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By: Dr 'Kunle Soyemi MB, BS; FWACS; FRCOG. Consultant Obstetrician & Gynaecologist.
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.
The major medical conditions which contribute to maternal mortality in the sub-Saharan region are little different to those in the developed regions.
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.
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.
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.
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.
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.
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.
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 21st 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:
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!
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Published: June 7, 2023
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