Access to skilled care from a trained midwife during pregnancy, childbirth and the first month after delivery is the key to saving a mother’s life and that of her child. Maternal mortality remains unacceptably high: more than 350.000 women, of whom 99% live in developing countries, die every year during pregnancy and childbirth.
In Sub-Saharan Africa a woman’s risk of dying from preventable or treatable complications of pregnancy and childbirth is 1 in 31, compared to only 1 in 4,300 in the developed regions. Fortunately most maternal deaths can be avoided. This can, amongst others, be done by assuring that the future mothers deliver their baby with help of a skilled midwife.
Unfortunately this is not common everywhere and there exists a shortage of midwives in the world.
The fifth of May is internationally established as the day for recognizing the work of midwives. This day is an occasion for every midwife to think about the many others in the profession, to make new contacts within and outside midwifery, and to widen the knowledge of what midwives do for the world. In the years leading up to 2015, ICM will use the theme “The World Needs Midwives Today More Than Ever” as part of their campaign to highlight the need for midwives. This reflects the WHO call for midwives and the need to accelerate progress towards MDGs 4 and 5. Over 350,000 women die each year, with millions more suffering infection and disability as a result of preventable maternal causes. The ICM, alongside UN agencies, WHO and a range of other international partners, is committed to addressing maternal mortality and morbidity through greater access to essential midwifery care worldwide, particularly in developing countries.
Improve Maternal Health
In the same month, besides Midwives Day also Mothers Day is celebrated. Both days are interconnected: educated midwives help mothers to stay healthy during pregnancy and after delivery, which consequently creates more healthy mothers (and infants). In the Netherlands Mothers Day is a festive day on which children do something special for their mothers.
Mothers are important for the development of their children and therefore also for the future generation of a country. To raise healthy children, healthy mothers are of importance.
Unfortunately in many development countries maternal health is not always natural. Still too many women die during pregnancy or childbirth, leaving their newborn - if they survive - motherless. These children are up to die ten times more likely within the first two years than those who have a mother taking care of them. MDG 5 addresses the importance of maternal health and the fact that this needs to be improved before 2015 (the target date for all MDG’s). The two targets of this Millennium Development Goals are a) to reduce by three quarters the maternal mortality ratio and b) to achieve universal access to reproductive health.
Based on current trends, Sub-Saharan Africa will not attain the Millennium Development Goals by 2015. MDGs 4 and 5, are those towards which the least progress has been made. MDG 5 which aims to improve maternal health is desperately off-track. In many countries, weak and fragmented health systems, and in particular inadequate human resources do not permit the scaling-up of crucial interventions for maternal, new-born and child health (MNCH).
Pregnancy in Africa
Especially for women in Southern Asia and Sub-Saharan Africa giving birth is extremely dangerous. What women in the developed world take for granted - skilled midwives, an obstetrician and operating theatre if needed, the antibiotics and drugs to ensure that should complications arise, the mother is rapidly brought back to good health – all these apparently basic things, are great luxuries in Africa. Most women in Africa, especially the ones living in remote areas, have no choice but to give birth at home. These women are lucky when all goes well and no complications occur. But if things go wrong help is far away and often comes too late. Actually Sub-Saharan Africa is now the epicenter of maternal mortality in the world. In actual numbers this is 280,000 women dying in pregnancy. These women die of conditions such as breech births, hemorrhaging and high blood pressure. The good news is that all these conditions can be avoided while making good quality healthcare available and getting help of trained midwives.
Midwives saving lives
Training midwives is a simple cost-effective way of reducing maternal deaths in Africa. By 2015 the NGO AMREF wants to train 15,000 midwives which could reduce the maternal death rate in Africa by 25%. This is mainly done in Southern Sudan where the situation is worst and by means of the campaign “Stand Up for African Mothers”. This campaign also takes place in other countries: Kenya, Tanzania, Uganda, Ethiopia and Senegal. The trainings take place at schools or via e-learning. With e-learning more people can be reached at the same time than in the class rooms, since the trainees can follow their training in their own time at home or in their office. They learn to manage common complications during delivery such as high blood pressure, excessive bleeding or retained placenta, as well as giving mothers antenatal and postnatal advice. They are also trained to recognize signs of more severe complications and are able to refer women on to better equipped facilities.
Reduce maternal, newborn and child mortality
The NGO AMREF has received a 4.2 million euro grant from the European Union (EU) to reduce maternal, newborn and child mortality in marginalized areas of Kenya, Southern Sudan and Tanzania, contributing to regional learning on MNCH while accelerating progress towards attaining the Millennium Development Goals in Africa. While global, regional and national policies to improve MNCH exist, and interventions to prevent maternal, neonatal and child deaths are available in Tanzania, Kenya, and Southern Sudan, MNCH indicators remain unacceptably poor. Progress has been slowed down by poor policy implementation and weak health systems, which do not engage with or respond to community needs. This results in poor access and use of preventive and curative health services.
One of the projects of the before mentioned NGO to improve maternal health by training of midwives, is located in Samburu County, situated in Kenya’s Rift-Valley Province. In Kenya about 15% of women aged between 15 and 40 years die during childbirth. In Samburu County the mortality rate is 1,000 out of 100,000 births. In this region child mortality is high and the population has limited access to health services, water and education. This area has more than double the national average of maternal deaths and infant mortality. Factors contributing to the poor health in Samburu are: high levels of malnutrition, poor access and utilization to maternal, newborn and child health services by mothers and children, low literacy levels, poor infrastructure and under-resourced health facilities. Furthermore cultural beliefs and practices such as female genital mutilation (FGM), early marriages and traditional birth attendants (tba’s) attended deliveries endanger the health of mothers and children in the area. The project started last year and will directly benefit 45,000 women of reproductive age and 25,000 children less than five years, to improve MNCH outcomes.
The situation in Kenya
Since 2010 the Kenyan Government is improving their efforts to reduce maternal mortality in the country. Here about 7,000 women die annually during pregnancy or childbirth. According to experts, there is urgent need to step up these efforts because maternal and child deaths are on the rise in most African countries. The fact that maternal health statistics in Kenya are not improving is cause for concern, given that only few years remain to the deadline for the achievement of the MDGs. Kenya is hoping to attain MDG 5 (improve maternal health) by 75%. “Poor women are seven times more likely to give birth at home than the rich, with little or no post-natal care,” said Public Health Minister Beth Mugo during the launch of a maternal and child health project.
In Kenya, 99% of women attend ante-natal clinics at least once in their life. However, only 46% of deliveries in the country are carried out by skilled attendants. The other deliveries take place in presence of a traditional birth attendant or family or friends. Lack of proper medical attention and hygienic conditions during delivery poses the risk of serious illness amongst mothers and their babies.
Community health centers in remote locations suffer an acute shortage of trained professionals because most doctors in Kenya go to work in the cities, leave public clinics for private ones or leave Kenya to work overseas.
Traditional birth attendants
Tba’s have long been the main health care providers for women during childbirth in Africa. They attend most of the childbirths in rural areas. They are often highly respected and perform cultural rituals and social support during women in childbirth. They also help with initiating breastfeeding, providing information on reproductive health and nutrition and visiting mothers during and shortly following delivery. Tba’s have no training on how to recognize and respond appropriately to pregnancy complications. Therefore training of tba’s has been a key strategy to improving maternal and child healthcare in many African countries. Until they are replaced by skilled birth attendants they remain the only option to many poor women. Besides training midwives, the before mentioned NGO will also train 500 tba’s by 2015 in Kenya.
One of the women, who had a healthy delivery in a hospital thanks to the skilled people of AMREF, is 28 year old Sudanese Maria Gasingo. When she was pregnant of her third child she went to the Tali Primary Health Care Center for a check-up. While she was walking towards the health center she went into labor and started to bleed. At the health center Maria was told that her placenta came out before the baby and that she needed to go to a hospital immediately. She was brought there by an AMREF vehicle. The journey took about 4 hours over a rough road. Maria: “I was accompanied by a clinical officer and my husband. When we arrived at the hospital they gave me more fluids and even gave me blood.” She was taken into surgery to deliver her baby and all went well. “I am so happy that I came. I was afraid that I was going to die, or that my baby would die, but we are both safe and well. Not all women are as fortunate as I.”
In general it can be concluded that in order to have more healthy and surviving mothers and a better maternal health in general, it is important that more midwives and other health personal (such as traditional birth attendants) are trained adequately. This way more women will deliver in a safe way and obtain good antenatal and postnatal care. The projects of AMREF help to improve the maternal health in sub-Saharan Africa and to come a step closer in reaching the targets of MDG 5.
* Jacqueline Lampe is director of AMREF Flying Doctors in the Netherlands.