Complications and deaths associated with pregnancy are assuming alarming dimensions in Africa and not a few people are agitated by this situation. Pregnancy which normally brings joy to couples is gradually becoming a nightmare to many. Reports show that the average maternal mortality ratio in the African region has jumped from 870 deaths per 100,000 live births in 1990 to 1000 deaths per 100,000 live births in 2001 and to 1500 per 100,000 live births in 2004. Of the estimated 529,000 maternal deaths that occur globally every year, 48% occur in Africa, a region that constitutes only 12% of the world population and 17% of all births in the world. Poor women in the region are especially vulnerable. In many countries in the African region between 25% and 33% of all deaths of women of reproductive age are as a result of complications of pregnancy or childbirth whereas in industrialised countries the risk of maternal death is very low. The estimate is just 1%.
Recent statistics also show that 80% out of every 100 would-be mothers are afraid of pregnancy and childbirth while another huge 95 cannot bear the horror of childbirth. The statistics also revealed that for every 100 childbirth, at least 65% of women came out with Post Traumatic Stress Disorder as a result of fear and stress before the childbirth. The statistical report in question therefore lamented that more than 15 years following the launching of the Safe Motherhood Initiative (SMI), the maternal and prenatal mortality levels in Africa have sadly continued to rise instead of declining. High fertility rate and low contraceptive use in Africa contributes to this high risk. The lifetime risk of maternal death in the African region is estimated at 1:16 compared to 1:3500 in North America, 1:2400 in Europe, 1:160 in Latin America and the Caribbean and 1:100 in Asia. For every maternal death there are at least thirty women who suffer short or long term disabilities, says the African Regional Reproductive Health Task Road Map for Accelerating the Attainment of the Millennium Development Goals Related to Maternal and New-born Health in Africa.
Approximately 13% of all maternal deaths occur among adolescents mainly as a result of complications of unsafe abortion. The majority of the disabilities especially obstetric fistulas are also more prevalent in the adolescent age group. Averagely, in Africa a woman has had her first pregnancy by the age of 19. Fourteen million adolescents aged 15 to 19 years in the world give birth annually, the majority-12.8 million-in developing countries which includes Africa. In spite of this, little attention is paid to married or pregnant adolescents when it has been proved that compared with women in their twenties, adolescents are twice more likely to die during childbirth and those that are 14 years and younger are five times more likely to die. The new-borns of adolescents also have a higher incidence of low birth weight and neonatal mortality. There is no doubt then that Africa has the highest new-born mortality rate estimated at a ratio of 45 deaths per 1000 live births compared with 34 in Asia, 17 in Latin America and five in developed countries. Given ineffective and gross under-reporting system and wide variations within the continent, these figures are without doubt much higher. However the Road Map quoted earlier was vocal in indirectly attributing the high maternal deaths at the moment in the continent to the three co-joined epidemics of HIV/AIDS, TB and Malaria. This is in addition to other factors that are peculiar to each country.
“Increasing numbers of maternal deaths in the region are due to indirect causes such as HIV/AIDS, TB and Malaria. Many pregnant women in Africa are being diagnosed with HIV. In regions of Southern, Eastern and Central Africa, 20-30% of all pregnant women are infected. HIV infection transmission rates from mother to child range from 25% to 40% in some countries. Tuberculosis kills over 1 million women from the age range of 18-45 years annually of which 600,000 of these deaths occur in the African region. Malaria is a major cause of maternal anaemia, low birth and neonatal death”, says the Road Map
In Nigeria the story is the same. In fact stakeholders in the health sector are of the opinion that the maternal and prenatal mortality has reached an embarrassing situation. Nigeria’s maternal mortality statistics have been cited as one of the highest in the world. While the maternal mortality ratio of 704 maternal deaths per 100,000 live births was obtained from a 1999 National Survey, a similar survey three years later indicated a figure of 948 maternal deaths per 100,000 live births. In the year 2004, it was 1,500 deaths per 100,000 live births. Analysis of the 1999 national survey revealed that there are wide geographical disparities with respect to maternal mortality incidence within the six geo-political regions of Nigeria with the rate in the North-East zone (1,549 deaths per 100,000 live births) almost ten times that of the South-West zone (165 deaths per 100,000 live births). That of North-West was 1,025 while South-East recorded 165. It identified the leading medical causes of maternal mortality in Nigeria as haemorrhage (23%), sepsis (17%), unsafe abortion (11%), anaemia (11%), malaria (11%), eclampsia (11%) and obstructed labour (11%) and added regrettably that effective medical approaches that would have managed each of these conditions currently do not exist.
“There is a dire and urgent need to effectively address the high maternal mortality situation in Nigeria in the interest of human development, social justice and poverty alleviation”, the report noted.
The number five of the Millennium Development Goals aims at reducing by 2015 maternal mortality rate by three-quarter. Maternal mortality has also been included as one of the key issues to be addressed under the new Nigerian national development initiative known as the National Economic Empowerment Development Strategy (NEEDS). From the pictures we are getting from the Nigeria health sector, it seems that the dream would never come true. In terms of Primary Health Care services only 49.8 percent of PHC facilities in Nigeria provide antenatal care services while 42.9 and 43.9 percent respectively provide delivery and postnatal services. Meanwhile only a third of PHC facilities in the country which is about 34.6% provide treatment for sexually transmitted infections.
“In respect of obstetric care services, less than a fifth (18.5%) of facilities offering maternal health care services in Nigeria met standards for Essential Obstetric Care (EOC) nationally. In the public sector, only 4.2 percent of facilities met the EOC criteria (1.2% for basic EOC and 3.9 for comprehensive EOC) while 32.8 percent of private sector facilities met the criteria (5.3% for basic EOC and 27.5% for comprehensive EOC)”, says a report from the Community Development and Population Activities Department of the Nigerian Federal Ministry of Health.
It also noted that among the 12 states involved in national EOC study, only one state which is Lagos, met the availability criterion of four basic EOC per 500,000 population and noted that on the whole, the proportion of pregnant women that delivered in EOC facilities was estimated at 5.9 percent. This indicates a high level of unmet need for EOC services. Approximately 15 percent of pregnant women are generally expected to develop complications, which require EOC services. The report titled the Maternal Mortality Situation and Determinants in Nigeria observed that a NEEDS assessment survey of the Primary Health Care system indicated that 5.9% of 679 PHC facilities sampled nationally did not have any of the 26 equipment described as minimum equipment package for use in a generic PHC facility. Also none of the sampled facilities had all the 26 equipment in the list even as it revealed that less than a quarter of government-owned hospitals sampled in all the geo-political zones of the country lack equipment as basic as Sphygmomanometer. It described the nation’s health facilities as poor in terms of medical supplies and related logistics and very poor the technical competence of its health workers in the area of various service delivery activities. However it noted that the poor funding of the sector is a major contributing factor to the poor quality service discovered and advised that reduction in maternal mortality should begin from the Primary Health Care sector which is the first point of call for the rural dwellers who are the major victims of the maternal mortality rate.
The report noted that efforts deployed since the launching of the Safe Motherhood Initiative seem not to have yielded the expected results due to the many challenges confronting the Maternal and New-born Health (MNH) programmes in the region.
“Most of the countries in the African region are poor and highly indebted. This limits the allocation of resources to health and in particular MNH programmes. The growing poverty especially amongst women is a great obstacle limiting women’s access to highly needed services. The situation is further aggravated by dwindling donor resources. Besides, numerous man-made and natural disasters in the region, such as civil conflicts, disease outbreaks and floods that rapidly destroy infrastructures, disrupt services and divert resources erodes gains made in the past”, said the Road Map for Accelerating the Attainment of the MDGs.
The Road Map also noted that some of the reasons for failure to significantly reduce maternal and neonatal mortality in the region include:
• Lack of national commitment and financial support
• Poor co-ordination amongst partners
• Inadequate male involvement coupled with low status of women with poor decision making power
• Growing poverty particularly among women
• Lack of access to, availability and use of quality skilled care during pregnancy, childbirth and the immediate postnatal period
• Focus on ineffective interventions such as the risk approach
• Poorly functioning health systems with weak referral system, especially during obstetric and neonatal emergencies
• Weak national human resource development and management, including the continuing brain drain of skilled personnel within and outside Africa and from public to private
• Negative impact of the HIV pandemic on human and financial resources for MNH care
• Poor logistic for management of drugs, family planning commodities and equipment
• Unclear policies concerning practice regulation and
• Harmful socio-cultural beliefs and practices.
Giving a note of warning the Road Map added that if nothing is done to effectively address the above challenges, there will be at least 2.5 million maternal deaths and 49.0 million maternal disabilities resulting in 7.5 million child deaths over the next ten years.
Nigeria therefore has a great lesson to learn from this. For instance, local councils which are supposed to be the first point of call for these pregnant women, indeed the seat of Primary Health Care, are not helping matters. The health sector is characterised by low sector funding, poor staff motivation, which is a major reason for the huge migration of health workers to Europe and America and the highest brain drain recorded by the sector. For instance, at the federal level, budgetary allocation for health has varied between 1.5 percent and 3.1 percent of total government budget between 1985 to date; short of the World Health Organisation (WHO) recommended level of 5 percent of national budgets. Budgetary allocations at state level vary considerably. At the council level a recent analysis of their expenditure showed that budgetary allocation to the health sector was between 12.94 and 12.6 percent in 1998 and 1999 respectively. The pattern of health expenditure at this level of government is very much skewed towards personnel cost, with the result that very little amount is actually available for the health activities and infrastructure development. This leads to undue dependence on donor funding.
In the same way lack of budgetary release and tampering with the council allocations by the state governors is a rampant occurrence, thus making it impossible for meaningful planning and execution of programmes to take place at the local level without undue dependence on donor funding with its attendant complications. Interventions are highly needed in reducing the number of pregnancies, the number of complications and the likelihood that a complication will result in death. According to Eyitayo Lambo, a professor and former Nigerian Minister for Health, “Effective knowledge and tools exist to reduce suffering and deaths. In order to make a real difference, the interventions must reach mothers and children who need them. Experience has shown that known interventions are affordable and can be delivered. For maternal deaths to be reduced dramatically, women need access to quality obstetric care, with at least three key elements viz skilled care at birth, emergency obstetric care in case of complications and a functioning referral system which ensures access to emergency care, if needed. Another key solution is helping women to avoid unwanted pregnancies and births since only pregnant women die of pregnancy-related complications”.
Finally it is worth noting that the well being of societies is directly linked to the health and survival of mothers and their children. When mothers and children live in a healthy atmosphere and thrive, the society in which they live prospers.
*The original of this article titled 'Africa's Maternal Care As Draw-back To World Health' was first published by the Guardian Newspapers of Nigeria on Thursday April 7, 2005.