Improving maternal health in Africa

On 27 February 2013, four-year-old Charlotte Mmowa sued Limpopo Province health authorities in South Africa for 1.1 million rand (about $100,000) for mishandling her own birth, during which her mother died. Months later the court agreed that the nurses and doctors who treated her mother had been negligent, and awarded Charlotte 547,000 rand ($50,000) compensation.
In 2009, 24-year-old Matlou Mmowa delivered Charlotte without also delivering the placenta, which is abnormal. The placenta connects a foetus to the uterine wall and allows a baby in utero to feed off its mother. Ms. Mmowa bled profusely as doctors unsuccessfully tried to manually remove her placenta. The Limpopo court heard that health personnel ordered blood at 4 p.m. and that by 9 p.m., when she died, the blood had not arrived. She was badly treated, claimed Charlotte’s custodian.
The bungling of Ms. Mmowa’s childbirth, and the novelty of the court case, drew attention and outrage from many South Africans. The Limpopo personnel claimed they had done their best with available resources — hinting that they might have saved the woman’s life if it hadn’t been necessary to drive a long distance for blood.
Poverty fuelling deaths
Africa accounts for a big chunk of global maternal deaths. In 2013 about 289,000 women worldwide died during pregnancy or childbirth, and of those deaths 62 percent occurred in sub-Saharan Africa, states the World Health Organization (WHO), the UN Population Fund (UNFPA), the World Bank, and the UN Population Division in their 2014 report, “Trends in Maternal Mortality: 1990 to 2013.” The report adds that in 2013, the maternal mortality ratio in developing countries was 230 women per 100,000 births, versus 16 women per 100,000 in developed countries. Globally, 3 million newborns die each year and there are 2.6 million stillbirths, with Africa accounting for more than half of both numbers.
Poverty fuels maternal mortality, experts say, which explains why death rates are higher in poor countries than in rich ones. “For mothers as well as for their infants, the risk of dying during or shortly after birth is 20 percent to 50 percent higher for the poorest…than for the richest quintile,” states a report by UNICEF, the UN Children’s Fund. To put this into perspective, in Chad, just 1 percent of the poorest pregnant women get antenatal care, compared with 48 percent of wealthy women.
Adolescent girls (ages 15–19) are at high risk of childbirth- and pregnancy-related complications, says WHO. “The probability that a 15-year-old woman will eventually die from a maternal cause is 1 in 3,700 in developed countries versus 1 in 160 in developing countries.” For many women in many countries, no nurses and doctors are available to assist in childbirth.
A woman’s pain
Ellen David, 17, of Monrovia, Liberia, did not have money for maternity bills last October when she went into labour late in the night; the clinics are not open at night, and the curfew imposed in the wake of the outbreak of the Ebola virus meant she could not have gone to any hospital even if she’d had the money. As a result, unskilled neighbours helped her to deliver in a bedroom very early in the morning. But her joy turned to sorrow when the child died hours later. By noon family members were by its grave, offering silent prayers as Ms. David sobbed uncontrollably.
“It was a harrowing experience,” Deddeh Howard, one of Ms. David’s neighbours, in an interview with Africa Renewal. “I can only imagine how many babies and mothers we lose in this manner.” Ms. Howard herself lost her baby just after giving birth in 2011. “It’s an awful pain. You look to cuddle your bundle of joy and it dies. You want the ground to swallow you up.” Ms. Howard is the corporate social responsibility manager for Chevron Corporation in Liberia, which is assisting Hope for Women, a local health nongovernmental organization, to provide antenatal care for adolescent girls.
The medical director of Hope for Women, Dr. Wilhelmina Jallah, says that Chevron’s support is significant but hardly enough. “Many, many young girls try to deliver at home; some of them may require Caesarean operations and it gets really complicated for them,” she told Africa Renewal in an interview.
Babies giving birth to babies
With 225 adolescents in every 1,000 cases of pregnancy, the Democratic Republic of the Congo has the world’s highest rate, followed by Liberia (221) and Niger (204). In fact, 75 percent of girls in Niger are married before the age of 18, the world’s highest percentage. Dr. Geeta Rao Gupta, UNICEF’s deputy executive director, warned that, “A 15-year-old girl living in sub-Saharan Africa faces about a 1 in 40 risk of dying during pregnancy and childbirth during her lifetime,” whereas in Europe the ratio is 1 in 3,300. “Babies giving birth to babies,” was how Ms. Howard described the adolescent pregnancy phenomenon in Liberia.
Also, younger girls are at high risk of developing obstetric fistula, a potentially serious medical condition in which a hole develops between the vagina and rectum or the urinary bladder. Tens of young fistula patients are hospitalised in Liberia.
According to WHO, the main causes of maternal deaths are severe bleeding after birth, post-childbirth infections, high blood pressure during pregnancy, unsafe abortion and diseases such as malaria and HIV/AIDS. “Many hospitals in my country don’t even have incubators for premature babies or doses of oxytocin to stop bleeding,” says Ms. Howard. In 2013, of the 7,500 AIDS-related maternal deaths worldwide, 6,800 (91percent) were in sub-Saharan Africa. South Africa alone accounted for 41.4 percent of global HIV-related maternal deaths, states WHO.
It gets complicated when women cannot even make decisions about their own health. In Mali, Burkina Faso and Nigeria, 70 percent of women surveyed by UNICEF said they had no influence over such decisions. In general, adds a report by the UN Population Fund (UNFPA), 95 percent of married girls under the age of 19 in sub-Saharan Africa “have no say over whether to access or use contraceptives.”
Progress is being made
Preventing maternal deaths is not complicated, some experts say. “All women need access to antenatal care during pregnancy, skilled care during childbirth, and care and support after childbirth,” states UNICEF. That may sound simple, but it’s not. For example, due to distance, poverty and a lack of information, women in remote parts of Africa have no access to health care. A study by Jose Luis Alvarez, Ruth Gil, Valentine Hernandez and Angel Gil for BMC Public Health, an online health journal, found that illiteracy, poverty and weak health care systems hamper progress in maternal health.
To be fair, African leaders have placed maternal health on the front burner. They are committed to Millennium Development Goal (MDG) 5, which envisions a 75 percent reduction in maternal mortality by 2015. A recent report by UNFPA shows some progress, though hardly enough for a victory lap. Equatorial Guinea has achieved MDG 5, having reduced maternal deaths by 81percent. With an annual average reduction of 6.2 percent, Eritrea has met the goal with a 77 percent reduction in maternal deaths. Ethiopia has achieved 69 percent reduction, Rwanda 76 percent, Angola 68 percent, Mozambique 64 percent and Cape Verde 77 percent. Twenty-six of the 46 sub-Saharan African countries are at the 40 percent mark, and that includes Nigeria, which accounts for 14 percent of global maternal deaths.
African First Ladies are spearheading advocacy efforts on maternal policy and investments in the sector. At the UN General Assembly debate last September, the First Ladies said they were “alarmed” at child wives, early pregnancy, unsafe abortions and the risk of HIV. “The current situation [of Ebola] in West Africa shows that we cannot shorthand progress on health,” admonished Ban Soon-taek, wife of UN Secretary-General Ban Ki-moon, at a forum attended by the First Ladies. “We have a long way to go post-2015, so we need each other…[to] deliver for women and girls in Africa,” added Roman Tesfaye, Ethiopia’s First Lady. In other words, women needn’t die or lose their babies in childbirth. The hard work is to make this dream a reality.