EDITORIAL: Tackling maternal mortality in Africa after 2015: What should the priorities be?

Annette Bazuaye, Friday E. Okonofua

Abstract

At the dawn of the new millennium, 189 member states of the United Nations signed the millennium declaration and committed themselves to eight goals (MDGs) for achieving global development parity in the first 15 years of the millennium. Maternal mortality was on the agenda as the fifth goal (MDG5) to reduce by threequarters, between 1990 and 2015, the Maternal Mortality Ratio (MMR) and to achieve universal access to reproductive health. To date, Africa accounts for the highest proportion of global maternal mortality estimates, with up to 56 per cent of recorded global maternal deaths occurring in the continent. While a woman’s chance of dying during pregnancy is currently placed at 1 in 42 in Africa, it is only 1 in 25,500 in a developed country such as Greece. Sub-Saharan Africa also has the lowest proportion of women attended by skilled birth attendants at the time of delivery.

While some African countries have made progress in achieving MDG5, several others are still struggling to make significant impact. Of the 10 countries that were reported to have achieved

MDG5 in 20101, at least five were in sub-Saharan Africa. These include Equatorial Guinea that achieved an impressive 81% reduction, Egypt, Eritrea, Cape Verde, and Rwanda. By contrast, although a country such as Nigeria achieved a 41 per cent reduction in maternal mortality during the period, due to its large population, its over 40,000 estimated maternal deaths still accounted for 14 percent of global mortality estimates. Indeed, Nigeria, India and four other countries (Pakistan,

Afghanistan, Ethiopia and Democratic Republic of Congo) currently account for 50 per cent of the total global estimates of maternal mortality.  

These results call for deeper reflections on the nature of the challenges that lie ahead. It points to the fact that maternal mortality will remain a daunting and unmet problem in development in sub-Saharan Africa after 2015. The countries which have recorded successes in reducing maternal mortality provide a glimmer of hope indicating that this goal can be achieved if greater enthusiasm is devoted to addressing the problem in the continent. Maternal mortality is currently one of the most important indicators for measuring human development. As such, going forward its prevention should be firmly rooted in the development aspirations of African nations. A post-2015 agenda is being proposed that will guide African countries in thinking about ways to improve the health of women and prevent maternal deaths.

Unresolved Challenges and Difficulties

The technical information and best practices needed to improve maternal health and reduce maternal mortality are well known.  However, what has been lacking is the knowledge and determinism to implement and entrench these practices and develop a strategic approach and framework to make them work in African settings.  Several systemic factors account for the persisting high rate of maternal mortality in Africa, which need to be addressed through 2015 and beyond if significant impact is to be made. These include: the lack of political commitment to address the  issue, inadequate provisions made to promote human development despite high economic growth rates achieved in the region over the past 10 years, poor quality of governance and accountability in some countries with negative consequences for  health systems development, pervading high rates of poverty, the socio-economic and political disempowerment of women, and continuing prevalence of harmful traditional and cultural norms and practices that are disadvantageous to women.

Indeed, policymakers in many sub-Saharan African countries are yet to demonstrate the necessary political will and commitment to address maternal health and to prevent maternal deaths. This is either due to a lack of proper understanding of the problem or to a low level prioritization of the issue. In a continent where countries often grapple with how to allocate scarce resources to address multiple problems, the prioritization of resources to address specific issues can be challenging. In many low income countries, resource allocation for health, especially for maternal health is often problematic as this is often not seen as a “visible” form of development for which politicians would gain immediate benefit. As an example, many African countries are yet to devote substantial financial resources to health to address recurring problems such as maternal mortality reduction. In April 2001, leaders of African countries met in Abuja and pledged to allocate 15 per cent of their annual budget to health to address challenging health issues such as maternal mortality prevention, malaria and HIV/AIDS. Ten years after, only two countries (South Africa and Rwanda) achieved the Abuja Declaration target of “at least 15%”; seven countries reduced their relative expenditure on health; while 12 countries remained static in terms of health expenditure.  

The low rate of health expenditure cannot be attributed to poor economic performance in the region. Indeed, a recent analysis by the Economist3 indicates that over the ten years up to 2010, six of the world’s ten fastest-growing economies were in sub-Saharan Africa. Forecast by the International Monetary Fund suggests that Africa will grab seven of the top ten places of world economic growth ranking over the next five years. In January 2011, Angola with a GDP growth rate of 11.1% was the fastest growing economy in the world.  Other African countries with high GDP growth rate during the period were Nigeria (8.9%), Ethiopia (8.4%), Chad (7.9%), Mozambique (7.9%) and Rwanda (7.9%). Yet, among this group of countries with high growth rates, only Rwanda was able to achieve its Abuja and MDG-5 targets during the period. Evidently the political will to direct the proceeds of economic prosperity to address social justice and human development issues was the problem rather than the lack of economic means, per se.

Added to this is the pervading low quality of governance in the region which exact negative impact on the management of health systems for the prevention of maternal mortality. The 2012 Mo Ibrahim ranking of quality of governance in Africa provide evidence of the association between quality of governance and performance in health care indicators4. The ten top countries rated as best governed in Africa – Mauritius, Cape Verde, Botswana, Seychelles, South Africa, Namibia, Ghana, Tunisia, Lesotho and Tanzania – also have the lowest maternal mortality ratios in the continent.  By contrast, countries ranked low in quality of governance – Somalia, Democratic Republic of Congo, Chad, Eritrea, Central African

Republic, Zimbabwe, Cote d’Ivoire, Guinea, Equatorial Guinea, and Nigeria have the highest reported rates of maternal mortality. These lowly ranked countries are not necessarily the least economically endowed, yet with comparatively adequate resources they are unable to organize their societies in ways to improve the quality of living of their citizens.

The central point being pursued in this paper is that the high rate of maternal mortality in subSaharan Africa is attributable to the lack of a purposeful and strategic orientation of governance to address the problems of social inequity and human development in the region. The fact that democratic practice that is increasingly gaining grounds throughout Africa is still characterized by high-level impunity in some places, lack of accountability and corruption implies that resources will never be available to address the often neglected issues of health disparity, especially those problems that are suffered largely by the most marginalised in society. Only good governance can address the problems of poverty and illiteracy and eliminate wastages that predispose women to high rates of maternal mortality. Massive investment in education and wealth creation opportunities can only happen through good governance, and only a socially conscious government will understand the need to address a problem such as maternal mortality that only affects women. Additionally, contravening issues such as harmful cultural and traditional norms and practices that disempower women can only be addressed on a sustainable basis if governments begin to understand the multidimensional nature of the problem and begin to owe the process of change that create meaningful and sustainable living in the continent.

Prioritising Solutions beyond 2015  

It should be evident that maternal mortality prevention would remain an unfinished business in the global development agenda after 2015. Given that Africa shares the largest proceeds of underdevelopment, it would be appropriate to situate such an agenda around the emergent needs of the continent. Based on evidence from research and policy analyses conducted in various parts of the continent over the past decade, four key priority strategies would seem to be relevant for gaining more momentum and scaling the prevention of maternal mortality after 2015.

First and by far the most important is to develop strategies for promoting good governance overall, including better health and economic governance in the continent. This implies the adoption and practice of basic principles in democratic governance, which would eventually benefit health indicators both directly and indirectly. Good governance means greater emphasis placed on participatory democracy (that includes women), the promotion of the rule of law and accountability, sustainable economic development and respect for and practice of basic human rights principles. Good governance also includes specific devotion paid by government policies to human development, including provisions made for the education, health and social welfare of citizens.  In this regard, a specific method needs to be identified within the framework to encourage governments to prioritize the implementation of social justice issues and to target services to reach the poor and the marginalized. Indeed, the extent to which governments demonstrate political will to address issues such as maternal mortality prevention would be a useful index for measuring social development after 2015.

Secondly, priority attention should be given to address the background and proximate factors that predispose women to high rates of maternal mortality. These include the reduction of poverty, education of the girl child, prevention of early marriage and the socio-economic empowerment of women. Evidence abound indicating that girl child education not only enhances the agency, independence and self-esteem of girls and women, it also has multiple effects in preventing early marriage and improving other socio-economic and health indicators for women. While child marriage has come to be recognised as one of the major risk factors for maternal morbidity and mortality, it is noteworthy that child marriage prevention was not included as a measurable target in the 2000 MDG. Going forward, the prevention of child marriage ought to feature prominently as an important target for measuring maternal mortality prevention initiatives in the continent.

Thirdly, efforts should be made to reposition maternal mortality prevention from being a donordependent initiative to be an important agenda item led and propelled by in-country governments. 

This means that governments should be encouraged to conduct their own needs assessment, conduct strategic plans of action based on the needs assessment and to formulate short, intermediate and long term plans of action for improving maternal health and reducing maternal mortality. Adequate budgetary allocation should be made by governments to the health sector, with specific budget lines devoted to maternal health, the prevention of maternal mortality and to reproductive health overall. The Abuja Declaration should be a starting point, while countries should be encouraged to exceed this target, where necessary. The quantum of resources deployed to health and to maternal health should be used as a key indicator for measuring the level of political commitment for addressing the issue.

Finally, the need to scale up interventions to achieve significant and sustained reductions in maternal mortality in Africa has never been more urgent.  Some of the most promising interventions include: 1) addressing unmet need for contraception and increasing the number of at-risk couples using effective contraception; 2) increasing women’s access to quality antenatal and skilled delivery care; 3) building the knowledge of women and communities about pregnancy and its risks through community health education and mobilization; 4) health systems strengthening; 5) improving women’s access to quality emergency obstetric care at all levels of the health care system; and 6) countering harmful norms, traditional beliefs and practices that deny women access to evidence-based information and services in maternal and reproductive health. Till date, programs that address these issues have been implemented in pilots and in “boutique formats” in many parts of Africa, with little efforts made to identify and scale up the most effective approaches.  Going forward, greater efforts should be concentrated on driving such interventions at scale so that they reach larger number of at-risk populations. This means greater involvement of governments and community gatekeepers as well as the private sector, civil society organizations and international partners. The tendency to implement projects and programs in silos without efforts made to build partnerships and to secure country ownership of such programs largely account for the current low success of development interventions aimed at reducing maternal mortality in the continent.

Conclusion

Despite the United Nations identifying maternal health as a global problem in 2000, high rate of maternal mortality remains a major challenge in Africa. As the world begins to prioritise its needs for development after 2015, the prevention of maternal mortality must remain top on the agenda, at least within the context of Africa.  However, it must not be business as usual. New approaches for tackling this problem must be devised and new actors and stakeholders much be brought on board. Africa’s political and democratic leadership must be made to appreciate the connection between development and the wellbeing of its most vulnerable citizens and be encouraged to lead the pathway of change for preventing maternal deaths. The technical information and interventions to improve maternal health and prevent maternal deaths are well known, especially learning from experiences in countries with lower rates of maternal mortality.  Failure to implement these interventions is not simply the lack of resources but more the result of the lack of political will to deploy available resources sensibly and responsibly. Surely in the coming years, the global community must devise ways to hold governments accountable on several social justice and human rights issues, including the prevention of avoidable deaths in vulnerable women. 

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References

WHO. Trends in maternal mortality: 1990 to 2010. Estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva http://whqlidoc.who. int/publications/2010/9789241500265_eng.pdf Accessed on November 2012, 12, 59

Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez AD, Lozano R, Murray CJ. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress made towards Millennium Development Goal 5. Lancet 2010 May 8; 375 (9726): 1609-23.

The Economist Online. Africa’s impressive growth, January 6, 2011. Accessed: http://www.economist. Com/blogs/dailychart/2011/01daily_chart.

Mo Ibrahim Foundation. Latest assessment of African governance: Mauritius consistently ranks in top five for governance quality. www.moibrahimfoundation. org/index. October 10, 2011.

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