Blog by Ekene Osakwe, Ipchita Bharali, and Dr. Megan Huchko
This blog summarizes the discussion and key takeaways from the webinar that was hosted on April 22, 2022 as part of the Asia-Africa Health Initiative Seminar series. Click here to view the live recording of the seminar.
No woman should die from childbirth. Although global trends in maternal mortality from 2000 to 2017 show a 38% reduction in the maternal mortality ratio (MMR), the agenda to eliminate preventable deaths in mothers and children on the African and Asian continents is still unfinished. Low- and middle-income countries contribute 99% of global maternal deaths for women aged 15-49 years. Maternal mortality has remained unacceptably high with 297 000 deaths occurring in 2017 alone. Sub-Saharan Africa and Southern Asia contributed 86% of the global maternal deaths in 2017, with two-thirds coming from sub-Saharan Africa and one-fifth from Southern Asia. Over 9 in 10 maternal deaths occur in low- and lower-middle-income countries.
Pregnancy and childbirth complications among adolescents aged 15-19 years are significant contributors to the global MMR, with complications during pregnancy and childbirth being the leading cause of death in this age group globally. Adolescents are at higher risk of complications and death from pregnancy than adult women. Sub-Saharan Africa has the highest birth rates among girls aged 16 and younger, with especially high rates in Chad, Guinea, Mali, Mozambique, Niger, and Sierra Leone. In South Asia and Southeast Asia, the adolescent fertility rate is highest in Bangladesh, Laos, Nepal, Philippines, Cambodia, Indonesia, Thailand, and Pakistan. Pregnancy in itself is a risk factor for maternal death—therefore, high adolescent fertility rates, combined with limited access to antenatal care and skilled delivery due to perceived discriminatory attitudes, may be precursors to high maternal mortality rates.
Globally, there has been significant progress in reducing the MMR since 2000, with Southern Asia recording the greatest reduction (60%) and sub-Saharan Africa achieving a 40% reduction. Building upon the lessons learned, Duke University’s Africa-Asia seminar on the unfinished agenda of maternal and child health prioritized specific gaps in the health care system. It proposed strategies for addressing these gaps, to increase equitable access to quality maternal health services for every woman and every girl.
The unfinished agenda: why unfinished?
Within and across Africa and Asia, there are disparities in the MMR and child mortality rates due to country-specific socio-economic factors such as poverty, poor education, and employment status. Weak health systems due to poor governance, poor allocation of resources for health, poor coordination, and weak accountability mechanisms drive health inequities, which in turn are a barrier to reducing the MMR in these continents. Existing evidence shows that skilled birth attendance and higher educational levels of women are factors associated with reduced maternal mortality. However, poor women living in remote areas are less likely to give birth with the assistance of a skilled birth attendant due to the long distance to hospital, health worker shortages, and poorly delivered health services.
An example is the MMR disparity between Northern and Southern Nigeria. From 2008 to 2013, the MMR fell in Southern Nigeria from 401 per 100,000 live births to 365 per 100, 000 live births and it increased in Northern Nigeria from 620 per 100,000 live births to 709 per 100,000 live births. Educational level, age, contraceptive use, and wealth index, are some of the factors linked to maternal mortality in both regions. A third of health facilities in northeast Nigeria’s Borno state were destroyed by insurgents and a significant number of health care workers were killed in the crises, hampering access to health care services for the people of Borno state. Armed conflict is associated with excess maternal deaths and many South Asian countries have experienced prolonged periods of conflict, including Afghanistan, Bangladesh, India, Nepal, Pakistan, and Sri Lanka.
There are also significant regional health care disparities within countries in Asia. Although China was one of the few countries to achieve the Millennium Development Goal 5 (the goal was a 75% reduction in MMR from 2000 to 2015), there are existing disparities between provinces with higher maternal mortality in provinces with more minority ethnic groups. The MMR in China is linked to GDP per capita, urbanization rates, average travel time to the nearest hospital, health human resources, and health infrastructure. The MMR is 118% higher in eastern China than in western China, and is associated with educational level, health workforce and the proportion of ethnic minorities living in the area.
Bridging the gap: approaches and strategies
While there has been a steady decline in the global MMR, this level of decline is not universal across the different continents and countries in Africa and Asia. Without bridging these health inequity gaps, achieving the Sustainable Development Goal to reduce maternal mortality rate to 70 per 100,000 by 2030 will be unattainable. Through a seminar focused on the unfinished agenda of maternal mortality in Asia and Africa, Duke University brought together experts working in both regions to share promising approaches on bridging the equity gaps to reduce the MMR. In alignment with the Leave No One Behind principle, the following three key approaches were identified during the seminar to improve maternal healthcare and reduce deaths related to pregnancy and/or childbirth:
- Enhance gender equality by amplifying women’s voices in providing women-centered maternal health care
At the crux of maternal and child mortality is gender inequality, gender discrimination, gender-bias and gender oppression. Gender patterns in the household tend to assign more food and resources to men based on their contributory level to income generation, which may give women limited access to monetary resources for their health needs. Gender-biased roles such as, cooking, taking care of the children, cleaning, washing clothes, fetching firewood, and other household chores are often regarded as a woman’s duty for which she is not paid. Therefore, women in sub-Saharan Africa account for most of the unpaid work and may lack the financial resources to access reproductive, maternal, and child health services. Having limited financial power also means less autonomy in decision making. In some cases, women are unable to make decisions about their own health care, including reproductive health care, without the permission of their husbands.
A study on gender inequality, health expenditure and maternal mortality in Africa showed that countries with a higher gender inequality index were more likely to have a high MMR than countries with a lower gender inequality index. This finding shows the absolute necessity of implementing maternal and child health policies with a gender lens.
In enhancing gender equality, we must amplify the voices of women, what women want, and how they want to be treated in the delivery of maternal health services. The World Health Organization recommends person-centered maternity care because person-centered maternity care and postnatal health are associated with better maternal and newborn health outcomes. All women deserve high quality, respectful care. We must advocate for respectful care for all women, including poor uneducated women living in rural areas, and support improved provider relationships to improve maternal care. By using digital tools to collect data on what women want, women can provide their feedback, and truly be part of providing solutions. The digital platform can also empower women with the right information to access quality maternal care.
- Design innovative data management systems for effective decision-making across all levels, from policy to community level
Maternal and child health programs should have feedback mechanisms that identify gaps and create pathways for effecting durable change. We must invest in durable information systems that count every death and that help us understand when, where and why women are dying from childbirth or experiencing complications. In analyzing maternal health related data, we must consider biological, environmental, community and socioeconomic factors that contribute to maternal health and wellness. The United States maternal vulnerability index is a good example of a data management tool that considers diverse factors associated with maternal health, such as reproductive healthcare, physical health status, mental health and substance abuse, general healthcare services, socioeconomic determinants of health and environment factors that influence maternal health outcomes. It applies behavioral science, data science and artificial intelligence to unlock the true picture of maternal mortality in the United States.
A robust data infrastructure helps women and governments to make better decisions about health services, navigating pregnancy, allocation of funds, accountability, and sustainability. Real time data information is particularly useful for providing real time information on events at health facilities and within communities, to drive the maternal health agenda. Because maternal and child health is multifactorial, it is imperative to design a data system that monitors it in real time.
- Strengthen health systems and increase access to skilled birth attendance
We can learn lessons from countries like Rwanda and Sri Lanka on health systems and how they impact on maternal health. Rwanda reduced its MMR by 77% from 2000 to 2013, and currently has an MMR of 320 deaths per 100,000 live births. It reduced its under-5 mortality rate by over 70% from 185 deaths per 1000 to 52 deaths per 1000 . The Rwandan success story is linked to increased skill birth attendance for women and improved immunization coverage for children. After the genocide, the government prioritized maternal and child health services as a way of rebuilding the health system. It focused on developing the health workforce and health infrastructure, establishing a comprehensive community-based health insurance scheme, and improving data collection and monitoring systems. Today, Rwanda is one of the few countries that have met MDGs 4 and 5 and is on track to achieving the SDG goal 3 targets.
Sri Lanka has one of the lowest MMRs in South Asia at 60 per 100,000 live births. For the government, saving mother’s lives was a priority through the extension of health care services, including maternal health service to the entire population, including those living in rural areas. The reduction of maternal deaths in Sri Lanka is attributed to broad access to maternal health care services based on a strong health system, systematic use of health information to guide decision making, and the professionalization of mid-wives.
History has proven that maternal mortality ratios and under-5 child mortality ratios can be reduced to almost zero-levels with appropriate measures. From the examples of Rwanda and Sri-Lanka, the following factors were responsible for reducing maternal deaths:
- Predictable and adequate funding from international and domestic sources
- The presence of strong political will, leadership, and maternal and child health champions
- Proper application of technical innovation within an effective delivery system at an affordable and sustainable price
- Technical consensus on the appropriate biomedical or public health approach
- Effective use of information through effective communication systems
- Good governance and effective accountability systems.
Evidence-based public health interventions, like creating an awareness campaign around maternal warning signs, can be adapted globally to change minds and societies. Strengthening community health systems by applying results-based health financing principles, using data to validate impact and inform decision-making at all levels, enhancing gender equality by amplifying women’s voices in providing respectful care, and establishing sustainable funding mechanisms for maternal and child health, are the key determinants of women’s health and well-being.