Maternal and newborn complications are among the leading causes of death and disability in the developing world. Worldwide, an estimated 287 000 women die during pregnancy and childbirth each year,⁽²⁾ along with 4-million neonatal deaths and a similar number of stillbirths.⁽³⁾ The burden of maternal and newborn mortality falls disproportionately on people living in the poorest regions of the world, predominantly in Sub-Saharan Africa (SSA) and South-East Asia. With 99% of these deaths occurring in developing countries globally, maternal and newborn mortality are the most inequitably distributed indicators of health.⁽⁴⁾

The World Health Organisation defines maternal mortality as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes”.⁽⁵⁾ A newborn death refers to the death of a baby during the neonatal period, the first 28 days of life.

With a maternal mortality ratio (MMR) of 500 maternal deaths per 100,000 live births, SSA suffers the highest rate of maternal mortality in the world, accounting for 56% of the global burden.⁽⁶⁾ Similarly, the risk of a newborn death in the first month of life is highest in this region. Furthermore, SSA is showing the least progress in improving maternal and newborn health outcomes.⁽⁷⁾ In addition to the tragic loss of life, high maternal and newborn mortality and morbidity come at a cost to society. The direct cost to individuals and the health system can be substantial, as are the indirect costs to societies resulting from loss of productivity. This paper discusses maternal and newborn mortality in Sub-Saharan Africa, outlining the particular challenges facing this region and identifying why investments in maternal and newborn health would lead to significant social and economic gains.

Causes of maternal and newborn mortality

The high rates of maternal and newborn mortality in SSA are particularly tragic considering that the vast majority of cases can be prevented or treated by simple, cost-effective interventions. The causes of maternal death are widely known, with just five conditions accounting for 80% of all maternal deaths, namely haemorrhage, sepsis, eclampsia, complications of abortion and obstructed labour. It has been estimated that for every woman who dies during pregnancy and childbirth from one of the aforementioned obstetric complications, approximately 20 or more suffer injury, disability or illness.⁽⁸⁾ Since the majority of obstetric complications cannot be predicted during antenatal care, all women are at risk of developing a complication at the time of birth. Consequently, access to emergency obstetric care at a healthcare facility is critical to managing these complications in order to prevent mortality and future disability.⁽⁹⁾

Maternal mortality is directly linked to newborn mortality since saving the life of a pregnant woman often means saving her newborn baby. Of the 4 million newborn deaths occurring worldwide, the majority die within the first 24 hours of life. Birth complications, in combination with a few diseases and conditions such as pneumonia and diarrhoea, are the most common causes of newborn mortality. In a recent paper, Piotie reviewed the clinical causes of newborn mortality in SSA, broadly inclusive of viral and bacterial infections, which goes into greater detail on this particular point.⁽¹⁰⁾

Lack of access to adequate medical interventions at the time of birth and shortly thereafter are also largely to blame for maternal and newborn mortality. In SSA, it is estimated that 4 in 10 people do not have access to medical services or personnel.⁽¹¹⁾ Poor access results from a range of barriers, including financial and structural, all of which contribute to a delay in reaching care when urgently needed. The ‘Three Delays’ model suggests that maternal mortality is overwhelmingly due to three stages of delays in accessing life-saving services; (i) the delay in deciding to seek care; (ii) the delay in reaching a medical facility to seek appropriate care; and (iii) the delay in receiving adequate care at a facility.⁽¹²⁾ These are discussed in further detail below.

First Delay: Deciding to seek care

The decision to seek care in an emergency is complex and involves many factors and actors. For instance, a woman’s socio-economic status can affect her ability to seek care, with financial means being a determining factor as to whether one visits a health facility or not.

Second Delay: Reaching a health facility

Physical barriers, such as distance to health facilities, the condition of roads and availability of appropriate transport, remain major factors contributing to maternal and newborn mortality in these regions. To put this into context, around 40-60% of people in developing countries live more than 8 km from a health facility.⁽¹³⁾

Third Delay: Receiving appropriate care at a facility

Many African countries face a chronic shortage of both financial and human resources. The delay in receiving appropriate care at a facility could be due to a shortage of trained personnel, lack of functioning equipment and medical supplies, and a timely, adequate referral system. Cost-effective medicines, such as magnesium sulphate for the treatment of hypertension, are simply not available in some lower-level facilities. These challenges are exacerbated by the fragmentation of healthcare services, resulting from the involvement of multi-lateral and donor organisations. For example, one effect of multiple programmes with different funders is that each has its own reporting system requiring different information. This duplicates the work of the already overburdened healthcare providers.

A major challenge facing the health systems in SSA is the ‘medical brain-drain’ – the migration of skilled healthcare providers to richer countries offering more favourable economic and/or professional environments. This migration has devastating implications for health systems in the countries that the doctors emigrate from.⁽¹⁴⁾ Given the importance of medical interventions in obstetric emergencies, the medical brain drain denies patients access to services by trained healthcare providers. This significantly compromises maternal and newborn health in the affected countries.

Together, these ‘three delays’ highlight the complexity of factors contributing to maternal and newborn mortality in SSA. A delay in any one of the three stages can result in the death of a newborn or its mother.⁽¹⁵⁾

Solutions

Despite significant progress in reducing global maternal and newborn mortality, a number of countries in SSA are lagging behind. Evidence over the last decade has demonstrated that a more strategic focus is required to help curb maternal and newborn mortality, and now there is greater consensus regarding the most appropriate solutions to improve the health of these sectors of the population. Previous attention on screening for high-risk patients during antenatal care has been replaced by an emphasis on ensuring timely access to emergency newborn care and obstetric services for all women, if and when required.⁽¹⁶⁾

Addressing the delay in receiving appropriate care at facilities, the third of the three delays, will be critical in achieving health gains in these settings. The presence of a skilled birth attendant at every birth is considered the single most critical factor to save lives.⁽¹⁷⁾ This involves ensuring that the primary level health centres, which are the first point of care, are equipped with trained personnel and basic medicines and medical equipment that can save the lives of the majority of women and their babies during labour. In addition, having in place a referral system to higher-level health facilities that offer more comprehensive emergency obstetric and newborn care is essential. This will ideally offer the best chance of survival for women and babies presenting with more complicated conditions.

Barriers to accessing high-quality health system services lie at the centre of maternal and newborn health. Addressing the first and second delay of the model, including improving understanding about the importance of skilled birth attendance and ensuring facilities can be easily reached, is fundamental to the reduction of maternal and newborn mortality in SSA. Undoubtedly, improvements in socio-economic status, nutrition, education and disease prevention among patients also have important roles to play in reducing mortality and morbidity in these settings.

Why invest in maternal and newborn health?

At the most basic level, health is a fundamental human right. The United Nations Declaration of Human Rights proclaims that everyone has the right to access the services required to live a healthy life, with mothers and children being “entitled to special care and assistance.”⁽¹⁸⁾ Besides the moral and ethical case for saving a woman and her baby’s life, there are strong social and economic justifications for investing in maternal health. The link between health and long-term economic growth and poverty reduction is much more powerful than generally understood. Health is both an end goal of development, as well as a means to achieving development goals and poverty reduction. In particular, women and children are central to human development and economic prosperity, as described below.

The interdependence between maternal and child health means that, in many cases, saving a woman’s life will save her newborn baby, which will in turn improve the chances of survival for the rest of her children. Studies show that children under the age of five are between 3 and 10 times more likely to die in the absence of their mother.⁽¹⁹⁾ Later in life, a child’s health, welfare and education status are directly linked to the health of the mother. Research shows that women are more likely than men to spend money on welfare-improving goods and services for the family such as food, healthcare and education, all of which have a positive impact on future economic prosperity for the family and, on a broader scale, poverty reduction.⁽²⁰⁾

Since pregnant women require services across a continuum of care from primary level health facilities to specialised hospital treatments, strengthening the efficiency of these healthcare facilities for such women is likely to improve care for the rest of the population. Many of the skills required for obstetric services are transferable to other medical specialities and health conditions.⁽²¹⁾ As a consequence, improved service quality can have a substantial impact on the use of healthcare facilities by the wider community. This is because a patient is more likely to seek care if a facility is perceived to be offering high-quality services.⁽²²⁾ Such developments would in turn have a significant impact on the overall health status of the population.

Women play an important role in society, being the foundations on which families and community structures rely. The broad health, social and economic benefits resulting from investing in maternal and newborn health services indicate that such investments are worth pursuing and offer good value for money.

Concluding remarks

The causes of maternal and newborn mortality are complex and involve an array of individual, socio-economic and health system factors. Despite significant progress globally in improving health outcomes for women and babies, a number of countries, predominately in SSA, are lagging behind. Since solutions are widely known, lack of access to life-saving services and treatment by women and babies in this region seem to be largely responsible for the high mortality rates among these sub-populations in SSA. Various social and economic justifications for investing in maternal and newborn health, as referred to in this paper, highlight the need for the improvement of these services, as well as facilitation of access to these by the public. Failure to do so will not only undermine the perceived progress in global health equality but also fuel and perpetuate the cycle of poverty in SSA.

Written by Megan Wilson-Jones ⁽¹⁾

NOTES:

(1) Contact Megan Wilson-Jones through Consultancy Africa Intelligence’s Public Health Unit (public.health@consultancyafrica.com). This CAI discussion paper was developed with the assistance of Tsholofelo Thomas and was edited by Liezl Stretton.
(2) ‘Trends in maternal mortality: 1999 to 2010 - World Health Organisation, UNICEF, UNFPA and The World Bank estimates’, UNFPA, 2012, http://www.unfpa.org.
(3) Lawn, J.E., Cousens, S. and Zupan, J., 2005. 4 million neonatal deaths: When? Where? Why? The Lancet, 365, pp. 977-988.
(4) Frenk, J., 2010. A women and health agenda: It’s time. Harvard Public Health Review, Spring/Summer edition, http://www.hsph.harvard.edu.
(5) International statistical classification of diseases and related health problems. World Health Organization Instruction manual: 10th Revision, 2010 edition, 2.
(6) ‘Trends in maternal mortality: 1999 to 2010 World Health Organisation, UNICEF, UNFPA and The World Bank estimates’, UNFPA, 2012, http://www.unfpa.org.
(7) ‘Child info; Monitoring the situation of children and women; Statistics by area – child survival and health’, UNICEF, 2013, http://www.childinfo.org.
(8) ‘Safe motherhood: Stepping up efforts to save mothers’ lives’, UNFPA, https://www.unfpa.org.
(9) Maine, D. and Rosenfield, A., 1999. The Safe Motherhood Initiative: Why has it stalled? American Journal of Public Health, 89(4), pp. 480-482.
(10) Piotie, N.P., ‘Premature deaths and avoidable trauma: A snapshot analysis of congenital infections in Sub-Saharan Africa’, Consultancy Africa Intelligence, 16 April 2013, http://www.consultancyafrica.com.
(11) Knapp, T., Richardson, B. and Viranna, S., ‘Three practical steps to better health for Africans: A new model to make care more accessible to Africa’s people is not only possible but affordable’, McKinsey, 2010, http://www.mckinseyquarterly.com.
(12) Thaddeus, S. and Maine, D., 1994. Too far to walk: Maternal mortality in context. Social Science & Medicine, 38(8), pp. 1019-1110.
(13) ‘Transport for health access’, The World Bank, 2006, http://web.worldbank.org.
(14) Taylor, A.L., 2011. Stemming the brain drain – a WHO global code of practice on international recruitment of health personnel. The New England Journal of Medicine, 365, pp. 2348-2351.
(15) Thaddeus, S. and Maine, D., 1994. Too far to walk: Maternal mortality in context. Social Science & Medicine, 38(8), pp. 1019-1110.
(16) Ibid.
(17) ‘Skilled attendance at birth’, UNFPA, 2013, http://www.unfpa.org.
(18) ‘The Universal Declaration of Human Rights’, 2010, United Nations,   http://www.un.org.
(19) ‘The state of the world’s children 2007: Women and children -the double dividend of gender equality’, UNICEF, 2006, http://www.unicef.org.
(20) Jowett, M., 2000. Safe motherhood interventions in low-income countries: An economic justification and evidence of cost effectiveness. Health Policy, 53, pp. 201-228.
(21) Ibid.
(22) Boulenger, S. and Dmytraczenko, T., ‘Cost of family care international’s skilled care initiative in Kenya and Tanzania’, Abt Associates Inc., 2007, http://www.familycareintl.org.