According to the World Health Organization (WHO) an estimated 800,000 Nigerian women are living with fistula, a disabling condition often caused by complications during childbirth. The number grows by 20,000 each year. In Tanzania, 9,000 women die annually of complications related to pregnancy. The tragic situation is partly due to high service costs, lack of trained staff and supplies, poor transport and patients’ insufficient knowledge. The combination of such factors means that 60 per cent of mothers in sub-Saharan Africa give birth without a health worker present. That in turn heightens the risk of complications and contributes to greater maternal and child death and disability.
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 WHO, Reducing Mortality Rates, notes that sometimes women or birth attendants “fail to recognize danger signals and are not prepared to deal with them.”
Rose Mlay, the Tanzania representative of the White Ribbon Alliance, an international coalition on maternal health, says half of all expectant mothers in Tanzania 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.”
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 also 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.”
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 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.
Cultural practices can also affect women’s health risks. Specifically, 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.”