Tag Archives: Maternal death

Unsafe Abortion on the increase in Africa, a new WHO Report reveals.

Unsafe abortion as a significant contributor to the persistently high maternal mortality rates in Kenya and other sub-Saharan Africa in general, has been highlighted in several earlier posts. Sadly, a WHO report in conjunction with the Guttmacher Institute published today in the Lancet (on 19th January, 2012), shows that rather than abating, unsafe abortion rates are still rising, this being particularly the case in sub-regions where access to safe abortion is restricted. While worldwide, 49% of all abortions were unsafe in 2008, in Africa, nearly all abortions (97%) were unsafe. The report confirms that restrictive abortion laws do not translate to lower abortion rates, and that unsafe abortion can be effectively minimized by ensuring women have easy access to contraceptive services, backed up by a positive legal framework that facilitates safe abortion. These are crucial steps toward achieving the Millennium Development Goal 5 in countries such as Kenya.

 

Read more on unsafe abortion…

The Status of Maternal Health and Unsafe Abortion in Kenya

Unsafe abortion is a public health concern;

  • In order to achieve MDG 5 on Improving Maternal Health, it is imperative that the issue of unsafe abortions is addressed.
  • Unsafe abortion is an important contributor to the high maternal mortality rates in Kenya
  • Granted unsafe abortion is simply one of several contributors to MMR, BUT it is one we know how to prevent- an important public health principle
  • Incidence of unsafe abortion generally reflects the magnitude of unwanted pregnancies in any particular community.
  • Unsafe abortion can be effectively minimized by ensuring women have easy access to contraceptive services, backed up by a positive legal framework that facilitates safe abortion.

Read more on the  Status of Maternal Health and Unsafe Abortion in Kenya

Evolution of Modern Obstetrics and Gynaecology Practice in Kenya

In a previous post it was opined that although Kenya has the capacity to train the nurse workforce it needs, the prevailing challenge is ensuring all trained nurses and midwives are employed and efficiently deployed. The State of World’s Midwifery[i] 2011 observes that appropriate employment and deployment of skilled midwives is essential for Kenya to make meaningful progress towards achieving MDG 5. The current post seeks to highlight some of the milestones in the evolution of modern practice of midwifery and midwifery training in Kenya.

In colonial Kenya and before the mid-1960s, obstetrics and gynaecology were practiced as separate services located in different facilities. Whereas gynaecology services were availed as sub-specialty within the department of Surgery at the King George VI Hospital (later renamed Kenyatta National Hospital), midwifery services were considered a separate service altogether, provided in maternity homes that were usually sited some distance away from the main hospital. The tradition of building maternity wards some distance away from the main hospital arose as a long-practised measure to prevent cross infection especially from surgical patients. It also reflected the colonial policy that whereas the Government undertook to provide Africans with what was described as ‘complete medical care’, this service did not extend to obstetric care, which was regarded as a responsibility of the local authorities, the Municipal Councils or in the reserves, the African District Councils[ii].

The initiative to develop midwifery services in urban areas of Kenya is credited to the East African Women’s League (EAWL)[iii] which, “out of concern for the lack of a maternity ward for African women”, and with the encouragement of Lady Grigg (Governor‘s wife), founded the Lady Grigg Child Welfare and Maternity League in 1926. By 1928 the Lady Grigg Maternity Home at Pumwani (now the Pumwani Maternity Hospital) had been built. Other maternity hospitals followed, in Mombasa- Lady Grigg Maternity Hospital Mombasa (now part of the Coast Provincial General Hospital), and in Nairobi- the Social Service League Ngara Maternity Home (sadly, this has since ceased to be a hospital).

The EAWL also advocated for the training of African nurses and midwives, and all three maternity hospitals mentioned above undertook the training of the early midwives in Kenya (to enrolled midwife level). Later on, in pursuit of primary health care following the Alma Ata Declaration of 1978, midwifery training was incorporated into nursing training to produce the Enrolled Community Health Nurse. Training at registered midwife level had to wait until registered nurse training had started in Kenya. Training at para-medical level in Kenya can be traced back to 1927 when the first group of students was recruited for training as Medical Assistants at the Native Civil Hospital, (later re-named King George VI Hospital and Kenyatta National Hospital). This cadre was trained to provide both Nursing and Clinical services. These are the forerunner of the Clinical Officer of today. In 1952 the first batch of Kenya Registered Nurses commenced training at the King George VI Hospital and the Medical Training Centre (now Medical Training College)[iv]. Registered nurses could then undertake a further year’s training in midwifery to qualify for registration as Registered Midwife.

By 1954 of the 12 full time specialists at the King George VI Hospital, only one, Dr Peter L Candler specialised in gynaecology[v]. According to Peter Candler, the most common gynaecological condition he dealt with at that time was vaginal fistula resulting from lacerations during childbirth. This was followed by complications of generalised pelvic sepsis and infertility. However, he reported that ‘attempted’ abortion was unlikely among Africans because of the strong desire to bear children! Nearly two decades later when we came into the scene, the pattern of gynaecology had changed little, except in the case of abortion which had since become a prominent gynaecological problem.

The expansion of obstetrics and gynaecology services in Kenya is largely attributable to the University of Nairobi’s Department of Obstetrics and Gynaecology. The medical school in Nairobi was established through a presidential directive shortly after 1963, the year of Kenya’s independence. To implement the directive, the Ministry of Health with British Government financing, invited the University of Glasgow to assist in preparing the KNH as a teaching hospital ahead of the launch of the University of Nairobi Medical School in 1967. Thus, a team from Glasgow arrived, and in September 1965, oversaw the opening of the Obstetric Unit at the KNH. Initially, patients were ‘borrowed’ from the Pumwani Maternity Hospital through a process whereby one of the consultants would select a couple of women in early labour and transport them to the Obstetric Unit at KNH for their management. In addition, the Department ran, on behalf of the Nairobi City Council, four antenatal clinics at the health centres in Riruta, Waithaka, Woodley, and Langata. This way it was possible to have enough clinical material for the medical students and student midwives from the School of Nursing. It should also be mentioned that the first medical students taught at KNH were actually ‘borrowed’ from Makerere Medical School! Initially these were Kenyan students who chose to spend an elective term at the KNH, but later the hospital provided refuge to students who fled Idi Amin’s tyranny in Uganda, including some students from other countries.

Establishment of gynaecology (gynae) as a specialty at KNH, separate from Surgery, was not without resistance and intrigues. There were those surgeons that felt there was absolutely nothing new to be gained by creating a department of gynaecology- after all, hadn’t they treated gynae cases all those years? A thorny area concerned the allocation of operating theatre space for a regular gynaecology list. We needed a theatre for emergencies such as ruptured ectopic pregnancy and incomplete abortion; as well as another theatre for elective (‘cold’) cases. I remember one senior surgeon openly saying incomplete abortion never required an evacuation- after all many occurred in the ‘bush’ where there were no doctors! He had always sent them away without any evacuation.


[i] The State of World’s Midwifery 2011, was launched in June 2011 by the United Nations Population Fund (UNFPA)

[ii] Letter written on October 20, 1954 by Robert F Gray to Mr Walter Rogers of Institute of Current World Affairs, 522 Fifth Avenue, New York 36, New York. http://www.icwa.org

[iii] The East Africa Women’s League is an organisation for white women who were born in, lived or worked in East Africa. It was founded in Nairobi in 1917, its main concern being the welfare of women and children of all races in the country then known as ‘British East Africa’. http://www.eawl.org

[iv] http://www.kmtc.ac.ke/public_site/webroot/cache/article/file/Nursing_log1.pdf

[v] Note: Dr Peter Lawrence Candler was admitted to the Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG) in 1962.

 

Postpartum Haemorrhage, that Crimson Barrier to Achieving MDG5

By Japheth Mati

Definition

Postpartum haemorrhage (PPH), antepartum haemorrhage (APH), and bleeding following an incomplete abortion are collectively referred to as obstetric haemorrhage. PPH is the single most important cause of maternal deaths worldwide.

The definition of PPH is somewhat arbitrary and problematic[i]. Postpartum haemorrhage is defined as blood loss of more than 500 mL following vaginal delivery or more than 1000 mL following delivery by caesarean section. A loss of these amounts within 24 hours of delivery is termed early or primary PPH, whereas such losses are termed late or secondary PPH if they occur 24 hours after delivery. Estimates of blood loss at delivery are subjective and generally inaccurate. Studies have suggested that caregivers consistently underestimate actual blood loss. Another consideration is the differing capacities of individual parturient to cope with blood loss. A healthy woman has a 30-50% increase in blood volume in a normal singleton pregnancy and is much more tolerant of blood loss than a woman who has pre-existing anemia, or other medical complications. The diagnosis of PPH is usually reserved for pregnancies that have progressed beyond 20 weeks’ gestation, even though bleeding related to spontaneous abortion may have causes and management in common with those for PPH.

Magnitude of the problem

United Nations estimates show that more than 500,000 women die each year worldwide due to complications arising from pregnancy and childbirth, which has been expressed as one woman dying every 7 minutes[ii]. In 2008 almost 99 per cent of all maternal deaths occurred in developing regions, with sub-Saharan Africa accounting for 57 per cent of all deaths. According to a UN report[iii] on “Trends in maternal mortality”, the number of maternal deaths globally had decreased by 34 per cent from an estimated 546 000 in 1990 to 358 000 in 2008. However, in sub-Saharan Africa, the decrease in maternal mortality was below average, being 26 per cent. The report concluded that although that progress was notable, the annual rate of decline (i.e. 2.3 per cent) was still less than half of what is needed (i.e. 5.5 per cent) to achieve the MDG 5 target of reducing the maternal mortality ratio by 75 per cent between 1990 and 2015.

In the sub-Saharan Africa, the main direct causes of maternal death are bleeding (34%), infection (10%), pre-eclampsia/ eclampsia (9%) and obstructed labour (4%). In Kenya, a national review of safe motherhood[iv] conducted in 1997, marking the tenth anniversary of the Safe Motherhood Conference held in Nairobi in October 1987, showed that haemorrhage, sepsis, pre-eclampsia/ eclampsia, ruptured uterus and complications of induced abortion were the leading direct causes of maternal mortality. Clearly, prevention and making accessible treatment of postpartum haemorrhage should be highly prioritised in the interventions to reduce maternal mortality.

Causes of and risk factors for PPH

Postpartum haemorrhage has many potential causes, but by far the most frequently encountered is uterine atony, a condition whereby there is failure of the uterine muscle to contract and retract following delivery of the baby. Besides primary uterine atony, other causes of bleeding may include: retained placental tissue; trauma to the birth canal, especially cervical tears; and occasionally bleeding may be associated with clotting failure (coagulation defect) [v]. Although in a large proportion of women experiencing PPH no risk factors can be identified, the following have been identified as significant risk factors for PPH in published data[vi]:

  • · Retained placental tissue
  • · Prolonged second stage of labour
  • · Placenta accrete (morbidly attached placenta)
  • · Lacerations of the birth canal
  • · Instrumental delivery, especially forceps delivery
  • · Large for gestational age (LGA) newborn
  • · Hypertensive disorders
  • · Induction of labour, and
  • · Augmentation of labour with oxytocin

Prevention of PPH

There is ample evidence, based on several randomized controlled trials (RCTs) and a Cochrane meta-analysis involving more than 6000 deliveries, which suggests that active management of the third stage of labour (AMTSL) reduces the incidence and severity of PPH[vii], and should be recommended and offered to all women[viii]. Active management involves interventions to assist in expulsion of the placenta with the intention to prevent or decrease blood loss. It is the combination of uterotonics, clamping of the umbilical cord, and controlled cord traction when the uterus is well contracted. Uterotonics promote uterine contractions and thereby prevent atony and speed up delivery of the placenta. In contrast, with expectant, or physiological, management, spontaneous delivery of the placenta is awaited, with subsequent intervention, if necessary, that involves uterine massage and use of uterotonics.

Generally, uterotonic drugs are used to induce (start) or augment (speed up) labour; facilitate uterine contractions following a spontaneous abortion; prevent postpartum hemorrhage during active management of the third stage of labor; treat hemorrhage following childbirth or abortion; and for other gynecological reasons. The three categories of uterotonic drugs used most frequently are the oxytocins, ergot alkaloids and prostaglandins. Uterotonic drugs may be given intramuscularly (IM), intravenously (IV), and as a tablet that can be given orally, vaginally, rectally, or buccally. The uterotonic agents that are listed in Essential Medicines List, and which are commonly used in East Africa include oxytocin, ergometrine, and Syntometrine (a combination of ergometrine and oxytocin), all of which have to be administered through an injection.

Misoprostol, a prostaglandin E1 analogue with uterotonic activity, is an attractive option for use in AMTSL because it is stable, active orally, and inexpensive[ix]. Besides, whereas ergometrine is contraindicated in women with a history of hypertension, heart disease, preeclampsia, or eclampsia, there are no known contraindications for use of Misoprostol as used in AMTSL. Where skilled attendance is not available, the International Confederation of Midwives (ICM) and International Federation of Gynaecology and Obstetrics (FIGO) recommend that in the context of prevention of PPH, if oxytocin is not available or birth attendants’ skills are limited, misoprostol should be administered orally soon after the birth of the baby[x]. There is sufficient research evidence to support use of misoprostol both for prevention and treatment of PPH, particularly in settings where the majority of births take place away from health facilities, where standard uterotonics are not available. Studies in Tanzania, Afghanistan, Nepal, and Bangladesh have shown that for prevention of PPH, pregnant women delivering at home without a skilled birth attendant can successfully self-administer misoprostol orally as soon as possible after their baby is delivered[xi].

Use of Misoprostol for prevention and treatment of PPH ought to be added to Essential Medicines List

In consideration of the above this author, along with others, recently supported applications[xii] to add misoprostol to the World Health Organization’s (WHO) Essential Medicines List (EML) for prevention and treatment of PPH[xiii]. The addition of misoprostol to the EML for PPH prevention and treatment has potential to contribute significantly to the efforts to achieve MDG5 target. This safe and effective drug has been shown to prevent and control postpartum bleeding suspected to be due to uterine atony. The drug’s wide availability, low cost, stability at room temperature and ease of use make it an ideal candidate to add to the package of interventions available to prevent PPH in low-resource settings. Meanwhile in Kenya, the Kenya Obstetrical and Gynaecological Society (KOGS) is also pushing for the registration of misoprostol, “as an effective intervention in controlling PPH, particularly in limited-resource settings”[xiv]. Currently misoprostol is registered in Kenya for treatment of gastric ulcer, and the fear has been that misoprostol might be used for purposes of procuring abortion. Nigeria, in 2010, became the first African country to register misoprostol, but, ironically, restricted it to obstetric use in medical centres only; this in a context where nearly75 percent of women give birth at home!


[i] John R Smith, Barbara G Brennan,  Postpartum hemorrhage http://emedicine.medscape.com/article/275038-overview

[ii] Potts M, Prata N, Sahin-Hodoglugil NN. Maternal mortality: one death every 7 min. Lancet 2010; 375: 1762–63.

[iv]Ministry of Health, Kenya. A Question of Survival? Review of Safe Motherhood, Division of Primary Health Care, June, 1997.

[v] A mnemonic for remembering the causes of PPH is “4 T’s”: tone, tissue, trauma, and thrombosis (coagulation defect).

[vi] Sheiner E, Sarid L, Levy A, Seidman DS, Hallak M. Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: a population-based study. J Matern Fetal Neonatal Med. Sep 2005;18(3):149-54. [Medline].

[vii] Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. Cochrane Database Syst Rev. 2000;CD000007. [Medline].

[x]International Confederation of Midwives (ICM), International Federation of Gynaecology and Obstetrics (FIGO). Prevention and Treatment of Post-partum Haemorrhage: New Advances for Low Resource Settings Joint Statement. The Hague: ICM; London: FIGO; 2006. Available at: http://www.figo.org/docs/PPH%20Joint%20Statement%202%20English.pdf. Accessed October 12, 2007.

[xi] Prata N, Mbaruku G, Campbell M, Potts M, Vahidnia F. Controlling postpartum hemorrhage after home births in Tanzania. Int J Gynecol Obstet 2005; 90: 51–55; Rajbhandari S, Hodgins S, Sanghvi H, McPherson R, Pradhan YV, Baqui AH,and Misoprostol Study Group. Expanding uterotonic protection following childbirth through community-based distribution of misoprostol: operations research study in Nepal. Int J Gynecol Obstet 2010; 108: 282–88; Sanghvi H, Ansari N, Prata JVN, Gibson H, Ehsan A, Smith J. Prevention of postpartum hemorrhage at home birth in Afghanistan. Int J Gynecol Obstet 2010; 108: 276–81; Potts M, Prata N, Sahin-Hodoglugil NN. Maternal mortality: one death every 7 min. Lancet 2010; 375: 1762–63.

[xiii] These applications have been submitted by Gynuity Health Projects and Venture Strategies for Innovations.

[xiv] Susan Anyangu-Amu Misoprostol Can’t Shake Bad Reputation http://ipsnews.net/news.asp?idnews=52385

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What are the prospects of achieving ‘skilled attendance’ for all births in Africa?

Ensuring that every birth is attended by skilled health personnel by 2015 is what is expected of all countries if they are to achieve Millennium Development Goal (MDG) 5. But how feasible is this for most African countries? According to WHO, skilled attendance at birth remains drastically low in sub-Saharan Africa; only about 42% of the childbirths are assisted by a skilled attendant in the Africa region, some countries registering as low as 5%[i]. This is against the target of 80% of births being assisted by a skilled attendant by 2015 if the goal of reducing maternal mortality rate by three quarters (between 1990 and 2015), is to be achieved.

Skilled attendance at the time of delivery is an important variable that influences the birth outcome and the health of the mother and her infant. Skilled attendance can be accessed at health facilities or through domiciliary or community midwifery. At both levels appropriate medical attention can reduce the risks of obstetric complications that increase the risk of morbidity and mortality for the mother and her baby.

Figure 1: Maternal mortality ratio by country, 2008

Source: UNICEF, Progress for Children: A Report Card on Maternal Mortality, 2008

Who is a skilled attendant?

A skilled attendant is defined as ‘an accredited health professional – such as a midwife, doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage uncomplicated pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns’[ii] This definition implies that the term ‘skilled attendant’ should refer exclusively to people with midwifery skills; people who are capable of managing normal deliveries and to diagnose, manage or refer complications. Midwifery skills are a defined set of cognitive and practical skills that enable the individual to provide basic health care services throughout the continuum of pregnancy, childbirth and postnatal period and also to provide first aid for obstetric complications and emergencies, including life-saving measures when needed. In 2006, a consensus was reached on what are essential competencies of the skilled attendant in the Africa Region of WHO[iii]. It should be noted that the definition of skilled attendant does not include Traditional Birth Attendants (TBA), trained or untrained.

Until the mid-1990s, the term “trained attendant” was commonly used in national statistics, which tended to lump both professionals and non-professionals (e.g. trained TBAs) together, as long as they had received some “training”. However, training does not necessarily guarantee the acquisition of the needed skills. From 1996 onwards, the word “skilled” has been employed to recognise competent use of knowledge[iv].

Effectiveness of ‘skilled attendants’ depends not just on their knowledge and competency, but also on the environment in which they function. Skilled attendance should therefore not be considered purely in terms of skills of the service providers but also the environment in which they work- physical space, equipment, supplies, drugs and transport for referral of obstetric emergencies. The political, policy and socio-cultural environment can also enable or prevent effectiveness of ‘skilled attendance’[v].

Does skilled attendance at birth lower maternal deaths?

There is no direct scientific evidence to show that skilled attendance lowers maternal mortality; however, comprehensive analyses of the factors behind the successful reduction of maternal deaths in countries such as Malaysia, Sri Lanka, Thailand and Honduras clearly indicate that a central feature in all of them was the presence of a skilled attendant at delivery. The experience from those countries is what is currently guiding maternal and neonatal health policy and programming; especially what was done to ensure high availability of skilled birth attendants, as well as the kind of environment that ensured their effectiveness[vi].

Two important lessons from these experiences are (a) achieving skilled attendance for all requires attention to the political, social and legal actions that address women’s human rights and equity, this being especially important if skilled attendance is to impact on the health outcomes of poor people; and (b) development of skilled attendants must go side by side with the creation of an enabling environment, including putting in place resources that are needed for emergency obstetric care and responsive referral systems.

Will skilled attendance result in reduced maternal deaths in Africa?

According to WHO ensuring skilled care at every birth can reduce the global burden of 536 000 maternal deaths, 3 million stillbirths and 3.7 million newborn deaths each year[vii]. Half of the 75 countries in which 97% of all maternal deaths worldwide occur are located in the sub-Saharan Africa. Within Africa, the eastern region has the lowest proportions of skilled attendance at birth (about 34%). In addition, enormous disparities exist within countries: poor women in rural and urban areas are far less likely than their wealthier counterparts to receive skilled care during childbirth. For example, the 2008-9 Kenya Demographic and Health Survey showed that women in the highest wealth quintile were nearly four times more likely to have been attended by a doctor or nurse/midwife, at their last delivery[viii].

The countries of sub-Saharan Africa are faced by numerous challenges in their effort to ensure skilled attendance at birth. These can be coalesced into the following two: developing the needed human resources for health, and creating an enabling environment for effective skilled attendance.

  • · Development of human resources for health- skilled attendants

Human resource for health is a key component of the health care system, which requires efficient mechanisms for recruitment, deployment, retention and supervision of the workforce, as well as ensuring accountability of service providers.

Five years ago, WHO estimated that to extend coverage of maternal and newborn care in the following 10 years (to 2015), 75 countries[ix] needed at least 334,000 additional midwives (or equivalent skilled attendants), as well as additional training for 140,000 existing professionals providing first-level care and of 27,000 doctors who are not currently qualified to provide back-up care[x]. According to these estimates the current health workforce in some of the most affected countries in sub-Saharan Africa would need to be scaled up by as much as 140% for the country to attain the Millennium Development Goals.

Health worker shortage in sub-Saharan Africa derives from many causes, including inadequate planning and investment for pre-service training, inadequate deployment, loss of trained personnel due to poor work conditions, internal and external movement, career changes among health workers, premature retirement, morbidity and premature mortality.  In some countries trained health workers remain unemployed for long periods because of inadequate budgetary allocations to ministries of health.

A recent study[xi] focused on 12 African countries[xii] has found alarming workforce shortages in all the countries, with the current rate of increase in health workforce density being much slower than what WHO considers necessary for achievement of desired levels of coverage of key health interventions[xiii] (a minimum density of 2.28 health workers per 1000 population). The study has suggested a variety of complementary, shorter-term responses if countries were to aspire to achieving international goals, among them, adoption of aggressive retention policies, e.g. improving the remuneration and working conditions of health workers; addressing current unemployment of trained professionals; and adoption of task-shifting[xiv] practices where necessary. However, all these should be viewed as stop-gap measures while countries further developed/expanded local pre-service training opportunities.

  • · Creating an enabling environment for skilled attendance

An enabling environment can be viewed more broadly to include the political, policy and socio-cultural context in which skilled attendance must operate (structure), as well as the more proximate factors such as pre- and in-service training, supervision and deployment, and health systems financing (inputs). Within the political and policy environment are considerations such as legislation/regulations which govern scope of professional activities, but more important is the level of government commitment and stability which are crucial to smooth functioning of health services. The social/cultural environment will include cultural factors which may influence acceptability and effectiveness of service providers and the services they provide; for example, Muslim societies may object to male skilled attendants (male doctors and nurses), examining women. Socio-economic status, gender and women empowerment are other important factors with strong bearing on the performance and effectiveness of skilled attendants. Finally, effectiveness of the service providers is enhanced by responsible management systems, functional infrastructure, equipment/ supplies, management and health information systems, communication and transport mechanisms. Above all, availability of the above depends on sound planning and financing of the health sector.

Conclusion

The countries of sub-Saharan Africa are faced by numerous challenges in their effort to ensure skilled attendance at birth, particularly the serious human resource shortages and weak health systems. Recent assessments of progress towards MDG 5 suggest that most sub-Saharan African countries have made only modest progress, with at least 8 countries[xv] demonstrating negative change[xvi]. These findings cast a lot of doubt as to whether many sub-Saharan African countries will achieve skilled attendance for all births in the remaining period to 2015. Factors such as limited funding for health services, and inequities in reaching all pregnant women irrespective of wealth status, are some of the major reasons for inadequate progress.

There is data to show that the current number of health workers in most countries is insufficient to meet population health needs[xvii]. Addressing this challenge will require expansion of pre-service training of nurses, midwives and doctors, with a view to increase health worker densities in order to meet the target level of 2.28 physicians, nurses and midwives per 1000 population. Considering that pre-service training is clearly a longer-term solution, a variety of complementary, shorter-term responses, (as discussed above), will need to be considered.

As a way forward African governments need to create health policies and necessary legislation in support of delivery of essential maternal health interventions. Such policies are important building blocks of a well functioning health system- including financing of health services, and ensuring equitable access to skilled attendants for all pregnant women. Despite the fact that total official development assistance (ODA) to maternal, newborn and child health programmes increased by 64%, from US$2.1 billion in 2003 to almost US$3.5 billion in 2006[xviii], expenditures on health in most African countries remain far less than the threshold below which it is difficult to ensure access to basic services (US$45 per person). As a result, out-of-pocket health expenditures in sub-Saharan African countries range from 6% in Namibia to 62% in Chad[xix]. Faced with heavy out-of-pocket expenses, many families either avoid seeking care altogether, or risk impoverishment when they do so. Under such scenario ill-health contributes to, and perpetuates, poverty in sub-Saharan Africa[xx].

Related links:


[i] WHO/AFRO. Consensus on Essential Competencies of Skilled attendant in the African Region Report of regional consultation, Brazzaville, 27th February-1st March 2006 WHO Africa Regional Office, 2006

[ii] WHO/UNFPA/UNICEF/World Bank Statement (1999). Reduction of maternal mortality: a joint statement. Geneva: WHO.

[iii] WHO/AFRO. Consensus on Essential Competencies of Skilled attendant in the African Region Report of regional consultation, Brazzaville, 27th February-1st March 2006 WHO Africa Regional Office, 2006

[iv] Starrs A (1997). The Safe Motherhood Action Agenda: Priorities for the Next Decade. New

York: Inter-Agency Group for Safe Motherhood and Family Care International.

[v] Wendy J Graham, Jacqueline S Bell and Colin HW Bullough Can skilled attendance at delivery reduce maternal mortality in developing countries ? Studies in Health Services Organisation & Policy, 17, 2001 pp97-129

[vi] Wim Van Lerberghe and Vincent De Brouwere Reducing maternal mortality in a context of poverty Studies in Health Services Organisation and Policy, 17, 2001

[viii] Kenya National Bureau of Statistics (KNBS) and ICF Macro. 2010. Kenya Demographic and Health

Survey 2008-09. Calverton, Maryland: KNBS and ICF Macro.

[ix] Half of these countries are in sub-Saharan Africa.

[x] WHO. 2005. World Health Report 2005. Geneva: WHO.

[xii] Central African Republic, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Kenya, Liberia, Madagascar, Rwanda, Sierra Leone, Uganda, the United Republic of Tanzania and Zambia

[xiii] World Health Organization, The world health report 2006.

[xiv] The shifting of certain tasks from professional that require longer-term training to those requiring less intensive training which may be more affordable, for example permitting midwives to administer perenteral drugs, to manually remove the placenta, to remove retained products of conception, and to resuscitate newborns.

[xv] Chad, Cote d’Ivoire, Kenya, Lesotho, Malawi, Nigeria, Senegal.

[xvi] Countdown to 2015, 2008 Report Tracking Progress in Maternal, Newborn & Child Survival New York, United Nations Children’s Fund, 2008.

[xviii] Note: The total amount of aid for maternal, newborn and child health-related activities represents just 3% of total ODA

[xix] Adam Leive, Ke Xu. Coping with out-of-pocket health payments: empirical evidence from 15 African countries. Bulletin of the World Health Organization Volume 86, Number 11, November 2008, 849-856

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