Africa Renewal (United Nations)
Mary Kimani
4 January 2008
Listerning to a mother's foetus in Liberia: African women not only need access to well-equipped health clinics, but also assistance from trained personnel who can recognize and deal with complications.
Pumwani Maternity Hospital, in Nairobi, Kenya, is the largest maternal health centre in East and Central Africa. Located close to Mathare and Korogocho, two of Nairobi's biggest slums, the hospital helps some 27,000 women give birth each year. Most are poor and young, between the ages of 14 and 18.
The government-run hospital struggles to provide even the most basic services, since it lacks sufficient resources, equipment and staff. "We told patients to buy their own things because of the shortage of supplies," explains Evelyn Mutio, the former head of the hospital's nursing staff. "We told patients to come with gloves, to buy their own syringes, needles, cotton wool and maternity pads."
The Pumwani Maternity Hospital exemplifies the state of the health infrastructure in Africa. According to the World Health Organization (WHO), high service costs, lack of trained staff and supplies, poor transport and patients' insufficient knowledge mean that 60 per cent of mothers in sub-Saharan Africa do not have a health worker present during childbirth. That heightens the risks of complications, contributing to greater maternal and child death and disability.
WHO estimates that in Nigeria, 800,000 women are living with fistula, a disabling condition often caused by problems in childbirth; the number grows by 20,000 each year. In Tanzania, 9,000 women die annually of complications related to pregnancy. Rose Mlay, the Tanzania representative of the White Ribbon Alliance, an international coalition on maternal health, says half of the mothers in the country have no access to medical facilities, because such facilities are too far away and the women lack adequate transport. And, she adds, "Even when attendants are present, they may not always have the training, skills or adequate equipment and facilities."
Health care on bicycles
Despite scarce resources, some countries have been able to find ways to expand access to maternal health care. In Senegal, the Ministry of Health and the UN Population Fund (UNFPA) jointly fund the work of community health workers who bicycle to visit women in their villages. They are trained to monitor the health status of pregnant women, refer the women to local heath centres for preÂnatal checkups and ensure that they get to a centre where skilled attendants can assist with delivery.
"These volunteers come from the populations they serve," says Dr. Suzzane Maiga-Konate, UNFPA's representative in Senegal. "Sensitive questions that people would never ask an outsider, they ask them. And if we can reach people, we can raise the health status of this country."
In addition, UNFPA provides the villages with about $50 in seed money to set up community health funds. Villagers work out among themselves how to replenish the funds, usually through small monthly donations. The funds are used for emergency cases, such as getting a woman to a district hospital when complications arise.
Preventable deaths
Across Africa, the challenge of preventing maternal deaths is enormous. While progress has been made in some countries, the 23 countries in the world with the worst mortality rates in 2006 were all in sub-Saharan Africa. While a pregnant woman in Sweden has only 1 in 30,000 chances of dying, in Sierra Leone the risk is 1 in 7. In 2002, the WHO warned that if nothing is done to improve access to maternal care in Africa, 2.5 million women would die before the end of the decade, and 49 million would be living with disabilities.
Dr. Luc De Bernis, UNFPA's senior advisor on maternal health in Africa, says the problem is the poor state of Africa's health systems. "What is needed is an effective system" by which women can be assisted during the birth, he told Africa Renewal. "We know that 15 per cent of pregnant women develop complications that require obstetric care, and up to 5 per cent will require some type of surgery. We have to invest in the infrastructure necessary to do it."
A pregnant woman gets medicine and advice at a rural clinic in Kenya: African governments have pledged to devote at least 15 per cent of their budgets to health, but only a few have reached that target.
Dr. Grace Kodindo, a former head of maternity at the main hospital in Ndjamena, the capital of Chad, agrees. "In Africa we have a shortage of qualified staff," she says. "In most of the continent, the ratio is 1 doctor for every 60-80,000 people. We lack equipment and drugs, and there is inadequate coverage in the rural areas."
WHO estimates that three quarters of maternal fatalities and disabilities could be prevented if deliveries were to take place at well-equipped health centres, with suitably trained and skilled staff.
According to Dr. Yves Bergevin, a senior adviser on reproductive health at UNFPA, every woman needs to be near a health centre so she can get advice about nutrition. Such centres should also have trained personnel who can recognize complications and either manage them or quickly refer the woman to a larger hospital. Facilities for emergency surgery or lifesaving blood transfusions must be available. "Even if it is three in the morning an obstetric emergency is not something for which you can tell the mother to come back tomorrow," he told Africa Renewal. "If that woman needs but doesn't get a caesarean, then it's very simple: she will die."
Millennium goal
The international community has agreed that bringing down maternal mortality is a priority. The Millennium Development Goals (MDGs), agreed to by world leaders in September 2000, include a specific target of reducing the number of women dying during pregnancy and childbirth by three quarters by 2015.
Achieving the MDG goals of reducing child and maternal mortality "is one of the most urgent tasks ahead of us," UN Deputy Secretary-General Rose Migiro said in New York in September 2007, at the launch of Deliver Now, a campaign by 80 governments, donor agencies and non-governmental organizations (NGOs) aimed at raising the commitment and funds to improve delivery of and access to maternal services.
Shaky commitments
African leaders have also committed themselves to improving health services. At a meeting in Abuja, Nigeria, in 2001, they pledged to put aside 15 per cent of their annual budgets to improve health access. By 2004, only Botswana and Gambia had met that target.
Dr. Kodindo questions African governments' commitment. "Yes, they are poor," she told Africa Renewal. "But they have some money. For example, Chad is producing oil, but the money is used to buy arms. Meanwhile maternal mortality is not on the agenda.... We have seen other countries like Honduras and Sri Lanka, which despite poverty have been able to do a lot. Our countries could do it if they really wanted. Maternal mortality is simply not a priority. If it were a priority, they could have put it in the governments' annual budgets."
A related problem, says Dr. De Bernis, is that governments and donor agencies tend to focus on specific themes, such as HIV infection, malaria and tuberculosis, while failing to address the general state of Africa's health care systems. "Strengthening health services to address maternal mortality would be very important for all these programmes," he says.
"A surgery room," he adds, "will not only serve the mothers. It will serve the needs of the community. A road which goes to a health centre will serve the community in other ways. This is a development issue and economists should recognize this. We have never seen any country developing without a minimal health system. What we need is long-term investment, which is not what is being done at present."
Austerity and 'cost sharing'
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