By: Catherine Jiang
Maternal health is suffering disproportionately in certain Sub-Saharan African regions. In 2017, the reported maternal mortality rate (MMR) in Uganda was around 336 deaths per 100,000 live births.¹ While this is a high rate, many other countries in this region are faced with a dramatically higher MMR. In 2017, the MMR in Somalia and Central African Republic (CAR) was 829 deaths per 100,000 live births.²,³ In this same year, Nigeria and Chad faced an MMR as high as 917 and 1140 deaths per 100,000 live births, respectively.⁴,⁵
So why are rates so much higher in certain regions? What is the difference between them that are driving these discrepancies?
Somalia, CAR, Nigeria, and Chad are countries with high levels of active conflict, civil war, or unstable government.⁶ This high intensity conflict is often internationalized and involves criminal networks, as well as violent, armed, extremist groups that are independent from the state. Conflicts are often rooted in religious, ethnic, or political disagreements, such as state corruption, or the unjust distribution of services and resources.⁷
How is this Affecting Mothers?
A high maternal mortality ensues amidst general conflict and violence, contributing to half of preventable maternal deaths.⁸ The war and conflict that transpires causes the destruction of physical environments, such as nature and crops, as well as infrastructure, such as healthcare facilities. This amplifies the existing struggles and social inequalities that these women face, such as malnutrition, poverty, lack of medical support, and limited access to resources. Essential services in pregnancy, such as labour and delivery services, become unavailable, which increases both maternal and neonatal mortality. And on top of this, women are being directly injured by the conflict.⁹
The health status of mothers is becoming more and more fragile due to this armed conflict. Women are dying from preventable pregnancy and childbirth complications, and many of these deaths are occurring with the added burden of their fragile health states.
In another realm, war and conflict are breaking down social structures, thereby shattering families and local communities.⁸ With the efforts of authorities being sucked up by the chaos that overwhelms society, public policy and social protection go down the drain, forcing women into compromising situations, such as forced marriage, and facilitating the use of women as weapons of war.⁸,⁹ What this means is that in conflict settings, sexual and gender-based crimes among women are used as a war tactic.¹⁰ As a result, women are increasingly subjected to sexual slavery and assault, thus compromising both their physical and psychological well-being. Inherently, this also increases instances of dangerous and unprotected sex, leading to increased STI incidence and transmission.⁸
So what is happening as a result of all of this? Women are increasingly vulnerable to unplanned and unsafe pregnancies. Familial, community, and societal supports are hindered. These pregnancies are not handled properly. Mothers, along with their babies, are dying. And a vicious cycle proceeds.
What can be done?
There are many barriers to implementing large-scale interventions in these areas due to limitations in funding, lack of skilled health personnel (ex: doctors, nurses, birth attendants, OB/GYNs), and unsafe circumstances. However, there is research that demonstrates the positive effects of utilizing lay community members in delivering maternal and neonatal health care in these high-conflict settings, especially among mothers in “out-of-camp” populations. With the appropriate training, community members can act as lower-skilled health workers to provide safe and non-judgemental care. Community leaders can also aid in delivering educational sessions. Education can increase awareness of important aspects of pregnancy and birth, such as family planning and sexual health. Further, outreach and community-based health sites, something as simple as someone’s home, can be used as a center for postnatal care, regular health check ups post birth, and follow-ups for diseases, such as STIs and HIV.¹¹ Relying more on community health workers with these interventions would improve the current state of maternal and newborn health in these regions.
At the end of the day, there are many intersecting factors that contribute to sky-high MMRs in Sub-saharan Africa. Unfortunately, conflict zones only add fuel to this fire, and terminating conflict is easier said than done. Therefore, alternative strategies must be taken in order to mitigate this state in the meantime. These strategies must be rooted in empowering women and the community from within, hopefully rebuilding some of the hope and support that has been lost to the violence around them.
References
1. Alobo G, Reverzani C, Sarno L, Giordani B, Greco L. Estimating the Risk of Maternal Death at Admission: A Predictive Model from a 5-Year Case Reference Study in Northern Uganda. Obstet Gynecol Int. 2022;2022:4419722. doi:10.1155/2022/4419722
2. Macrotrends. Somalia Maternal Mortality Rate 2000-2023. Accessed February 14, 2023. https://www.macrotrends.net/countries/SOM/somalia/maternal-mortality-rate
3. Macrotrends. Central African Republic Maternal Mortality Rate 2000-2023. Accessed February 14, 2023. https://www.macrotrends.net/countries/CAF/central-african-republic/maternal-mortality-rate
4. Macrotrends. Nigeria Maternal Mortality Rate 2000-2023. Accessed February 14, 2023. https://www.macrotrends.net/countries/NGA/nigeria/maternal-mortality-rate
5. Macrotrends. Chad Maternal Mortality Rate 2000-2023. Accessed February 14, 2023. https://www.macrotrends.net/countries/TCD/chad/maternal-mortality-rate 6. Rogo KO, Oucho J, Mwalali P. Maternal Mortality. In: Jamison DT, Feachem RG, Makgoba MW, et al., eds. Disease and Mortality in Sub-Saharan Africa. 2nd ed. The International Bank for Reconstruction and Development / The World Bank; 2006. Accessed February 14, 2023. http://www.ncbi.nlm.nih.gov/books/NBK2288/
7. Stockholm International Peace Research Institute. Armed Conflict and Peace Processes in Sub-Saharan Africa. Accessed February 14, 2023. https://www.sipri.org/yearbook/2020/07
8. Woldetsadik MA. Family Planning Must Be Part of the Humanitarian Response in Africa’s Conflict Zones. Published July 1, 2015. Accessed March 8, 2023. https://www.rand.org/blog/2015/07/family-planning-must-be-part-of-the-humanitarian-response.html
9. Wagner Z, Heft-Neal S, Wise PH, et al. Women and children living in areas of armed conflict in Africa: a geospatial analysis of mortality and orphanhood. Lancet Glob Health. 2019;7(12):e1622-e1631. doi:10.1016/S2214-109X(19)30407-3
10. Kapp C. The Devastating Use of Sexual Violence as a Weapon of War | Think Global Health. Council on Foreign Relations. Published November 1, 2022. Accessed March 8, 2023. https://www.thinkglobalhealth.org/article/devastating-use-sexual-violence-weapon-war
11. Munyuzangabo M, Gaffey MF, Khalifa DS, et al. Delivering maternal and neonatal health interventions in conflict settings: a systematic review. BMJ Glob Health. 2021;5(Suppl 1):e003750. doi:10.1136/bmjgh-2020-003750