The Influence of Antenatal Healthcare Services on Maternal Mortality Rate in Sub Saharan Africa
Maternal mortality is defined by the World Health Organisation (WHO), as “the death of a woman while pregnant or within 42 days of termination of pregnancy, with a cause related to the pregnancy or its management, and not from accidental cause”(1) .
The rate of maternal mortality reached unacceptably high levels at the turn of the millennium, with the United Nations (UN) reporting a rate of 385 death per 100 000 births. Following the adoption of their millennium declaration in 2000, the UN established 8 millenium development goals (MDG) to be achieved by 2015, with the hope of improving the lives of the world’s poorest people(2) . In lieu of the global maternal mortality crisis, Goal 5 called for a reduction in the maternal mortality rate (MMR) by 75% between 1990 and 2015. This was later supplemented by goal 5b which aimed to achieve universal access to reproductive health(3).
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In 2015, the UN reported a fall in the global MMR by 45%, with rates in sub-saharan Africa (SSA) dropping by 49%. Although the initiative of the MDG caused a significant reduction in maternal mortality, it had failed to achieve its goal(4) . As a result, maternal mortality is still a critical issue, with many regions of the developing world being affected the most. In contrast, during the same time period, the MMR in developed countries, such as the United Kingdom (UK) was as low as 8.8/100 000(5) . The significant disparity in MMR between these regions is likely to be a result of socioeconomic and cultural differences between countries of SSA and the UK. In 2015, the UN prioritised further reducing the burden of maternal health by setting an ambitious target to reduce the MMR to 70/100 000 by 2030 as part of the Sustainable Development Goals (SDG)(6) .
This essay will discuss the shortcomings of maternal healthcare in SSA which contributed in the failure of achieving the MDG 5, as well as what steps are, and should be made in order to achieve the SDG targets by 2030.
Determinants of the MMR in SSA
According to the WHO, the majority of maternal deaths in SSA are as a result of direct obstetric complications, including haemorrhage, hypertension and sepsis(7) . Improving maternal health care in the developing regions of the world, such as much of SSA, is pivotal to saving the lives of hundreds of thousands of women afflicted by complications of pregnancy and childbirth each year. Almost all cases of maternal mortality in the developing world are preventable through access to basic amenities, such as sanitation facilities, clean water, adequate diets, basic literacy, and health services during pregnancy and childbirth.
In 2015, 303,000 women died from complications of pregnancy and childbirth. The highest rates of maternal mortality occurred in low- and middle-income countries, with SSA accounting for approximately two-thirds(8) . Reducing this burden of ill health requires an understanding of the timings and causes of maternal deaths, as it helps to enable strategies to reduce maternal mortality. Kassebaum et al found that nearly one quarter of maternal deaths occurred in the antepartum period, another quarter occurred in the intrapartum and over half the cases of maternal mortality in SSA occurred in the postpartum(9) . An important determinant of antenatal mortality is access to quality antenatal care (ANC), which can subsequently affect the outcome during the subsequent intrapartum and postpartum periods.
Antenatal Care and Maternal Mortality
Since 1990, global data found that deaths during the intrapartum has decreased by more than 35%, however estimates from SSA showed fewer changes over time. Through ecological analysis, studies have identified a positive correlation between access to antenatal healthcare and a reduced rate of maternal mortality(10) . The majority of women (>95%) throughout SSA attended at least 1 antenatal clinic throughout their pregnancy. However, it was found that regions where women attended >4 clinics had a significantly lower rate of MMR.(11). However, an important caveat to consider is that ANC is often measured as a frequency of attendance, without consideration of the content, quality or timing of appointments. Although utilization of ANC services has increased over the past two decades, less than a quarter of health facilities provided hypertensive disease case management and syphilis detection, which was found to be accountable for approximately 11% of stillbirths(12) . Furthermore, reports found that the majority of ANC services failed to deliver adequate urine testing and provision of information about complications of pregnancy and childbirth(13) . Thus, although a country may have high uptake of ANC, few women may be receiving the recommended interventions if the ANC service provided is poor. However, improvements in provision of health care service is unlikely to improve outcomes if attendance to ANC is low.
Therefore, it appears that in order to reduce the number of maternal deaths, women require access to consistent, good-quality antenatal health-care. Throughout my time at medical school I have been able to appreciate the positive impact that high-quality ANC has on maternal mortality and satisfaction. In the UK, women are invited to attend their first antenatal clinic in their first trimester, as early as 10 weeks into their pregnancy. During this clinic, women are screened for factors which may complicate their pregnancy, such as pre-eclampsia, diabetes, red cell isoimmunisation and infections. Furthermore, I was able to attend clinics which focussed on treating women who had developed complications, such as pre-eclampsia, hyperemesis and gestational diabetes. These women were provided with the appropriate provisions to ensure their pregnancy remained low risk for morbidity and mortality, thus allowing for a much lower MMR in comparison to countries of SSA, which failed to deliver a similar standard of care.
The Impact of Socioeconomic Status on Maternal Healthcare Outcomes
When reflecting on my time spent at the maternal assessment unit, I was able to appreciate that timing of provision of the first ANC visit is vital for optimising health outcomes for both women and children. As of 2013, the uptake of early ANC visits, defined as occurring in the first trimester, was as low as 25% in SSA. This is compared to 84.8% in the developed world. This disparity is believed to be caused by socioeconomic inequalities, as It has been reported that there is greater overage of ANC for those living in the wealthier quintile, and in Urban areas of SSA(14) . As such, utilization of ANC in SSA is influenced by cost of service and medication, in addition to cost of transport to a healthcare facility. Thus, it was found that women from a wealthier household attended more ANC visits and select suitable health facilities for delivery. In contrast, almost all countries of the developed world provide universal healthcare regardless of socioeconomic status(15) . As a UK medical student, I have able to appreciate the importance on universal health coverage, as delivered by the National Health Service (NHS). Free healthcare is provided for all citizens, thus eliminating disparity of health care provision as a result of inequalities in wealth and social class. This disparity in ANC is seen throughout SSA, and is therefore likely to have also contributed to their failure in achieving the MDG 5 targets(16) . Consequently, this demonstrates how the MMR can be indirectly influenced through improving socioeconomic inequalities throughout SSA, and through provision of universal healthcare.
Government corruption and MMR
Access and quality of ANC is determined by numerous factors, most importantly of which is allocation of government funding for the procurement of the required equipment and medication. Some reports posit that the persistently high MMR in SSA is a result of corruption in healthcare systems throughout regions of SSA(16) . A report by Lan et al found that the perceived corruption of a government correlated with a higher rate of maternal mortality within that country(17) . It Is thought that misallocation of government funding reduces the quality of maternal health and deter women from delivering in health facilities(18) . Corruption appears to disproportionally affect women more than men, therefore there is a movement calling for the empowerment of women to become more active in addressing health sector corruption(17) . Furthermore, inappropriate allocation of funding due to corruption further drives disparity in healthcare, which may have been a barrier leading to the failure of achieving MDG 5 targets.
The global disparity in the MMR is alarming. Almost all cases of preventable maternal deaths occur in the developing world, with over 60% pertaining to SSA. In order to achieve the suggested SDG targets by 2030 in SSA, countries of SSA should focus their interventions on increasing the uptake of ANC, improving the quality of ANC service provisions and increasing access to skilled birth attendance. Furthermore, interventions should focus on challenges pertaining to maternal empowerment, with a focus to increase access to ANC and reducing the socioeconomically driven inequality in maternal healthcare. Additionally, a paradigm shift in the structure of the healthcare system, and its related financing, should be implemented in keeping with the framework of universal health coverage.
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