Not far from Mathare and Korogocho, two of the biggest slums in Nairobi, Kenya’s capital, lies the Pumwani Maternity Hospital. Some 27,000 women give birth there each year. Most are poor and young. Yet the government-run hospital, the largest maternal health centre in East and Central Africa, lacks resources. Patients have to buy their own syringes, needles, cotton wool and maternity pads.
The case of Pumwani exemplifies the state of health institutions 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. The country’s maternal health facilities are often too far away and the women lack adequate transport.
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 community health workers who bicycle to visit women in their villages. They are trained to monitor the health of pregnant women, refer the women to local health centres for prenatal checkups and ensure that they get to a centre where skilled attendants can assist with delivery. Similar efforts are under way in Rwanda.
Across Africa, the challenge of preventing maternal deaths is enormous. Of the 536,000 women worldwide who die each year from complications of pregnancy or delivery, 99 per cent are in developing countries. Of those, half are in sub-Saharan Africa.
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. “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.”
According to Dr. Yves Bergevin, a senior adviser on reproductive health at UNFPA, women need to be near health centres so they can get advice about nutrition. 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.
The international community has agreed that bringing down maternal mortality is a priority. The Millennium Development Goals (MDGs), agreed to by world leaders in 2000, include a target for reducing the number of women dying during pregnancy and childbirth by three quarters by 2015. In 2001 African leaders pledged to put aside 15 per cent of their annual budgets to improve health access.
One 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 improve 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.”
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 that was 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. 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.
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.
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. 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 more likely than 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.”
Concerned that high costs were impeding access to maternal health care, Kenya’s Health Ministry abolished maternity fees in public hospitals such as Pumwani in May 2007. But the money still has to come from somewhere.
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, Norway announced that it would give $1 billion over the next decade towards improving maternal health worldwide.
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. However, even in such schemes, the really poor should still be exempted from paying, he argues.
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.”
Social hurdles to better maternal health
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, UNFPA’s former 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. “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.