tragedy. No woman should have to fear for her own life or the life of her unborn child upon discovering she is pregnant. Through documentation, reporting and care, the international community can fight to reduce maternal mortality in Africa.

Alina Patrick
Photo: Flickr

Healthcare in Bihar
Bihar is one of the poorest states in India as approximately 55 percent of the population lives below the poverty line. There is an overwhelming need for quality health care facilities and workers in this region. In the past ten years, the World Bank Group and the Bill and Melinda Gates Foundation have made great strides toward the improvement of healthcare in Bihar.

The World Bank’s collaboration with the Bihar Government led to an increase in the accountability and accessibility of healthcare from 2005 to 2008. By 2008, the number of outpatients visiting a government hospital grew from 39 per month to almost 4,500. The number of babies delivered in healthcare facilities also increased from some 100,000 to 780,000.

Bihar’s infant and maternal mortality rates are higher than India’s national average. According to the Sample Registration Survey in India conducted in 2013, 208 women per 100,000 died during childbirth. Furthermore, 28 out of every 1,000 newborns die within their first month of life.

Most of these deaths are preventable if basic care is provided to women and newborns during and immediately following childbirth. Unfortunately, the infrastructure of healthcare in Bihar falls short in nearly all required categories, including the number of health assistants and nurses.

According to the Huffington Post, there are not enough nurses in Bihar to allow for lengthy off-site training to prepare nurses for treatment of postpartum hemorrhage or premature births while also keeping health facilities adequately staffed.

In order to improve maternal health and newborn care, the Bill and Melinda Gates Foundation along with the Bihar Government launched a Mobile Nurse Mentoring Program called AMANAT.

Through AMANAT, nurses in public health facilities are mentored on-site by mobile nurse mentors, who ensure that basic standards of care are provided for pregnant women and newborns.

The program has greatly improved healthcare in Bihar for women and children before and after deliveries since its implementation in 2012. A few of these improvements include:

  • The administration of the correct use of oxytocin to induce labor has increased from 9 percent to 59 percent.
  • The use of sterile instruments by nurses during deliveries has increased from 13 percent to 43 percent.
  • The implementation of mothers breastfeeding has increased from 49 percent to 72 percent.

The number of stillbirths declined from 19 to 12 per 1,000 live births due to improvements in basic care practices. AMANAT was implemented in 160 public health facilities across Bihar and is expected to be administered in 240 over the course of this year.

There is a long way to go in creating a stable system of healthcare in Bihar. However, these crucial improvements made by the World Bank, the Bill and Melinda Gates Foundation and Bihar’s Government have saved and will continue to save countless maternal and newborn lives.

Kristyn Rohrer

Photo: World Bank

During the 14-year civil war in Liberia, the health system became increasingly fragile, and a lack of roads and transportation made it difficult for pregnant women to receive necessary emergency care. This issue has created a strong need for strengthened midwifery in Liberia.

As a result, Liberia had one of the highest maternal mortality rates in the world according to a 2015 USAID article, but the country is now trying to change that through investment in midwifery programs.

Currently, 44 percent of Liberian women give birth without a skilled attendant, and nearly one out of 138 mothers die from preventable causes during childbirth. Such issues could be avoided with basic or strengthened midwifery in Liberia, according to the World Health Organization.

Bentoe Tehounge, a trained midwife in Liberia, told WHO, “We need midwives who can ensure a safe pregnancy even before a woman is pregnant. People who can provide advice on family planning, nutrition, physical activity and preventing mother-to-child transmission of HIV.”

There are six midwifery schools in the Liberia, half of which are in rural areas, and less than 200 midwives for over four million people. Most of these midwives work in urban areas. Strengthening these schools, especially the rural ones, will improve access to quality care for women around the country.

Retaining these midwives is one step towards Liberia’s investment in the profession. According to WHO, many health professionals were driven out of the country due to the civil war and the Ebola crisis, and now midwives lack “safe accommodation and transport, are overworked and paid poorly and have limited opportunities for career advancement.”

A new B.S. program addresses a portion of these concerns by providing further professional development. The program graduates 50 to 75 registered midwives per class, which is expected to staff more than 700 health facilities in the country. To develop better teaching methods, Liberia is working with the Danish Midwives Association to pair Liberian and Danish midwives in order to learn more advanced skills, like preventing and treating hemorrhages. It is hoped that this new alliance will result in strengthened midwifery in Liberia.

In the United States, this final element is comparable to the apprenticeships or clinicals that midwives do to obtain a license. Mary Anne Brown, a midwife serving the Great Falls and Helena areas of Montana, said that degree programs require that their students find and work directly with a midwife to gain clinical experience.

Past midwife training in Liberia tried to work within a culture of home birth in Liberia (USAID reported that 63 percent of Liberian women gave birth outside of a health facility) and with the knowledge of traditional midwives.

The goal was to shift the focus to encouraging birth preparedness, recognizing and referring complications and providing appropriate emergency care through what USAID called “home-based life-saving skills.” By utilizing storytelling, case histories, discussion, role-play and demonstrations, midwives, expectant parents and community leaders were able to educate themselves at community meetings.

One of the greatest achievements of the previous midwife training in Liberia was its ability to connect traditional midwives to both health facilities and certified midwives. Certified midwives perform their own visits to discuss problems the traditional midwives are having, replenish supplies and reinforce the training.

The current programs are a part of WHO’s efforts to provide clear guidelines, tools and an evidence base to lead to strengthened midwifery in Liberia and around the world in order to improve care for pregnant women and reduce both maternal and neonatal mortality rates.

Anastazia Vanisko

Photo: Public Domain Images

Hamlin Fistula EthiopiaHamlin Fistula Ethiopia is a charitable organization in Ethiopia dedicated to treating and preventing a specific childbirth injury known as obstetric fistula.

An obstetric fistula is a hole between “the vagina and rectum or bladder that is caused by prolonged obstructed labor, leaving a woman unable to control her urine or feces.”

According to Hamlin Fistula, “more than 75 percent of women with obstetric fistula have endured labor that lasted three days or more.”

The organization has built the world’s first fistula hospital and also has five regional centers in Ethiopia, providing healthcare to rural women.

Having the Hamlin Fistula Clinic in Ethiopia is vital because it is one the fastest growing economies in Africa. Unfortunately, the country has less than 7,000 trained midwives making the ratio of midwives to women having children very low.

According to the organization, “the childbearing population ratio is approximately 1:14,000, well below the World Health Organization’s recommendation of 1:5,000.”

This lack of services and health professionals has a direct impact on Ethiopian women. Approximately 9,000 women die in obstructed labor each year. Another 9,000 survive but with an obstetric fistula.

Hamlin Fistula Ethiopia provides a world class center of excellence for treating obstetric fistulas and training doctors to specialize in this surgery. Also, “the hospital also has the Hamlin College of Midwives and the Desta Mender – a farm and training center for long term patients.”

In addition, Hamlin Fistula offers rehabilitation services such as physical therapy, psychotherapy and job training. This helps patients rebuild their self-esteem, find meaningful employment and reintegrate into their village life.

“Over 700 Ethiopians are employed across Hamlin Fistula Ethiopia and only two of the staff are from overseas. Dr. Catherine Hamlin and Mr. Martin Andrews, the CEO.” It is with the generosity of donors that the Hamlin Fistula Ethiopia continues its work in treating and preventing obstetric fistulas.

“Mourning the stillbirth of their only child, incontinent of urine, ashamed of their offensiveness, often spurned by their husband, homeless, unemployable, except in the field, women with obstetric fistula endured, existed, without friends and without hope.”

However, thanks to Hamlin Fistula Ethiopia, Ethiopian women have the hope of receiving good, quality healthcare during childbirth. These women will be able to integrate themselves back into their families, communities and society at large, after delivery of their children.

Vanessa Awanyo

Sources: World Health Organization, Hamlin Fistula Ethiopia, Fistula Foundation
Photo: Flickr

Maternal Mortality
Earlier this year, the World Health Organization (WHO) published a report containing new data about maternal mortality. It revealed that maternal mortality has dramatically decreased by 45 percent since 1990. Many organizations have made decreasing maternal deaths an international priority.

Improving maternal health is the United Nation’s fifth Millennium Development Goal (MDG), one of eight goals related to decreasing global poverty set forth by the international community in 2000. The fifth goal is lofty, intending to reduce the maternal mortality rate (MMR) by 75 percent before 2015.

Nineteen countries, including Nepal, Rwanda and Cambodia, have already achieved over a 75 percent decrease in their MMR. However, over 100 other countries analyzed in the report have much more progress to make before next year’s target date. Unfortunately, it is unlikely that each country will meet this goal.

Still, enormous strides have been made in the maternal health arena on a global scale in the last two decades that deserve to be celebrated. It is estimated that 234,000 fewer women died from pregnancy complications and childbirth in 2013 than in 1990. This number represents a real change that has affected the lives of people across the globe.

The number of maternal deaths isn’t the only thing that is changing. Another recent WHO study shows that the causes behind maternal deaths have evolved over the last 20 years. Data about the actual causes of death during pregnancy and childbirth, though difficult to collect in some areas, is essential if further progress toward decreasing MMR is to be made.

The WHO’s study found that pre-existing medical conditions such as diabetes and obesity, worsened by pregnancy, were the cause of 28 percent of maternal deaths, followed by severe bleeding during childbirth, pregnancy-induced high blood pressure and infections.

Dr. Marleen Temmermen, a co-author of the study, notes, “The new data show a changing profile in the conditions that cause maternal deaths; reflecting the increasing burden of noncommunicable diseases in women throughout the world. Ending preventable maternal deaths will require both continued efforts to reduce complications directly related to pregnancy, and more of a focus on noncommunicable diseases and their effect in pregnancy.”

The new findings about the ways in which maternal health has evolved since 1990 have produced two noteworthy conclusions. The first outcome is the insight that countries all around the world have made much more progress than many ever expected in decreasing the number of maternal deaths. The second is the realization that maternal mortality must be tackled differently as the world of maternal health has changed significantly since the inception of the MDGs in 2000. The causes of maternal deaths have changed, and so must the strategy used to battle them.

Although this progress merits celebration, there is still much to be done to improve maternal health for women everywhere. Fortunately, the new data emerging from the WHO can be used to form more effective strategies in the fight against maternal mortality and global poverty.

— Emily Jablonski

Sources: The Guardian, The Lancet, WHO
Photo: Gallery Hip