Maternal Mortality in sub-Saharan Africa: A Call to Action

 

By: Dr 'Kunle Soyemi MB, BS; FWACS; FRCOG. Consultant Obstetrician & Gynaecologist.

 

 

Highlights

 

• Maternal mortality ratio (MMR) for sub-Saharan Africa in 2020 was estimated by the WHO as 545/100,000 live births equating to 202,000 maternal deaths in that year in the region.

• Sub-Saharan MMR accounts for 70% of total global maternal mortality ratio in 2020.

• The major social and clinical contributors to maternal mortality in the region (namely poverty, financial and diverse structural inadequacies, haemorrhage, hypertensive disorders, unsafe abortions, infection and obstructed labour) are well known and the mechanisms underlying the clinical contributors are reasonably well understood.

• What is needed the most is the collaborative co-production by the people, governments, state and non-state stakeholders in the region to take action and implement short, medium and long-term  policies and programs to tackle the problem and reduce the needless death and disabilities associated with procreation.

 

                                                              

Overview

 

According to the WHO and their partners the estimated maternal mortality ratio (MMR) for sub-Saharan Africa in 2020 was 545/100,000 live births equating to 202,000 maternal deaths in that year in the region.

 

Although these figures represent significant reduction (28%) compared to those of the year 2000, there has been no further significant improvement over the past 10 years between 2010 and 2020 as might have been expected.

 

Compared with a global MMR of 223/100,000 live births, 103/100,000 live births in the North Africa region, 13/100,000 live births in Europe and North American regions and 4/100,000 live births in Australia and New Zealand, sub-Saharan MMR accounts for 70% of total global maternal mortality ratio in 2020.

 

Thus a 15 year old girl in sub-Saharan Africa in 2020 had a lifetime risk of 1 in 40 of dying from a maternal cause, approximately 400 times that of her peer in Australia and New Zealand where the equivalent risk is 1 in 16000. 

 

Notwithstanding the best efforts of the Maternal Mortality Estimate Inter Agency (MMEIG), a technical body instituted to generate internationally comparable maternal mortality estimates and to provide as accurate as possible MMR data, it should be noted that the figures quoted for the sub-Saharan region are more likely to be underestimates. This is due to the poor or non-existent systems for reporting incidences of health occurrences and the collection of data, including those for maternal morbidity and mortality, especially in the rural areas.

 

In 2000 in an effort to improve global healthcare, universal access and reduction in global morbidity and mortality in several areas of healthcare, including maternal health, the United Nations (UN) member states launched a series of Millenium Development Goals MDG's). 

 

Amongst these was MDG 5A, whose aim was a 75% reduction in the 1990 global MMR by the year 2015. 

 

As a follow on to the MDG's, the Sustainable Development Goals (SDG's) were launched in September 2015 to come into force on 01 January 2016 for a 15 year period until 31 December 2030.

SDG 3:1 was aimed at reducing global MMR to 70/100,000 live births or under by 2030. 

 

Sadly sub-Saharan Africa region failed to achieve the MDG 5A target notwithstanding an initial significant improvement, and it is estimated that, extrapolating from the region's 2017 MMR, a reduction of 86% in MMR would be required for the region to achieve the SDG 3:1 target. 

 

 

What Are The Contributory Factors To The High Maternal Mortality In SSA?

 

The major medical conditions which contribute to maternal mortality in the sub-Saharan region are little different to those in the developed regions.

These include:

• Haemorrhage
• Infection
• Hypertensive diseases (to include preeclampsia and eclampsia)
• Obstructed labour and
• Unsafe abortions. 

 

HIV/AIDS an indirect cause, contributes minimally to the overall MMR in the region (11/100,000 live births or 4000 maternal deaths). 

 

The mechanisms by which the causal factors of MMR work are reasonably well understood and can either be anticipated and prevented in those women known to be at high risk for them, or diagnosed early and brought under control as is usually the case in the more developed regions.

 

The question therefore is why this is not the case in the sub- Saharan Africa region?

 

The following would appear to be the major reasons.

 

• Lack of/inadequate facilities

In the sub-Saharan Africa region there is widespread paucity of where a pregnant woman might receive ante-natal care. 

 

The WHO recommends a minimum of 4 ante-natal attendances during pregnancy, to be undertaken by a skilled healthcare attendant (i.e. doctor, midwife or nurse).

 

One survey showed that 33% of pregnant women in the West African zone of the region did not receive any ante-natal care during their pregnancy. 

 

In another survey of 47 countries in the region in 2022, there were 1.5 such skilled attendants per 1000 women, in comparison to the WHO recommendation of a minimum of 4.45 skilled attendant for 1000 women.

 

Poor or lack of transport infrastructure is another disincentive for these women who may need to travel long distances in order to access the nearest health facility which may be several miles away from their homes, most especially in the rural areas.

 

• Financial

Where they exist healthcare services often have to be funded fully or partially out-of-pocket by the woman and/or her family.

 

With rising poverty and inequity of wealth distribution, accessing maternal care services can be an additional constraint.

 

 In 2021, the Atlas of African Health Statistics found that 7.8% of the population in the region spent more than 10% of their income on health expenditure; this notwithstanding WHO's promotion of Universal Health Coverage (UHC), established to allow access to healthcare immaterial of wealth status and to ensure that no one is pushed into poverty by healthcare costs. 

 

Despite great efforts the major indicators for monitoring UHC has shown stagnation since 2017.

 

• Education and Enlightenment

The low level of literacy and general education in most countries of the region has usually meant that most women often have very little knowledge about pregnancy and childbirth, and coupled with the poor infrastructure for disseminating healthcare information in many countries of the region, many women are poorly informed about care during their pregnancy and childbirth.

 

• Abortion and Teenage Pregnancy

Unsafe abortions account for 16% of all maternal deaths in the sub-Saharan Africa region. 

 

The risk of a woman dying from abortion in the region is estimated to be 1 in 40, compared to approximately 1 in 4000 in the more developed/high income region.

The majority of these abortions occur in adolescent women (10-19 years of age).

 Similarly, adolescent birth rate is highest in the region (approx. 99 births/1000 women), compared to a rate of 12-14 births/1000 women in the more developed/high income regions.

 

It is known that adolescent women face higher incidence of complications during pregnancy and childbirth.  Complicating this further is the fact that family planning through modern contraceptive methods are generally less adequately met in the region than in the more developed regions.

 

• Other (indirect) Causes

HIV/AIDS contributes minimally to overall maternal mortality in the region (11/100,000 live births or 4000 maternal deaths).

Inadequate public health services such as the provision of clean water supply, sanitation and hygiene facilities also contribute to the general poor reproductive health. 

It is estimated that only 23% of people in the region have access to basic sanitation services.

 

 

What Are Some Strategies for Improving Maternal Mortality in sub-Saharan Africa?

 

It would be tempting to simply regard the poor maternal mortality in the region as just another arm of the problem of the general and extreme under-development of the region; other areas including high infant morbidity and mortality, very low general standard of living, poor life expectancy etc.

 

Nevertheless, strategies must be evolved and proactive measures taken that can accelerate development in all these areas. 

 

Reason would suggest that the primary and main responsibility for this should lie with the governments and political leadership of the countries of the region, since by and large they control the wealth of the countries and its distribution, and are responsible for policies and spending priorities.

 

However such is the magnitude of the task that all hands must be on deck in achieving the improvement needed in all these areas of development.

 

Non-Governmental Organisations (NGO's), professional associations, individual philanthropists in addition to well meaning international organisations and agencies such as the different arms of the United Nations and other partners, must all have roles to play. 

 

This point was well emphasized in its executive summary by the 50th session of the regional committee for Africa, (which adopted as the subject for its technical discussion in March 2000 "Reducing maternal mortality: A challenge for the 21^st century") viz: "There is a need for stronger commitment and political will on the part of member states in addressing the problem of reducing the high maternal mortality in a coordinated manner. Awareness and knowledge of the problem have to be translated into concrete and sustained action by the various sectors of the government, Non-Governmental Organisations, communities and partners."

 

Since the major clinical contributors to maternal mortality in the region (namely haemorrhage, hypertensive disorders, unsafe abortions, infection and obstructed labour) are well known and the mechanisms underlying these conditions reasonably well understood, attention must be focused at much better management of these conditions through urgent and prioritised investment in the following areas:

 

• The building of primary, secondary and tertiary facilities, appropriately equipped and fit for purpose in the region.

• Provision of adequate physical infrastructure such as roads and efficient, affordable transport systems (existing structures and systems that have fallen into disrepair and, or disuse can be rehabilitated).

• Education and training of skilled health workers (doctors, midwives, nurses, technicians and paramedical personnel), and their retention through the provision of conducive working environments as well as their adequate remuneration (to obviate the brain and skill drain that is presently extant in their effort to combat what many see as an existential issue), must be one of the utmost priorities.

• Intensive enlightenment programmes, through easily understanble leaflets and community talks, to ensure basic information regarding general self help during their pregnancy, available facilities and how to access these facilities, should made widely available and disseminated to all pregnant women.  

• Another of the most important is the need for urgent measures to eliminate widespread poverty still dominant in the region despite its vast resources; through more equitable distribution of the region's abundant wealth.

• As a matter of urgency also, there must be a wholesale embrace and development of modern technological methods that will enable the region to add value to and make optimal and meaningful use of its abundant natural resources.

• These must be the goals of all those who, both from within and without, truly wish to see the region emerge from its current depressed and deplorable position. 

 

 

Conclusion

 

In conclusion, what needs to be done in reducing maternal mortality and morbidity in sub-Saharan Africa is not rocket science.

The causal factors and related issues are already known.

What is most essential and in short supply is the political will and interest especially by governments and other state and non-state leaders to work with the people of the region and co-produce well funded Interventions that will reduce maternal deaths in the region into the long term. African women deserve this and it is a task that must be done!

 

 

References

1. World Health Organisation (WHO), United Nations Children's Fund (UNICEF), United Nations Population Fund (UNFPA), World Bank, United Nations Department of Economic and Social Affairs (UNDESA/Population Division). Trends in maternal mortality; 2000 - 2020; estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organisation; 23 February, 2023. https://www.who.int/publications/i/item/9789240068759.Accessed June 2, 2023.

 

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5. Millenium Summit, 6 -8 September 2000, New York. In: United Nations Conferenc es [website], New York (NY): United Nations; September 2000. https://un.org/en/conferences/environment/newyork2000. Accessed June 2, 2023.

 

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 9. World Health Organisation (WHO), United Nations Children's Fund (UNICEF), UNICEF/WHO joint database on SDG 3.1.2. Skilled Attendance at Birth. In:8 Delivery care [website]. New York (NY): UNICEF; 2022. https://data.unicef.org/topic/maternal-health/delivery.-care/. Accessed June 2, 2023.

 

10. Zaba B, Calvert C, Marston M, Isingo R, Nakiyingi-Miiro J, Lutalo T, et al. Effect of HIV infection on pregnancy - related mortality in sub - Saharan Africa; secondary analyses of pooled community based data from the network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA). Lancet 2013; 381(9879): 1763-71. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60803-X/fulltext. Accessed June 2, 2023.

 

  11. Arguing for Universal Health Coverage. Geneva: world Health  Organisation; 2013. https://apps.who.int/iris/bitstream/handle/10665/204355/9789241506342_eng.pdf. Accessed June 2, 2023.

 

12. Adolescent and young adult health [website]. Geneva: World Health Organisation; April  28, 2023. https://www.who.int/news-room/fact-sheets/detail/adolescents-health-risks-and-solutions. Accessed June 2, 2023.

 

  13. World Health Organisation (WHO), United Nations Children's Fund      (UNICEF). Declaration of Astana. Geneva and New York (NY); 2018. https://www.who.int/docs/default-source/primary-health/declaration/gcphc-declaration.pdf. Accessed June 2, 2023.

 

  14. The Atlas of African Health Statistics 2022 - Full report. https://www.afro.who.int/publications/atlas-african-health-statistics-2022-health-situation-analysis-who-african-region-1. Accessed June 2, 2023.

 

 15. World Health Organisation (WHO). Regional Committee for Africa 50th session. Ouagadougou, Burkina Faso, 28 August - 02 September 2000: Reducing Maternal Mortality: A challenge for the 21st century. Technical discussions. https://apps.who.int/iris/bitstream/handle/10665/95460/AFR_RC50_TD_1E.pdf. Accessed June 2, 2023.

 

 

 

Published: June 7, 2023

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