How to reduce maternal deaths in Africa

from The Mail and Guardian

Mary Kimani

In 2002, the World Health Organisation (WHO) warned that if nothing was 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. While progress has been made since then, much remains to be done.

In 2006, the 23 countries with the worst mortality rates worldwide were all in sub-Saharan Africa. The WHO says that 75% of all maternal fatalities and disabilities could be prevented if deliveries were to take place at well-equipped health centres, with suitably trained and skilled staff.

Dr Luc de Bernis, a maternal health adviser for Africa at the United Nations Population Fund (UNFPA), says the problem is the poor state of Africa's health systems. "We know that 15% of pregnant women develop complications that require obstetric care, and up to 5% will require some type of surgery. We have to invest in the infrastructure necessary to do it," he says.

"We have a shortage of qualified staff," says Dr Grace Kodindo, a former head of maternity at the main hospital in Ndjamena, the capital of Chad. "In most of the continent, the ratio is one doctor for every 60 000 to 80 000 people. We lack equipment and drugs, and there is inadequate coverage in the rural areas."

Dr Yves Bergevin, an adviser on reproductive health at the UNFPA, says health centres are often unable to identify complications and manage them or quickly refer the woman to a larger hospital. Emergency surgery or lifesaving blood transfusions are also often unavailable.

"An obstetric emergency is not something for which you can tell the mother to come back tomorrow," he says. "If that woman needs but doesn't get a caesarean, then it's very simple: she will die."

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. Moreover, at a meeting in Abuja, Nigeria, in 2001, African leaders committed themselves to improving health services by putting aside 15% of their annual budgets to improve health access. By 2004, only Botswana and The Gambia had met that target.

Kodindo questions African governments' commitment. "Yes, they are poor," she says. "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."

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 institutions prescribed a regimen of reduced domestic spending by African governments intended to improve fiscal balances and ensure continued debt payments.

However, Bergevin argues, such austerity also had the negative effect of reducing funding for healthcare. 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 necessary to improve financial discipline, austerity had a terrible effect on the health sectors."

Since enough financing is not available to provide free care, many African health facilities are locked into "cost sharing" practices where patients "pay for service". This model, notes Bergevin, has a catastrophic impact on the poor, who cannot afford to pay fees and thus have no access to healthcare. "If the poor have no access, we will never reduce maternal mortality in a meaningful way."

Some donors are seeking to bridge the financing gap for maternal health. In October 2007, at the launch of an international campaign known as Deliver Now, Norwegian Prime Minister Jens Stoltenberg announced that his country would give $1-billion over the next decade towards improving maternal health worldwide.

"That there is hardly any progress on maternal health is unacceptable," he said. "It is so simple to do something about it ... 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."

Stoltenberg said $1-billion is only a small fraction of Norway's official development assistance, which is currently 0,97% of its gross domestic product, higher than the international community's agreed goal of 0,7%. The average for all donors is about half that level, however. So, Stoltenberg argued, much more would become available if donor governments met their promises.

De Bernis warns that efforts to make healthcare affordable should not depend entirely on donor assistance. Given the uncertainties of external aid, "this is not sustainable". But there are other options, he argues.

"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. But, "Even in such schemes, the really poor should still be exempted from paying."

Reprinted from UN Africa Renewal