Salud Pública Africana
African News:Investing in the health of Africa’s mothers
Many are too poor to survive childbirth
By Mary Kimani
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 prenatal 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.
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.”
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.”
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.
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’
The poor state of Africa’s health sector is partly a legacy of policies pursued in the 1980s and 1990s at the urging of the International Monetary Fund and the World Bank. To counter the continent’s burgeoning debt, corruption and misuse of resources, these international financial institutions prescribed a regimen of reduced domestic spending by African governments that were intended to improve fiscal balances and ensure continued debt payments.
However, Dr. Bergevin argues, such austerity also had the negative effect of reducing funding for health care. Health centres became dilapidated and there was limited hiring of new health workers, especially doctors. Those already on the payroll left in large numbers because of poor pay and bad working conditions. Many doctors emigrated to developed countries. “Africa has never recovered from that,” he explains. “While the adjustments were necessary to improve financial discipline, it has had a terrible effect on the health sectors.”
The Millennium Development Goals (MDGs) call for reducing the number of women dying during pregnancy and childbirth by three quarters by 2015.
In an effort to overcome the decline in government financing, many hospitals and clinics began asking patients to pay more for services. In Kenya, the government introduced “user fees” at public health facilities like Pumwani Maternity Hospital in 1989, as part of a World Bank push for cost-sharing in public services. “We are asking people to die because they can’t [afford to] be treated,” Dr. Shadrack Ojwang, a gynecologist at the main hospital, was quoted as saying in a joint report by the Federation of Women Lawyers in Kenya and the Centre for Reproductive Rights, a US non-profit group. “We can’t do anything about this until parliament repeals cost sharing. We went into this blindly. Nobody thought of it properly.”
The report by the two groups notes that in the face of the negative impact on health care systems, the World Bank has backed away from promoting user fees. It now supports the provision of less expensive basic health care, including maternal health services.
But since enough financing is not available to provide free care, many African health facilities remain locked into “cost sharing” practices. Such a “pay-for-service” model, notes Dr. Bergevin, has had a catastrophic impact on the poor, who cannot afford to pay fees. As a result, they have less access to health care.
The situation at Pumwani Maternity Hospital is typical. Up until May 2007, patients wishing to receive maternal care had to deposit 1,200 Kenya shillings (US$17). Women without the money were turned away. It costs Ksh3,000 for a normal delivery and Ksh6,000 for a caesarean, along with Ksh400 to cover the bed charge for the first day. Daily bed charges of Ksh400 accrue throughout a woman’s stay at the hospital. The hospital’s fees are low compared to those charged at private facilities, but significant for the 60 per cent of Kenyans who live on less than Ksh140 ($2) a day.
In Ethiopia, which has a similar model, a rich woman is 28 times as likely as a poor mother to have a doctor available during delivery, according to the UN’s Department of Economic and Social Affairs. In Chad and Niger, the gap is 14 times or more.
“We cannot accept systems which do not provide access to everybody,” says Dr. De Bernis. “If the poor have no access, we will never reduce maternal mortality in a meaningful way.” He notes that charging for services might improve access to medical care for those who can afford it, and thereby reduce the total number of maternal deaths. But leaving the poor behind would be unacceptable. “We need to ensure that maternal mortality reductions are based on reduction of deaths for everyone, rich or poor.”
Concerned that high costs were impeding access to maternal health care, Kenya’s then Health Minister Charity Ngilu in May 2007 abolished maternity fees in public hospitals such as Pumwani. But the money still has to come from somewhere. Dr. Frida Govedi, the doctor in charge of clinical services at Pumwani, points out that the hospital already struggles to get the limited subsidy it is entitled to from the Nairobi City Council. The council currently owes the hospital Ksh100 mn. Without that amount and without user fees, the hospital simply “can’t run,” she says.
“We cannot accept systems which do not provide access to everybody. If the poor have no access, we will never reduce maternal mortality in a meaningful way.”— Dr. Luc De Bernis, senior adviser, UN Population Fund
Dr. Ojwang is a member of a task force set up in 2004 by the government to study the running of the hospital. He notes that the Nairobi City Council has been marked by mismanagement and corruption. “Money was disappearing from the treasury,” he explains. Only recently has the hospital begun to gain greater control over the funds.
Across Africa, spending on health remains limited. “Currently sub-Saharan countries are spending less than $2 per person for maternal health,” Dr. Bergevin notes. “Most experts agree that you need to spend at least $8. To see a fully functioning health system, you need to spend $40–50 dollars per person, excluding anti-retroviral drugs.”
Some donors are seeking to bridge the financing gap for maternal health. In October 2007, at the launch of the Deliver Now campaign, Norwegian Prime Minister Jens Stoltenberg announced that his country will give $1 bn over the next decade towards improving maternal health worldwide. He also called for maternal mortality to become a higher priority. “That there is hardly any progress on maternal health is unacceptable,” he said. “It is so simple to do something about it. It is cheap and we know what to do. We would never have accepted that kind of a death toll if it was white rich men who were dying. Something would have been done a long time ago. So this is obviously also a question of gender and financial equality.”
Mr. Stoltenberg pointed out that while a billion dollars may look like a lot, “it is not much. It is a small fraction of our development aid.” Norway’s official development assistance is currently 0.97 per cent of its gross domestic product, higher than the international community’s agreed goal of 0.7 per cent. The average for all donors is about half that level, however. So, Mr. Stoltenberg argued, much more would become available if donor governments met their promises.
Dr. De Bernis warns that efforts to introduce free health care should not depend entirely on donor assistance. Given the uncertainties of external aid, “this is not sustainable.”
But there are other options, he adds. “In West Africa, we have seen examples of useful cost sharing,” so that the burden is not placed solely on the patients. “A calculation is made of the health cost, how much the government can afford to provide and the rest of the financial burden is shared with the community,” he explains. “This helps improve the quality of care and involves the community. If the ambulance is not working or drugs are not available, the community will ask why.” Even in such schemes, the really poor should still be exempted from paying, he argues. “The community has to agree on how to do this.”
Despite the challenges, his compatriot, Dr. Bergevin, is optimistic. “We know that maternal mortality can be reduced. We know what to do, and how to do it. Other countries are on track.” The biggest challenge lies with 66 countries in the developing world, including 45 in sub-Saharan Africa. “We know it can be done.”
Even when maternal health facilities are available, expectant mothers in Africa do not always get timely care. A study by the Africa regional office of the World Health Organization (WHO), Reducing Mortality Rates, reports that sometimes women or birth attendants “fail to recognize danger signals and are not prepared to deal with them.” One answer, argues Dr. Yves Bergevin, senior adviser on reproductive health for the UN Population Fund (UNFPA), is to improve the skills of birth attendants and the knowledge and capacity of women, their families and their communities.
Involving men is important, says Lucy Idoko, the UNFPA’s assistant representative in Nigeria. Most men, she says, do not know the risks of going through labour. “Maternal health is not only a woman’s issue but also a man’s issue, and important to society as a whole.”
Cultural practices can also affect women’s health risks. WHO cites genital mutilation, early marriage and multiple pregnancies. Women who have undergone infibulation, a form of genital mutilation where the external genitalia are stitched, are more likely to suffer from obstructed labour. UNFPA data show that girls who give birth between the ages of 15 and 20 are twice as likely to die in childbirth as those in their twenties, while girls under 15 are more than five times as likely to die.
“Adolescent girls face the highest risk of premature delivery,” says Dr. Grace Kodindo, former chief of maternity at the Ndjamena general hospital in Chad, now working at the maternal mortality programme of Columbia University in New York. “Because their bodies are not yet fully mature, they risk obstructed labour. This is why we encourage young women to postpone their first pregnancy.”
Dr. Kodindo argues that both young age and the low status of women in society often leave them with little power to determine if, when and with whom to become pregnant. They also have little choice in the number and timing of their children. “Women should be able to decide the spacing of their children,” she told Africa Renewal. “But in Africa the woman cannot make this decision freely. Her status in society is often determined by how many children she has, and women often have children even when they don’t feel like having more. Many men don’t want family planning because they want the status that more children bring.”
In 2004, WHO reported that about 4 mn abortions take place annually in Africa. Since abortion is illegal in most countries, most of these are performed in unsafe conditions, contributing to nearly 30,000 deaths, about 13 per cent of all maternal deaths in Africa.
WHO believes that some 90 per cent of all abortion-related deaths and injuries could be avoided if women who wanted to avoid pregnancies were able to use contraception. Yet overall, less than 25 per cent of African women are able to obtain contraceptives. In West Africa, fewer than 10 per cent can. “If family planning could be made available, we would reduce maternal deaths,” says Dr Kodindo.
She is optimistic. “We are seeing positive indications. The economic burden of many children is making men more cooperative.” Such a shift is especially notable in the Democratic Republic of Congo, Dr. Kodindo observes. “My only regret is that it is only in the urban areas. There is much work to do in the rural areas.”