Healthcare
provision and midwifery are paramount in saving the lives of mothers and their
children in developing nations, explain AMREF
UK’s Samara Hammond and Jay Levy...
Globally,
around 350,000 women die every year either while pregnant or giving birth.
Levels are especially striking in terms of their localised prevalence: lifetime
risk of maternal mortality for adults is one in 39 in sub-Saharan Africa,
compared to one in 4,600 in the UK. Developing nations and rural areas display
far higher maternal mortality ratios (MMR – maternal deaths per 100,000 live
births). Levels are additionally remarkable in that these are deaths that could
be easily prevented. These are women’s human rights issues, where, as
emphasised by the World Health Organization
(WHO), ‘human rights include access to services that will ensure safe
pregnancy and childbirth’. Thus, increasing women’s access to healthcare
provision and midwifery services has become a global priority in striving to
achieve the UN Millennium Development Goal of reducing maternal mortality by 75
per cent come 2015.Two-thirds of maternal deaths are due to just a few direct causes, including obstetric haemorrhage, obstructed labour, high blood pressure, and complications resulting from unsafe foetal termination. Other problems result in long-term harm: prolapsed uteruses, fistulas and infertility all cause long-term damage, stigma, and/or social exclusion. Different factors pose varying risk in different places: unsafe terminations carry huge risk in some areas, and the primary cause of maternal mortality is HIV/AIDS related where HIV prevalence and mortality in the general populace is high. As of 2009, the WHO notes that HIV was the leading cause of mortality world-wide amongst women of reproductive age, and sub-Saharan Africa has the highest proportion (10 per cent) of HIV-attributed maternal deaths. Globally, 89 per cent of such deaths take place in sub-Saharan Africa, where infectious diseases have superseded obstetric reasons for maternal mortality. HIV is responsible for significantly elevating maternal mortality rates and for increasing MMRs in several countries between 1990 and 2000. However, these ratios are now declining following rollouts of antiretroviral treatment programmes.
Poverty, intersecting with geographical disparities in wealth, is key in determining the likelihood of a woman dying as a result of pregnancy or childbirth: 99 per cent of maternal mortalities occur in developing countries, with mortality highest in sub-Saharan Africa and South Asia, and the MMR highest globally in sub-Saharan Africa at 500 deaths per 100,000 live births. Indeed, sub-Saharan Africa accounts for more than half of the global burden of maternal mortality.
Intranational differences between urban and rural areas in poorer countries are also considerable. Women in rural areas and/or who have to travel long distances to healthcare facilities are considerably more likely to die. In sub-Saharan Africa, MMR is estimated at 640 deaths per 100,000 live births in rural areas, compared to 447 per 100,000 in urban areas.
Further to direct and indirect causes, MMRs are impacted by barriers to accessing healthcare and service provision. These are determined by a multitude of sociocultural factors such as social exclusion and marginalisation, racial/ethnic discrimination and inequality, and cultural practice and belief.
In the context of such high levels of maternal mortality, it is generally
accepted that healthcare provision needs to be scaled-up in sub-Saharan Africa.
A mixed-methods approach is argued to be key in addressing maternal mortality,
and antenatal care – as well as care after delivery – should be provided
alongside care during childbirth. As well as improvements and expansion of
healthcare, meeting increasing demand for healthcare provision through removing
the multitudinous barriers to accessing services is paramount, but this is not
necessarily resource-intensive. With many barriers resulting from gender-based
inequalities, grassroots empowerment – particularly education of women – plays
no small role.In reducing maternal mortality through healthcare provision, improving access to those trained in midwifery is fundamental, and there is a need to ensure that the International Confederation of Midwives’ (ICMs) standards are met – the quality and quantity of midwives needs to be addressed. Midwives save lives, reduce disabilities, and facilitate medical referrals.
According to the 2011 ‘State of the World’s Midwifery’ report, published by the United Nations Population Fund (UNFPA) in 2011, ‘Investing in midwifery saves lives…as many as 3.6 million maternal, foetal and newborn deaths per year could be averted if all women had access to the full package of reproductive, maternal and newborn care…the midwifery workforce are important in the provision of all these services’.
In the same report, the UNFPA notes severe shortfalls in such healthcare provision. Three groupings of countries are highlighted, with the first containing nine countries that need to increase numbers of midwives by up to 15 times. Group 2, consisting of seven countries, needs to multiply numbers by between three and four, and the midwifery workforce needs to be doubled for Group 3 – 22 countries in total. Again, sub-Saharan Africa is striking, where most countries in sub-Saharan Africa and South Asia have lower than 50 per cent skilled birth attendance coverage.
The African Medical and Research Foundation’s (AMREF) Stand up For African Mothers campaign aims to utilise midwives in reducing maternal mortality through providing healthcare and service provision for pregnant women, with the goal of training 15,000 midwives in 13 priority African nations by 2015. e-Learning initiatives have been used to increase the number of midwives trained to diploma level in Uganda, where until recently, only 38 per cent of midwives held diplomas and were registered. Further to increasing available services, the project focuses on breaking down aforementioned barriers to accessing healthcare. In the Sudanese area of Maridi – an area with a high MMR and low number of midwives – demand for and uptake of services is increasing, with daily attendance of the Maridi hospital antenatal clinic rising from 30 to 70.
Illustrating that reductions in mortality can be both rapid and substantial, global maternal mortality dropped by almost half in the 20 years between 1990 and 2010. While there have been improvements in service provision and a corresponding overall global decline in maternal mortality, there is room for improvement: as noted in the WHO’s ‘ Trends in Maternal Mortality: 1990-2010’, 14 countries are classed as having made ‘insufficient progress’, and 11 are seen as having made ‘no progress’ at all. As of 2010, only 23 states were on track to fulfil the ambition to decrease maternal mortality rates by 75 per cent by 2015. Care leading up to, during, and following birth is vital in preventing the deaths of, and mitigating the avoidable harms experienced by, mothers and newborns. In reducing levels of maternal and infant mortality, healthcare provision needs to be more readily available, targeting the most vulnerable groups, with barriers to access challenged in order to increase demand for available services. Crucial to these improvements are initiatives to train healthcare providers in midwifery.
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