tag:theconversation.com,2011:/ca/topics/maternal-mortality-16752/articlesMaternal mortality – The Conversation2023-08-18T12:38:57Ztag:theconversation.com,2011:article/2102532023-08-18T12:38:57Z2023-08-18T12:38:57ZRisk of death related to pregnancy and childbirth more than doubled between 1999 and 2019 in the US, new study finds<figure><img src="https://images.theconversation.com/files/542870/original/file-20230815-17-eor4q4.jpg?ixlib=rb-1.1.0&rect=6%2C20%2C4454%2C3845&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Maternal death rates are higher in the U.S. than in other high-income countries.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/pregnant-woman-holding-teddy-bear-against-stomach-royalty-free-image/73448795?phrase=death+pregnancy&adppopup=true">Tetra Images/Getty Images</a></span></figcaption></figure><p>Black women were more likely to die during pregnancy or soon after in every year from 1999 through 2019, compared with Hispanic, American Indian and Alaska Native, Asian, Native Hawaiian or other Pacific Islander, and white women. That is a <a href="https://doi.org/10.1001/jama.2023.9043">key finding of our recent study</a> published in the Journal of the American Medical Association. The risk of maternal death increased the most for American Indian and Alaska Native women during that time frame. </p>
<p>Maternal deaths refers to death from any cause except for accidents, homicides and suicides, during or within one year after pregnancy. </p>
<p>Notably, maternal mortality rates more than doubled for every racial and ethnic group from 1999 through 2019. Most maternal deaths are considered preventable because, in the U.S., maternal deaths are most often caused by <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/mmr-data-brief.html">problems that have very effective treatments</a>, including bleeding after delivery, heart disease, high blood pressure, blood clots and infections.</p>
<p>Previous research has focused on <a href="https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer">high rates of maternal mortality in the Southern U.S.</a>, but our results showed that there are high-risk populations throughout the country. </p>
<p>For Black women in 2019, the states with the highest maternal mortality ratios – meaning the proportion of maternal deaths per 100,000 live births – were Arizona, New Jersey, New York and Georgia, along with the District of Columbia. Each had a maternal mortality ratio greater than 100 for Black women. In comparison, the national maternal mortality ratio for all women in the U.S. was 32.1 in 2019. </p>
<p>Among American Indian and Alaska Native women, the states with the largest increases in maternal mortality between the first half of the time period (1999-2009) and the second half (2010-2019) were Florida, Kansas, Illinois, Rhode Island and Wisconsin. In each of these states, risk of maternal death increased by more than 162%. Across the whole U.S., maternal mortality for American Indian and Alaska Native women was higher in 2019 than in all other years. Some individuals other than women, including girls, transgender men and people who identify as nonbinary, are also at risk of maternal death.</p>
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<h2>Why it matters</h2>
<p>In order to prevent maternal deaths in the U.S., it’s crucial to understand who is most at risk. Prior to our study, estimates of maternal mortality for racial and ethnic groups within every state had never been released. </p>
<p>The U.S. has a high rate of maternal mortality <a href="https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer">compared to other high-income countries</a>, despite <a href="https://doi.org/10.1377/hlthaff.23.3.10">spending more per person on health care</a>. Disparities in maternal mortality have persisted for many decades. </p>
<p>Because <a href="https://theconversation.com/more-than-4-in-5-pregnancy-related-deaths-are-preventable-in-the-us-and-mental-health-is-the-leading-cause-193909">most maternal deaths are preventable</a>, interventions have the potential to make a significant difference. Better prevention of <a href="https://theconversation.com/us-preterm-birth-and-maternal-mortality-rates-are-alarmingly-high-outpacing-those-in-all-other-high-income-countries-203745">related events, such as preterm birth</a>, is also necessary. We hope that our research continues to help policymakers and health care leaders put solutions in place to better prevent these deaths from happening. </p>
<p>Recently, U.S. Democratic Senators <a href="https://www.booker.senate.gov/news/press/booker-menendez-cosponsor-reintroduction-of-legislation-to-lower-death-rates-for-women-of-color-following-alarming-study-that-found-maternal-mortality-doubled-in-the-us">Cory Booker and Bob Menendez of New Jersey</a>, <a href="https://www.warnock.senate.gov/newsroom/press-releases/following-alarming-study-that-maternal-mortality-doubled-in-the-u-s-senators-reverend-warnock-padilla-reintroduce-legislation-to-lower-death-rates-for-women-of-color/">Raphael Warnock of Georgia, and Alex Padilla of California</a> reintroduced the <a href="https://www.congress.gov/bill/117th-congress/house-bill/1212">Kira Johnson Act</a> to improve maternal health outcomes for racial and ethnic minority groups and other underserved populations, citing our study. </p>
<h2>What’s next</h2>
<p>We would like to investigate how the most common causes of maternal death, such as blood clots, high blood pressure and mental health issues, are contributing to the overall estimates. </p>
<p>Understanding these trends will help clinicians and policymakers tailor solutions to be as effective as possible. </p>
<p>Our study did not include data from the pandemic years. So far, maternal mortality has only been reported at the national level for those years, but reports suggest that maternal mortality rates have increased since the start of the COVID-19 pandemic and that <a href="https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.pdf">racial disparities have only gotten worse</a>.</p>
<p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p><img src="https://counter.theconversation.com/content/210253/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laura Fleszar receives funding from Gates Ventures, LLC. </span></em></p><p class="fine-print"><em><span>Allison Bryant Mantha receives funding from Gates Ventures, LLC.</span></em></p><p class="fine-print"><em><span>Catherine O. Johnson receives funding from the National Heart, Lung, and Blood Institute and Gates Ventures, LLC.</span></em></p><p class="fine-print"><em><span>Greg Roth receives funding from the National Heart, Lung, and Blood Institute and Gates Ventures, LLC.</span></em></p>Black women died during or soon after pregnancy at higher rates than any other racial group in every year from 1999 to 2019. American Indian and Alaska Native women had the greatest increase in risk during this period.Laura Fleszar, Public Health Researcher at the Institute for Health Metrics and Evaluation, University of WashingtonAllison Bryant Mantha, Associate Professor of Obstetrics, Gynecology and Reproductive Biology , Harvard UniversityCatherine O. Johnson, Research Scientist in Public Health, University of WashingtonGreg Roth, Associate Professor of Medicine and Adjunct Associate Professor of Health Metrics Sciences, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2105922023-08-16T15:14:18Z2023-08-16T15:14:18ZNigerian women ensure they get the best possible healthcare by managing unequal power relations with men<figure><img src="https://images.theconversation.com/files/541539/original/file-20230807-31794-nxav4q.jpg?ixlib=rb-1.1.0&rect=9%2C0%2C6221%2C4147&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rural women in Nigeria negotiate healthcare decisions with their partners. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/cameroonian-refugee-couple-that-ran-away-with-dozens-of-news-photo/1239282860?adppopup=true">Kola Sulaimon/AFP via Getty Images</a></span></figcaption></figure><p>Nigeria is a patriarchal society. Authority is vested in men, who tend to exert power and control over women in various spheres of life. This has an impact on women’s health and decisions about their healthcare.</p>
<p>Women’s health is affected not only by medical conditions and childbearing, but also by cultural behaviour and traditions. Social factors such as gendered access to healthcare or employment also affect people’s capacity to lead healthy lives. </p>
<p>The Nigerian feminist scholar Obioma Nnaemeka has described feminism in an African context as a matter of <a href="https://doi.org/10.1086/378553">negotiation</a> and compromise. She calls it “negofeminism”. It involves “give and take” instead of confrontational exchanges. </p>
<p>This concept helped me, as a <a href="https://www.researchgate.net/profile/Ogochukwu-Udenigwe">global health researcher</a>, to understand what rural Nigerian women said about seeking healthcare during and after pregnancy. </p>
<p>For our <a href="https://doi.org/10.1186/s12978-023-01647-3">study</a>, my colleagues and I interviewed women and their spouses in two rural communities in southern Nigeria. </p>
<p>Our findings describe ways in which women negotiate authority by ascribing the role of decision-maker to their men spouses while maintaining influence over their pregnancy healthcare decisions and actions. Negofeminism’s concepts of alliance, community and connectedness were highlighted through men’s constructive involvement in maternal health.</p>
<p>We found women were not passive victims. Instead, they navigated patriarchal environments to yield the best possible maternal health outcomes by gaining control of their healthcare decisions.</p>
<p>Recognising this form of agency can help in formulating policies and programmes that acknowledge how women’s wider social environments influence their health. </p>
<h2>Maternal health in Nigeria</h2>
<p>In Nigeria, limited access to quality healthcare contributes to <a href="https://dhsprogram.com/pubs/pdf/FR359/FR359.pdf#page=411">556 pregnancy-related deaths per 100,000 live births.</a>. UNICEF reports that Nigeria contributes <a href="https://www.unicef.org/nigeria/situation-women-and-children-nigeria">10% of the global pregnancy-related death burden</a>.</p>
<p>Some scholars have argued that women are only able to seek healthcare if they <a href="https://doi.org/10.1177/0162243917736139">can make independent decisions</a>. But this approach often ignores <a href="http://dx.doi.org/10.1136/bmjgh-2020-003808">women’s realities</a>, such as the fact that their social network (mothers, grandmothers, spouses and community members) influences their use of healthcare services. </p>
<p>Nevertheless, as <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-023-01647-3">our study</a> shows, social dimensions don’t necessarily impede women’s autonomy.</p>
<p>Therefore, I believe that discussions of maternal health in an African context need to consider women’s experiences of being “African” and “women”. </p>
<h2>The study</h2>
<p>We <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-023-01647-3">studied</a> two predominantly rural communities in Esan South-East and Etsako West, local government areas of Edo State in southern Nigeria. We conducted five women-only focus group discussions with a total of 39 women, and three men-only focus group discussions with 25 men. Participants were chosen from a database of women participating in maternal health interventions.</p>
<p>We asked them who women first consulted for pregnancy care, and who made the decisions about seeking maternal healthcare. We also asked about their experiences of men’s involvement in maternal and child health.</p>
<p>We categorised their responses as negotiation, collaboration and manoeuvring. </p>
<p>It appeared that men were considered the decision-makers at the household level. Participants said a woman’s spouse should be the first to know of her pregnancy. Both men and women said men should make all the decisions about healthcare during pregnancy, even though it was clear that women sometimes influenced decisions.</p>
<p>Describing her experience, one woman said: </p>
<blockquote>
<p>In the aspect of care, I will tell my husband, so he will decide. After my husband knows, I will go to the hospital to tell the doctor so he can tell me what to do. </p>
</blockquote>
<p>Similarly, men noted that women “cannot just go to healthcare facilities without the husband’s decision”. </p>
<p>But they also made comments like:</p>
<blockquote>
<p>My wife will tell me, ‘take me to go and see the nurse’. When I am not around, she can go see the doctor on her own. It is a normal thing in our community.</p>
</blockquote>
<p>Both men and women said it was important to get skilled care, especially for complications.</p>
<p>The act of the women telling the men can be thought of as a form of negotiation by women to influence decisions on access to maternal healthcare. First, she recognises the patriarchal environment and assigns the decision-making authority to men. But she is also using her agency in that environment.</p>
<p>Notions of men’s responsibility and collective action on maternal health were evident in the study. In these communities, men’s duties as expectant fathers were mainly of financial support to cover costs associated with pregnancy, including clinic visits, cost of delivery, essential medicines and feeding. </p>
<p>It can be argued that in ascribing decision-making authority to men, women benefit from men’s duty and responsibility to be providers. Women said they could not afford the high cost of maternal healthcare on their own. There was “give and take”.</p>
<p>Some women showed their resistance to men’s involvement in their pregnancy. They reported secretly seeking maternal healthcare without informing their partners. In this they were indicating control over their lives. </p>
<h2>Why this matters</h2>
<p>Our findings show that it’s important to involve women’s communities and spouses in maternal health programmes. </p>
<p>We show that patriarchy affords men power over decision-making or financial resources. Women are not passive in these situations, they actively find ways around it to ensure they have access to skilled healthcare during pregnancy.</p>
<p>This study shows that maternal health is not always an individual responsibility – it can be one for the woman’s community and the nation. Ignoring this can undermine programmes and policies aimed at improving women’s health.</p><img src="https://counter.theconversation.com/content/210592/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ogochukwu Udenigwe does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Rural women in Nigeria circumvent patriarchy to make decisions on their healthcare.Ogochukwu Udenigwe, Doctoral Candidate, L’Université d’Ottawa/University of OttawaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2037452023-08-03T12:25:11Z2023-08-03T12:25:11ZUS preterm birth and maternal mortality rates are alarmingly high, outpacing those in all other high-income countries<figure><img src="https://images.theconversation.com/files/537367/original/file-20230713-19-6sry09.jpg?ixlib=rb-1.1.0&rect=183%2C15%2C4928%2C3395&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Maternal and infant health crises are growing worse in the U.S.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/black-mother-cuddling-sleeping-baby-son-on-sofa-royalty-free-image/758282421?phrase=african+american+baby+sleeping&adppopup=true">LWA/Dann Tardif/Digital Vision via Getty Images</a></span></figcaption></figure><p>Every two minutes, in about the time it takes to read a page of your favorite book or brew a cup of coffee, a woman dies during pregnancy or childbirth, according to a <a href="https://www.who.int/publications/i/item/9789240068759">February 2023 report</a> from the World Health Organization. The report reflects a shameful reality in which maternal deaths have either increased or plateaued worldwide between 2016 and 2020.</p>
<p>On top of that, of every 10 babies born, one is preterm – and every 40 seconds, <a href="https://www.who.int/news/item/09-05-2023-152-million-babies-born-preterm-in-the-last-decade">one of those babies dies</a>. Globally, preterm birth is the <a href="https://www.who.int/news-room/fact-sheets/detail/preterm-birth#">leading cause</a> of death in children under the age of 5, with complications from preterm birth resulting in the death of 1 million children under age 5 each year. </p>
<p>The WHO has designated preterm birth an “<a href="https://www.who.int/news/item/15-11-2022-who-advises-immediate-skin-to-skin-care-for-survival-of-small-and-preterm-babies">urgent public health issue</a>” in recognition of the threat it poses to global health. </p>
<p>Those numbers reflect a worldwide problem, but the U.S. in particular has an abysmal record on both preterm births and maternal mortality: Despite significant medical advancements in recent years, the U.S. suffers from the <a href="https://tcf.org/content/commentary/worsening-u-s-maternal-health-crisis-three-graphs/">highest maternal mortality rate</a> among high-income countries globally. And the 2022 March of Dimes Report Card, an evaluation of maternal and infant health, gave the United States <a href="https://www.marchofdimes.org/peristats/reports/united-states/report-card">an extremely poor “D+” grade</a>. That data also revealed that the national preterm birth rate spiked to 10.5% in 2021, representing a record 15-year high. </p>
<p>We are maternal <a href="https://physiology.med.wayne.edu/profile/ad8024">fetal medicine experts</a> and <a href="https://womenshealth.wayne.edu/about/leadership/">scholars of women’s health</a> who focus on treatments and programs to help women have better maternal health, especially those that reduce preterm birth.</p>
<p>Our <a href="https://womenshealth.wayne.edu/">Office of Women’s Health</a> leads the <a href="https://today.wayne.edu/medicine/news/2023/07/11/wsu-leads-statewide-network-to-combat-high-rates-of-pre-term-birth-53745?wonderplugin-box-action=READ+PRESS+RELEASE">SOS Maternity Network</a>, which stands for the Synergy of Scholars in Maternal and Infant Health Equity, a research alliance of maternal fetal medicine physicians across the state of Michigan. </p>
<p>Maternal and infant death are the <a href="https://doi.org/10.1016/S2352-4642(20)30369-2">worst possible outcomes of pregnancy</a>. These numbers make clear just how crucial it is to change this trajectory and to ensure all Americans have practical access to quality reproductive health care.</p>
<h2>Dire state of maternal health care</h2>
<p>Tori Bowie, an elite Olympic athlete, <a href="https://www.npr.org/2023/06/13/1181971448/tori-bowie-an-elite-olympic-athlete-died-of-complications-from-childbirth">tragically lost her life</a> at just age 32 because of complications of pregnancy and childbirth. </p>
<p>Bowie’s story drives home the devastating state of maternal health in the U.S. Maternal mortality is a sad and unexpected ending to the often beautiful journey of pregnancy and childbirth. It means that a baby has to go without its mother’s love, care and comforting touch and at the same time the family has to mourn the sudden loss of their loved one. Unless substantial progress is made for lowering maternal deaths, the lives of over <a href="https://www.who.int/publications/i/item/9789240068759">1 million more women</a> like Bowie could be at risk by the year 2030, if current trends continue. </p>
<p>Unfortunately, the <a href="https://www.marchofdimes.org/peristats/reports/united-states/report-card">maternal and infant health crises are worsening</a> in the U.S., and this association is far from being an unfortunate coincidence. There is an important link between infant health and maternal health, as they both rely on the <a href="https://www.ajmc.com/view/us-has-highest-infant-maternal-mortality-rates-despite-the-most-health-care-spending">accessibility and quality of health care</a>. These U.S. rates have been increasing since 2018, when improved reporting of maternal deaths was adopted. </p>
<p>In 2020, the U.S. maternal mortality rate was 23.8 deaths per 100,000 live births – nearly three times as high as the country with the next-highest rate of 8.7 deaths per 100,000 live births, France.</p>
<p>The number of women who died within a year after pregnancy <a href="https://doi.org/10.1001/jama.2023.9043">more than doubled in the U.S.</a> over the 20-year period of 1999 to 2019. And there are significant racial disparities in this statistic: The highest number of pregnancy-related deaths were recorded among Black women, increasing from 26.7 per 100,000 births to 55.4 per 100,000 during that same time period. </p>
<p>Worse yet, the Centers for Disease Control and Prevention has determined that about <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/docs/pdf/Pregnancy-Related-Deaths-Data-MMRCs-2017-2019-H.pdf">84% of such maternal deaths</a> <a href="https://theconversation.com/more-than-4-in-5-pregnancy-related-deaths-are-preventable-in-the-us-and-mental-health-is-the-leading-cause-193909">are preventable</a>.</p>
<figure>
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<figcaption><span class="caption">The U.S. maternal mortality rate for Black women is nearly three times higher than that of white women.</span></figcaption>
</figure>
<h2>Tragic rates of infant mortality and preterm birth</h2>
<p>Notably, in 2020 the U.S. also experienced the <a href="https://www.ajmc.com/view/us-has-highest-infant-maternal-mortality-rates-despite-the-most-health-care-spending">highest infant mortality rate</a> of all high-income countries. The U.S infant mortality rate was 5.4 deaths per 1,000 live births, in contrast to the 1.6 deaths per 1,000 live births in Norway, the country with the lowest infant mortality rate. </p>
<p>You may have heard the term “preemie” before, perhaps when a loved one delivered a baby more than three weeks before the expected due date. A premature birth is one that occurs before the 37th week of pregnancy. Preterm-related causes are responsible for <a href="https://www.marchofdimes.org/peristats/reports/united-states/prematurity-profile">35.8% of infant deaths in the U.S</a>. </p>
<p>Preterm babies are often not fully physiologically prepared for delivery, which can result in a range of medical complications. While preterm births lead to rising infant mortality rates, even those who survive can face health problems such as breathing difficulties, problems with feeding, significant developmental delay and more <a href="https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm#">throughout their lives</a>. Preterm birth also presents additional risks for the mother, as women who deliver preterm are at higher risk for cardiovascular complications later in life.</p>
<p>Thus, preterm birth <a href="https://doi.org/10.1002/14651858.CD007235.pub4">takes a significant toll</a> on families and their communities, with serious ramifications in medical, social, psychological and financial contexts. </p>
<h2>Maternal care during pregnancy is key</h2>
<p>Maternal care appointments and screenings are essential to prevent prenatal complications and a women’s increased risk for developing <a href="https://doi.org/10.1161/CIR.0000000000000961">long-term complications such as cardiovascular disease</a>. For that reason, patients should secure prenatal care as early as possible in the pregnancy and continue to regularly have prenatal care appointments. </p>
<p>Preterm birth can occur unexpectedly in an otherwise normal-seeming pregnancy. It looks no different from the early signs of a typical labor, except that it occurs before 37 weeks of pregnancy. The symptoms of premature labor can include contractions, unusual vaginal discharge, the feeling of pressure in the pelvic area, low dull backache or cramps in the uterus or abdomen. A person who experiences these symptoms during pregnancy should seek medical attention.</p>
<p>Some people are more predisposed to preterm birth based on individual risk factors like substance use, multiple pregnancy – such as twins – infections, race, a medical history of prior preterm delivery and heightened stress levels. Our research team and others have shown that <a href="https://doi.org/10.1080/14767058.2023.2199343">COVID-19 is a known risk factor</a> for preterm birth.</p>
<figure>
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<figcaption><span class="caption">Be aware of the risk factors for preterm birth.</span></figcaption>
</figure>
<p>It’s important to speak with your primary care provider to assess how your current health may affect future pregnancy and whether lifestyle changes – such as adopting a healthy diet and active lifestyle and avoiding smoking and drinking alcohol – can improve your likelihood of a full-term delivery.</p>
<h2>Preterm birth prevention</h2>
<p>The more that pregnant women take ownership of their health and ask their doctors to perform a simple cervical length screening during their pregnancy, the earlier preterm birth can be detected and prevented and the more lives will be saved.</p>
<p>Evidence has shown that patients with a short cervix face a greater risk of the <a href="https://doi.org/10.1002/uog.7673">cervix’s opening too early</a> in pregnancy, resulting in preterm birth and other adverse outcomes. The cervix is the lower section of the uterus, which connects to the vaginal canal. As pregnancy progresses, it stretches, softens and ultimately opens in the process of normal childbirth.</p>
<p>All patients – even those who are seemingly low risk – should ask their doctors to have their cervical length checked by transvaginal ultrasound during pregnancy between 19 and 24 weeks. A short cervical length indicates a high risk of a premature delivery. Luckily, there are treatments available, such as vaginal progesterone, which can prevent preterm birth in women found by ultrasound to have a short cervix. This treatment can <a href="https://doi.org/10.1002/uog.9017">reduce the risk of preterm birth by more than 40%</a>.</p>
<p>We are optimistic that with greater awareness of these issues and a shift in the focus to evidence-based practices coupled with increased access to vulnerable populations, the U.S. can begin to give women like Bowie and so many others the health care they and their infants deserve. </p>
<p><em>This article has been updated to highlight the most recent trends in maternal mortality that were reported on July 3, 2023, and to highlight the stark racial disparities.</em></p><img src="https://counter.theconversation.com/content/203745/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sonia Hassan receives funding from Wayne State University. The Office of Women's Health receives funding from the Total Health Care Foundation and the Detroit Medical Center Foundation. </span></em></p><p class="fine-print"><em><span>Hala Ouweini does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A March of Dimes report gave the US a grade of D+ for maternal and infant health care, highlighting that the national preterm birth rate hit 10.5% in 2021, a record 15-year high.Sonia Hassan, Professor of Obstetrics and Gynecology and Maternal Fetal Medicine, Wayne State UniversityHala Ouweini, Research Associate in Women's Health, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2094202023-07-11T16:37:32Z2023-07-11T16:37:32ZDRC has one of the fastest growing populations in the world – why this isn’t good news<figure><img src="https://images.theconversation.com/files/536580/original/file-20230710-16123-co1r02.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Getty Images</span></span></figcaption></figure><p><em>The demographic profile of a country matters because it sets its development pace – it creates opportunities and presents risks. For many developing countries, the challenge is to manage a demographic profile that puts pressure on particular cohorts of people. One country that needs to manage this challenge is the Democratic Republic of Congo. Jacques Emina, who has <a href="https://www.researchgate.net/profile/Jacques-Emina">studied demography</a> in the country for the last two decades, unpacks the numbers.</em> </p>
<h2>What are the DRC’s demographic challenges? What’s driving them?</h2>
<p>With <a href="https://www.macrotrends.net/countries/COD/democratic-republic-of-congo/population">102 million</a> people in 2023, the Democratic Republic of Congo is the <a href="https://worldpopulationreview.com/country-rankings/countries-in-africa">fourth most populous country in Africa</a> after Nigeria, Ethiopia and Egypt. It’s the <a href="https://worldpopulationreview.com/">15th most populous</a> country in the world. </p>
<p>It’s estimated that by 2050, the DRC will have <a href="https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/wpp2022_summary_of_results.pdf#page=9">215 million people</a> and join the world’s 10 most populated countries. This isn’t so surprising, given the size of the country: <a href="https://ins.cd/wp-content/uploads/2022/06/ANNUAIRE-STATISTIQUE-2020.pdf#page=30">2.3 million square kilometres</a>, making it the second-largest country in Africa (behind Algeria).</p>
<p>The country’s population reflects higher-than-average growth compared to other countries on the continent. The DRC’s population grew by <a href="https://www.macrotrends.net/countries/COD/democratic-republic-of-congo/population-growth-rate">3.3% in 2022</a>. The continent’s average was <a href="https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/wpp2022_summary_of_results.pdf#page=17">2.5%</a>. The average world population growth rate was <a href="https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/wpp2022_summary_of_results.pdf#page=17">0.8% in 2022</a>. </p>
<p>The DRC’s growing population has serious consequences for the wellbeing of its people. Without policies that take account of the country’s demographic profile – a growing population and <a href="https://www.britannica.com/place/Republic-of-the-Congo/Demographic-trends">a very high number of young people versus working age people</a> – social conditions like poverty and hunger will increase.</p>
<p>There are two main reasons for the high population growth: a decrease in deaths and a high number of births. </p>
<p>Over the past decades, the DRC has seen a consistent drop in <a href="https://data.unicef.org/country/cod/">under-five mortality</a>, though this is still relatively high compared to the world average. In 1995, under-five mortality was estimated at 175 deaths per 1,000 births. This dropped to 87 deaths per 1,000 births in 2018. In the same year the <a href="https://data.unicef.org/topic/child-survival/under-five-mortality/">global under-five mortality rate</a> stood at 40 deaths per 1,000 births.</p>
<p><a href="https://www.worldometers.info/demographics/democratic-republic-of-the-congo-demographics/#life-exp">Life expectancy in the DRC</a> has also increased from 49 years in 1995 to 62 years in 2023. The current global life expectancy is <a href="https://www.worldometers.info/demographics/life-expectancy/">73 years</a>.</p>
<p>When it comes to numbers of births, Congolese women average <a href="https://www.prb.org/international/indicator/fertility/table">6.2 babies</a> in their lifetimes. This is four births more than the global average of 2.3 babies. </p>
<p>The DRC’s fertility rate is driven by four major factors.</p>
<p>Firstly, cultural values encourage people to have children. Large families are celebrated. The country’s most recent <a href="https://dhsprogram.com/pubs/pdf/sr218/sr218.e.pdf">demographic and health survey</a> found that Congolese women on average wanted <a href="https://dhsprogram.com/pubs/pdf/sr218/sr218.e.pdf#page=6">six children</a>; men wanted seven. </p>
<p>Secondly, an early start to childbearing means more years of giving birth. <a href="https://dhsprogram.com/pubs/pdf/sr218/sr218.e.pdf#page=6">More than 30% of girls</a> in the DRC are married before they turn 18. About a quarter of young women give birth by their 18th birthday compared to <a href="https://data.unicef.org/topic/child-health/adolescent-health/">14% worldwide</a>. And <a href="https://dhsprogram.com/pubs/pdf/sr218/sr218.e.pdf#page=5">27%</a> of adolescent Congolese girls aged 15-19 have children. </p>
<p>Thirdly, <a href="https://dhsprogram.com/pubs/pdf/sr218/sr218.e.pdf#page=7">very few women use contraception</a> in the DRC. The percentage of women of reproductive age who use an effective form of modern contraception was estimated at around <a href="https://www.unicef.org/drcongo/media/3646/file/COD-MICS-Palu-2018.pdf#page=107">7% in 2018</a>. This was up from 4% in 2007. </p>
<p>The fourth factor driving population growth is the absence of a national population policy. This typically includes a set of measures designed to influence population dynamics. </p>
<h2>What impact is this having?</h2>
<p>The DRC’s galloping demography has several implications.</p>
<p>The first is a high dependency ratio. This is when there are far more economically dependent people than economically active ones because of the demographic age profile of the country. The economically active population faces a greater burden to support economically dependent people, particularly children. Children under the age of 15 account for <a href="https://www.britannica.com/place/Republic-of-the-Congo/Demographic-trends">41.6%</a> of the DRC’s total population. This indicates that employed people aged 15-64 bear a heavy burden amid <a href="https://www.worldbank.org/en/country/drc/overview">low incomes</a>. </p>
<p>The country also faces significant planning challenges. <a href="https://www.unicef.org/drcongo/en/what-we-do/education">School attendance rates</a> increased from 52% in 2001 to 78% in 2018. Nevertheless, <a href="https://www.unicef.org/drcongo/en/what-we-do/education">7.6 million children aged 5-17 are still out of school</a>. </p>
<p>The DRC lags behind in other key human development measures.</p>
<ul>
<li><p>It’s among the five poorest nations in the world. In 2022, <a href="https://www.worldbank.org/en/country/drc/overview">62% of Congolese (60 million people)</a> lived under the poverty line (less than US$2.15 a day). About one in six people living in extreme poverty in sub-Saharan Africa lives in the DRC. </p></li>
<li><p>The country has faced <a href="https://theconversation.com/military-interventions-have-failed-to-end-drcs-conflict-whats-gone-wrong-205586">political unrest and armed conflicts</a> for six decades. The <a href="https://www.visionofhumanity.org/wp-content/uploads/2023/06/GPI-2023-Web.pdf">2023 Global Peace Index</a> – which measures the relative peacefulness of nations and regions – lists the DRC as <a href="https://www.visionofhumanity.org/wp-content/uploads/2023/06/GPI-2023-Web.pdf#page=11">one of the least peaceful countries</a> in the world after Afghanistan, Yemen, Syria and South Sudan.</p></li>
<li><p>The country has one of the <a href="https://data.unicef.org/topic/maternal-health/maternal-mortality/">world’s highest maternal mortality ratios</a> at 547 deaths per 100,000 live births. The global average is 223 deaths per 100,000 live births. </p></li>
<li><p>It’s one of the world’s hungriest countries. Its <a href="https://www.globalhungerindex.org/">Global Hunger Index</a> score – which measures and tracks levels of hunger globally – stands at <a href="https://www.globalhungerindex.org/drc.html">37.8</a>, which is tagged as “alarming”. </p></li>
</ul>
<h2>What interventions are needed?</h2>
<p>A country’s population profile can offer opportunities, or what’s known as a demographic dividend. This is when a high percentage of people are young and there are jobs for them. </p>
<p>But the DRC is missing out on this opportunity and will continue to do so unless it:</p>
<ul>
<li><p>invests in human capital by improving its education and health systems. Most Congolese are <a href="https://reliefweb.int/report/democratic-republic-congo/can-t-afford-be-sick-assessing-cost-ill-health-north-kivu-eastern">paying out of their own pockets</a> for healthcare. Education is free, but the <a href="https://2017-2020.usaid.gov/democratic-republic-congo/education">system is weak</a> due to low budget allocations.</p></li>
<li><p>designs a population policy to guide population dynamics. This would include policies on birth, migration and where people live. These should be linked to an integrated national development policy.</p></li>
<li><p>makes progress on gender equality. This should include increasing the enrolment of girls in high schools, discouraging child marriage and enabling young mothers to attend school.</p></li>
<li><p>improves governance and tackles corruption to promote investment in education, health and employment.</p></li>
<li><p>creates data systems that can underpin evidence-based policies.</p></li>
</ul><img src="https://counter.theconversation.com/content/209420/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jacques Emina does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Without policies that take account of a growing population with few working-age people, DRC risks seeing an increase in poverty and hunger.Jacques Emina, Professor of population and development studies, University of Kinshasa Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2070342023-06-28T07:50:53Z2023-06-28T07:50:53ZEvery 2 seconds in the world a baby is born prematurely – report identifies biggest challenges for their survival<figure><img src="https://images.theconversation.com/files/531103/original/file-20230609-25-ucxday.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A premature infant receives care at Koidu Government Hospital in Kono, Sierra Leone. </span> <span class="attribution"><span class="source">Melina Mara/The Washington Post via Getty Images</span></span></figcaption></figure><p>Globally, about <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30451-0/fulltext">one baby in 10</a> is born too soon – that’s around one baby
every two seconds. A full term pregnancy is around nine months or 37 weeks. Babies born before this mark are considered premature. Preterm birth is a significant global health issue. It can cause serious short term consequences, such as respiratory and cardiac problems. In the long term, babies born prematurely may face motor, neurosensory, cognitive and behavioural deficits. </p>
<p>A decade ago in 2012, a global coalition of stakeholders launched <a href="https://www.who.int/publications/i/item/9789241503433">Born Too Soon: The Global Action Report on Preterm Birth</a>. The report made a case for global action to mitigate the problems of preterm birth. </p>
<p>Since then, many countries have adopted plans and resolutions on newborn health. Global guidelines now include life-saving interventions, such as the use of antenatal corticosteroids and kangaroo mother care (skin-to-skin contact). There’s also been growth in community activism on preterm birth and stillbirth prevention, driven by networks of parents, health professionals, academia and civil society. </p>
<p>Despite these interventions, the last decade has seen no measurable change in global preterm birth rates in any region of the world. For example, in southern Asia 13.3% of babies in 2010 were born premature; this figure was 13.2% in 2020. In sub-Saharan Africa 10.1% of babies in both 2010 and 2020 were premature. A group of over 140 individuals from more than 70 organisations contributed to a new report, <a href="https://www.who.int/publications/i/item/9789240073890">Born Too Soon: decade of action on preterm birth</a>, to coincide with the 10th anniversary of the first report.</p>
<p>The latest report shows that the overall progress in improving the wellbeing of babies born prematurely, and that of their families, has not gone fast enough or far enough. Where babies are born often dictates whether they will survive. Inequalities related to race, ethnicity, socioeconomic and educational status, and access to quality healthcare services determine the likelihood of death and disability. For example, one in 10 extremely preterm babies (born before 28 weeks or seven months) survive in low-income countries. In high-income countries more than nine in 10 of these babies survive. </p>
<p>Strategies to reduce preterm birth include: pre-conception care such as access to family planning; sexual health programmes aimed at prevention and treatment of infections prior to and during pregnancy; and assessment and treatment of low nutritional status before conception. </p>
<p>The report is a wake-up call. The problem of preterm birth needs concerted efforts from governments and donors. Families, communities, healthcare providers and the civil society must also be actively involved in the solutions. </p>
<h2>Key findings</h2>
<p>In addition to established global issues, the report highlights new and intensified challenges which have affected efforts to improve preterm birth outcomes. We call these the “four Cs”:</p>
<p><strong>Conflict:</strong> By the end of 2022, over 100 million people were driven from their homes by war, violence or human rights abuses, particularly in countries such as Ukraine, Afghanistan, Sudan and Mozambique. Worldwide, 61% of maternal deaths, 51% of stillbirths and 50% of newborn deaths occurred in countries that required UN humanitarian aid in 2023. Surviving newborns from conflict zones are particularly vulnerable to lifelong risks as a result of poor healthcare services.</p>
<p><strong>COVID-19:</strong> The pandemic destabilised health services for women and newborns. Separation of newborns from caregivers threatened high-impact practices like kangaroo mother care and exclusive breastfeeding (giving no other food or drink – not even water – except breast milk). A recent <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955179/">study</a> found that if universal coverage of kangaroo mother care were achieved, more than 125,000 newborn lives around the world could have been saved. The number of newborn deaths from COVID-19 could have been lower than 2,000. </p>
<p><strong>Climate change:</strong> Climate change (including extreme heat) and natural disasters are displacing millions of people. The health impacts are wide-ranging. In 2020, <a href="https://www.stateofglobalair.org/health/newborns#fragile-stage">20%</a> of newborn deaths were attributed to air pollution, mostly because of preterm birth. Toxic chemicals in maternal blood <a href="https://www.stateofglobalair.org/health/newborns#risk-home">results</a> in immune system stress and placental dysfunction.</p>
<p><strong>Cost of living crisis:</strong> Disruptions to supply chains caused by the COVID-19 pandemic and the climate crisis have dramatically increased the cost of living. Global <a href="https://www.imf.org/en/Publications/WEO#:%7E:text=Global%20inflation%20is%20forecast%20to,to%204.1%20percent%20by%202024.">inflation</a> rose from 4.7% in 2021 to 8.8% in 2022, creating a global cost of living health crisis. There are <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(22)00120-7/fulltext#:%7E:text=Good%20nutrition%2C%20shelter%2C%20and%20the,health%20timebomb%20for%20the%20future.">reports</a> of babies dying in low- and middle-income countries following discharge to families who cannot afford heating and oxygen at home, further compromising maternal and newborn health outcomes.</p>
<h2>Recommendations</h2>
<p>The <a href="https://www.who.int/publications/i/item/9789240073890">new report</a> sets an ambitious agenda to reduce the burden of preterm birth by addressing contributory factors both within and outside the health system. Its recommendations have crucial contextual relevance to Africa, where preterm birth is the <a href="https://www.who.int/news-room/fact-sheets/detail/levels-and-trends-in-child-mortality-report-2021#:%7E:text=Sub%2DSaharan%20Africa%20has%20the,36%25%20of%20global%20newborn%20deaths.">leading cause of deaths</a> in babies under a month old. </p>
<p>In summary, the report recommends:</p>
<p><strong>1. Counting and accounting for preterm births</strong></p>
<p>Data availability and quality must improve. This can be done by counting every baby everywhere, including those stillborn, and accurately recording gestational age and birth weight. </p>
<p><strong>2. Rights and respect</strong> </p>
<p>Women and their families should be empowered and cared for with respect. This will take more healthcare providers and stronger accountability.</p>
<p><strong>3. Women’s and maternal health services</strong></p>
<p>Women’s access to high-quality, respectful sexual, reproductive and maternal health services is fundamental. All women and adolescent girls should be able to determine the number and spacing of their children. </p>
<p><strong>4. Care for small and sick newborns</strong></p>
<p>Most of the major causes of neonatal death can be prevented by caring for the small or sick newborn. This requires commitment, resources and joined-up systems. </p>
<p><strong>5. Intersectoral action</strong> </p>
<p>There is a need to invest in policies that prioritise equitable and inclusive education, including sexuality education, and innovative financing schemes that support families with preterm babies. Countries also need emergency response plans to avoid service interruptions in times of crisis.</p><img src="https://counter.theconversation.com/content/207034/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The last decade has seen no measurable change in global preterm birth rates in any region of the world.Priya Soma-Pillay, Chair: School of Medicine and Head of Department: Obstetrics and Gynaecology, University of PretoriaDilly OC Anumba, Professor of Obstetrics and Gynaecology, University of SheffieldLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2073902023-06-21T12:30:58Z2023-06-21T12:30:58ZOne year after the fall of Roe v. Wade, abortion care has become a patchwork of confusing state laws that deepen existing inequalities<figure><img src="https://images.theconversation.com/files/532284/original/file-20230615-17-u98cyj.jpg?ixlib=rb-1.1.0&rect=22%2C0%2C4914%2C1638&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The range of reproductive health care available to women depends significantly on the state they live in.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/sad-young-woman-sitting-looking-out-window-and-royalty-free-image/1132941100?phrase=abortion&adppopup=true">fizkes/iStock via Getty Images Plus</a></span></figcaption></figure><p>In the year since the <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf">U.S. Supreme Court’s Dobbs v. Jackson ruling</a> <a href="https://theconversation.com/supreme-court-overturns-roe-upends-50-years-of-abortion-rights-5-essential-reads-on-what-happens-next-184697">struck down the constitutional right to abortion</a>, society has been seeing the results of a post-Roe world. </p>
<p>While there is no law in the U.S. that regulates what a man can do with his body, the reproductive health of women is now more regulated than it has been in 50 years. And the scope of reproductive health care that women can receive is highly dependent on where they live. </p>
<p>This creates a <a href="https://doi.org/10.1177/10901981221125430">system of inequalities</a> and further exacerbates health disparities.</p>
<p>I am a <a href="https://www.uml.edu/health-sciences/nursing/faculty/collins-fantasia-heidi.aspx">nurse practitioner</a> who <a href="https://scholar.google.com/citations?user=6rrHhmUAAAAJ&hl=en">studies women’s reproductive health across the lifespan</a>. </p>
<p>My research found that college women are concerned about pregnancy, but they lack knowledge and skills about <a href="https://doi.org/10.1097/JFN.0000000000000046">navigating sexual consent</a> and often participate in <a href="https://doi.org/10.1111/j.1939-3938.2011.01108.x">sexual activity without explicit consent</a>, leaving them at risk for not using contraception and exposure to sexually transmitted infections. </p>
<p>These findings indicate that women are at risk of pregnancy at a historic time when women’s reproductive rights in the U.S. are restricted and not guaranteed. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/z4nHG4_Sqhw?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A retrospective on Roe v. Wade – and a look ahead.</span></figcaption>
</figure>
<h2>Current state of abortion in the US</h2>
<p>The <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf">Dobbs v. Jackson ruling</a> returned decisions regarding abortion to individual states. This has led to a <a href="https://theconversation.com/in-the-year-since-the-supreme-court-overturned-roe-v-wade-and-ruled-states-should-decide-the-legality-of-abortion-voters-at-the-state-level-have-been-doing-just-that-4-essential-reads-207299">patchwork of laws</a> that <a href="https://states.guttmacher.org/policies/">span the entire range</a> from complete bans and tight restrictions to full state protection for abortion.</p>
<p>In some states, such as Texas, Louisiana and Mississippi, <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">abortion is banned</a> beginning at six weeks gestational age, when very few women even know they are pregnant. Other states, such as Massachusetts, Vermont, New York and Oregon, have enacted state-level protections for abortion. </p>
<p>The patchwork of state laws also results in a great deal of confusion. In the past year, women’s rights organizations and women’s health advocates have brought numerous <a href="https://www.kff.org/womens-health-policy/issue-brief/legal-challenges-to-state-abortion-bans-since-the-dobbs-decision/#">legal challenges to restrictive abortion laws</a>. These cases have halted the implementation of some of the strictest abortion regulations until additional court rulings are finalized. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Protesters gather in a small crowd holding signs including " src="https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Protesters against a stricter abortion ban stand in the State House lobby on May 23, 2023, in Columbia, S.C.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/AbortionSouthCarolina/a08c0479d51341e493cf4850cb1df634/photo?Query=abortion%20bans&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=2705&currentItemNo=12">AP Photo/Jeffrey Collins</a></span>
</figcaption>
</figure>
<h2>Downstream effects for health care professionals</h2>
<p>Abortion training is considered <a href="https://doi.org/10.1097/ACM.0000000000005154">essential health care and a core competency</a> for physicians in obstetrics and gynecology, or OB-GYN, residency programs. Approximately 50% of OB-GYN residency programs are located in states <a href="https://doi.org/10.1097/AOG.0000000000004832">with restricted or highly restricted access to abortion</a>. This will logically result in not only fewer health care providers being trained to perform gynecologic procedures for abortion, but also other conditions such as miscarriage, fetal death and nonviable pregnancies. </p>
<p>In states with changing abortion laws and legal challenges to new laws, <a href="https://www.ama-assn.org/delivering-care/population-care/ambiguous-anti-abortion-laws-are-putting-patients-risk">physicians are uncertain</a> of what procedures can be legally done. <a href="https://www.politico.com/news/2022/05/06/potential-abortion-bans-and-penalties-by-state-00030572">Penalties for violating abortion laws</a> may include arrest, loss of medical license, fines and discipline by state boards of medicine. </p>
<p>As a result, physicians are <a href="https://www.axios.com/2023/04/18/abortion-ban-states-drop-student-residents">choosing to leave states</a> with the <a href="https://www.npr.org/sections/health-shots/2023/05/23/1177542605/abortion-bans-drive-off-doctors-and-put-other-health-care-at-risk">most restrictive abortion laws, and clinics are closing</a>, which is contributing to the current <a href="https://www.cnn.com/2023/04/19/health/abortion-ban-affects-physician-training/index.html">shortage of health care providers</a>.</p>
<h2>Inequalities in health care access</h2>
<p>The unequal access to abortion procedures across the country is most directly affecting the poorest women in the U.S.</p>
<p>Currently, 12 states restrict abortion coverage by private insurance, and more than 30 states <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">prohibit public Medicaid payment</a> for abortion. Women who qualify for Medicaid are among the poorest in the U.S. Lack of access to abortion limits education and wage earning and <a href="https://www.npr.org/2022/08/18/1111344810/abortion-ban-states-social-safety-net-health-outcomes">contributes to poverty</a>. States with the most restrictive abortion laws also have <a href="https://www.axios.com/2022/05/20/abortion-roe-supreme-court-babies-mothers">limited access to pregnancy care</a> and <a href="https://www.usnews.com/news/politics/articles/2022-04-07/social-programs-weak-in-many-states-with-tough-abortion-laws">supportive programs</a> for pregnant and parenting women. </p>
<p>In addition, traveling to a different state to obtain an abortion is often not possible for poor women. Lack of transportation and limited financial resources reduce or eliminate options to obtain an abortion in a different geographic location. </p>
<p>What’s more, states with the most abortion restrictions have some of the <a href="https://worldpopulationreview.com/state-rankings/maternal-mortality-rate-by-state">worst pregnancy and maternal health outcomes</a> for women, especially women of color. Pregnancy itself is associated with a <a href="https://doi.org/10.1097%2FAOG.0000000000003762">risk of dying</a>. </p>
<p>Maternal morbidity is the term used to describe short- or long-term <a href="https://www.nichd.nih.gov/health/topics/maternal-morbidity-mortality">health problems that result from pregnancy</a>. Maternal mortality refers to the <a href="https://www.who.int/news-room/fact-sheets/detail/maternal-mortality">death of women during pregnancy</a> or within the first six weeks after birth. </p>
<p>For example, Mississippi and Louisiana have the highest rates of maternal mortality in the U.S. and also <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">have the most restrictive abortion laws</a>. Black women have the <a href="https://www.ama-assn.org/print/pdf/node/66881">highest maternal mortality of all races</a> and ethnicities. Women in these states who are unable to terminate a pregnancy have a higher risk of dying as a result of the pregnancy than women in other states. </p>
<p>Additionally, research shows that a <a href="https://doi.org/10.1097/aog.0b013e31823fe923">woman’s risk of dying</a> related to pregnancy or childbirth is about 14 times higher than the risk of death from an abortion. </p>
<p>In addition to the increased risks of death, there are other <a href="https://www.ansirh.org/research/ongoing/turnaway-study">physical and mental health implications</a> associated with carrying an undesired pregnancy to term. Being denied access to abortion is associated with increased anxiety and <a href="https://www.ansirh.org/research/ongoing/turnaway-study">fewer future plans</a> for the next year. Research also shows that not being able to obtain an abortion makes women more likely to <a href="https://doi.org/10.2105/AJPH.2017.304247">live below the federal poverty level</a> and to <a href="https://doi.org/10.1363/psrh.12216">lack partner support</a>. </p>
<p>Conversely, research has shown that there are <a href="https://doi.org/10.1016/j.contraception.2008.07.005">few if any significant negative mental health outcomes</a> among women who have abortions. </p>
<h2>Unsafe abortions</h2>
<p>Restricting legal abortion increases the risk that women will seek out <a href="https://doi.org/10.1016/j.bpobgyn.2010.02.012">pregnancy termination from unskilled people</a> in unsafe settings. Or they may not seek care quickly for pregnancy complications due to fear of being accused of a crime.</p>
<p>In Texas, physicians are <a href="https://www.newyorker.com/news/dispatch/in-the-post-roe-era-letting-pregnant-patients-get-sicker-by-design">reporting an increase in sepsis</a>, or an <a href="https://theconversation.com/sepsis-still-kills-1-in-5-people-worldwide-two-icu-physicians-offer-a-new-approach-to-stopping-it-175650">overwhelming response to infection</a>, from incomplete abortions. These physicians predict that sepsis will become the leading cause of maternal death in Texas. </p>
<p>Prior to 1973, when Roe v. Wade established constitutional protection for abortion in the U.S., women often resorted to unsafe methods to induce abortion that resulted in a high death toll. <a href="https://doi.org/10.2307/3419941">Septic abortion wards</a> – or designated areas of hospitals where women were treated for sepsis as a result of illegal abortions – were common. In 1965, 17% of all deaths related to pregnancy were <a href="https://www.guttmacher.org/sites/default/files/article_files/gr060108.pdf">attributed to illegal abortion</a>. </p>
<p>Now that the constitutional right to abortion has been eliminated, more women will inevitably <a href="https://doi.org/10.1016/j.ajog.2022.07.033">die or become seriously ill</a> due to lack of safe access to abortion services. In states with the most restrictions on abortion, whether a woman meets the criteria for an exemption to save the life of the mother may be <a href="https://publichealth.jhu.edu/2023/a-year-without-roe">decided by a hospital committee</a>. This can delay necessary care and increase the risk to the mother.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/rSWwX7lBEGk?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Said one: “I didn’t know I was important enough to draw boundaries around what people could and couldn’t do with my body.”</span></figcaption>
</figure>
<h2>Women affected by violence</h2>
<p>In the U.S., more than 25% of women will <a href="https://ncadv.org/STATISTICS">experience physical or sexual violence</a> in their lifetime. Violence from an intimate partner is a <a href="https://www.ansirh.org/research/ongoing/turnaway-study">leading reason for abortion</a>. My research shows that women affected by violence have a <a href="https://doi.org/10.1016/j.contraception.2012.03.005">higher risk of pregnancy</a> and that college women are at increased risk of <a href="https://doi.org/10.1097/jfn.0000000000000086">nonconsensual and forced sexual encounters</a>.</p>
<p>Currently, there are 14 states with abortion bans that contain <a href="https://www.kff.org/womens-health-policy/issue-brief/a-review-of-exceptions-in-state-abortions-bans-implications-for-the-provision-of-abortion-services/">no exception for rape or incest</a> or require that the sexual assault be reported to law enforcement to qualify for exception. </p>
<p>Research has shown that women often <a href="https://doi.org/10.3200/JACH.55.3.157-162">don’t report sexual assault</a> due to stigma, embarrassment or fear of not being believed. Even if women qualify for an abortion as a result of sexual violence, those who have not filed a formal police report lack “proof” that their pregnancy resulted from assault. </p>
<p>While the changes that have occurred since the fall of Roe one year ago are already deeply concerning, the full effect of eliminating the constitutional right to an abortion won’t be known for years. And as laws are enacted and subsequently challenged, uncertainty and confusion regarding women’s reproductive health care will undoubtedly continue for years to come.</p><img src="https://counter.theconversation.com/content/207390/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Heidi Collins Fantasia has received funding from the National Institutes of Health, National Institute of Child Health and Human Development and Heart, Lung, and Blood Institute. Dr. Fantasia is the editor of Nursing for Women's Health. </span></em></p>Abortion bans and restrictions have numerous downstream effects on health care. For instance, medical students in states where those laws exist will not receive training for some standard procedures.Heidi Collins Fantasia, Associate Professor of Nursing, UMass LowellLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2047092023-06-01T14:06:22Z2023-06-01T14:06:22ZBlack women are at greater risk of maternal death in the UK – here’s what needs to be done<figure><img src="https://images.theconversation.com/files/529541/original/file-20230601-16-dd836h.jpg?ixlib=rb-1.1.0&rect=0%2C17%2C5760%2C3811&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Poorer maternity care may be one explanation.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-woman-deep-thought-looks-out-1565039914">zulufoto/ Shutterstock</a></span></figcaption></figure><p>Black women are <a href="https://www.ndph.ox.ac.uk/news/latest-mbrrace-uk-figures-for-maternal-and-perinatal-mortality-in-the-uk-are-published">four times more likely</a> to die while pregnant or just after childbirth than white women, according to the latest figures published by <a href="https://www.npeu.ox.ac.uk/mbrrace-uk">Mbrrace</a> – a national programme which surveys and investigates the causes of maternal deaths and infant deaths in the UK. Although this report only includes data from 2019-2021, reports from previous years show maternal mortality rates have been largely unchanged for the <a href="https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2021/MBRRACE-UK_Maternal_Report_2021_-_FINAL_-_WEB_VERSION.pdf">last decade or more</a>.</p>
<p>The reason for this racial disparity still isn’t fully understood. It’s likely due to a <a href="https://committees.parliament.uk/publications/38989/documents/191706/default/">combination of many factors</a>, including socioeconomic status and pre-existing health conditions. Numerous reports have also shown that black women receive <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9735204/">poorer maternity care</a> compared with women from other ethnic backgrounds, which may further contribute to poorer health outcomes. </p>
<p>But in order to improve maternal outcomes for black women, work will need to be done at every level of the NHS to fix a root cause of these racial disparities in care – a concept philosophers call <a href="https://academic.oup.com/book/32817">epistemic injustice</a>.</p>
<p>Epistemic injustice is defined as unfairly preventing someone from properly communicating their ideas or making sense of their experiences. This typically happens when someone is biased against a person – for example, due to their race or social class. This leads to them to downplay the other person’s credibility.</p>
<p><a href="https://www.fivexmore.com/blackmereport">Examples of this</a> in maternity care include patients having concerns about their health and their pregnancy dismissed or treated as trivial, being passed off as “dramatic”, questions being brushed aside or not taken seriously, and practitioners not taking patients’ pain seriously. By denying someone credibility, it may make them feel less able to request care and raise worries. </p>
<h2>Racial prejudice</h2>
<p>Numerous studies have highlighted the ways that epistemic injustice is present in real-world healthcare settings. Often, <a href="https://www.pnas.org/doi/10.1073/pnas.1913405117">racial prejudice</a> is a root cause.</p>
<p>For example, research shows that white health workers are more likely to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843483/">disbelieve reports of pain</a> by black patients and less likely to provide them with proper pain relief, compared with white patients. Reports have also found that when black women raise health concerns, they’re <a href="https://www.birthrights.org.uk/wp-content/uploads/2022/05/Birthrights-inquiry-systemic-racism_exec-summary_May-22-web.pdf">often dismissed</a> – even in severe cases, such as instances where c-section stitches are bleeding and infected. </p>
<p>A <a href="https://blackequityorg.com/state-of-black-britain-report/">2022 report</a> by the Black Equity Organisation, which works to dismantle systemic racism in the UK, found that more than 65% of respondents reported they’d been discriminated against because of their ethnicity by healthcare professionals. The <a href="https://www.nhsrho.org/wp-content/uploads/2022/02/RHO-Rapid-Review-Final-Report_v.7.pdf">NHS Race and Health Observatory</a> has made similar conclusions, showing many black patients experience patronising and judgemental attitudes from healthcare staff.</p>
<figure class="align-center ">
<img alt="An expectant mother cradles her stomach while speaking with her doctor." src="https://images.theconversation.com/files/529543/original/file-20230601-29-xaxev9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/529543/original/file-20230601-29-xaxev9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/529543/original/file-20230601-29-xaxev9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/529543/original/file-20230601-29-xaxev9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/529543/original/file-20230601-29-xaxev9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/529543/original/file-20230601-29-xaxev9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/529543/original/file-20230601-29-xaxev9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Healthcare workers may be more likely to dismiss the health concerns of black mothers.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/nurse-using-digital-tablet-meeting-pregnant-155727371">Monkey Business Images/Shutterstock</a></span>
</figcaption>
</figure>
<p><a href="https://www.mayadusenbery.com/book">Knowledge gaps</a> in healthcare research are another example of epistemic injustice. Black people have historically been <a href="http://www.brown.uk.com/teaching/HEST5001/douglas.pdf">underrepresented in research studies</a> and continue to be so.</p>
<p>One reason for this may be their <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0282088">experiences of racism</a> from doctors, which fosters distrust and discourages black people from participating in research studies. But researchers are also slow to engage with black participants and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7904098/">close these knowledge gaps</a>. Many justify this lack of engagement on feeble grounds – for instance, by insisting black women are <a href="https://committees.parliament.uk/oralevidence/10072/html/">hard to recruit</a>. </p>
<p>This lack of representation can lead to <a href="https://www.tandfonline.com/doi/full/10.1080/15265161.2020.1851811">knowledge gaps</a> at every level – including in the medical guidelines used to identify and diagnose certain diseases. Take the <a href="https://www.hsib.org.uk/news-and-events/new-report-examines-delayed-detection-of-jaundice/">recent case</a> of a black infant who was not diagnosed and treated for jaundice as quickly as she should have been. Although multiple blood tests showed high blood levels of bilirubin (a symptom of jaundice), healthcare staff were still relying on visual signs to detect jaundice – and these aren’t typically as evident in darker-skinned patients. </p>
<p>Although just one example, this highlights the way knowledge gaps make it harder for staff to understand the distinct care needs and experiences of black patients. This may lead to worse health outcomes for these patients, and further <a href="https://www.pnas.org/doi/10.1073/pnas.1913405117">diminish levels of trust</a> the black community has in healthcare practitioners and institutions.</p>
<h2>Making change</h2>
<p>While the negative impacts of epistemic injustice on the maternal healthcare that black women receive is clear, addressing these problems within the NHS will require change at nearly every level.</p>
<p>A report on <a href="https://committees.parliament.uk/publications/38989/documents/191706/default/">black maternal health</a> by the House of Commons’ Women & Equalities Committee, published in March 2023, suggests some measures are already being taken by Health Education England to improve cultural competence and address racism in maternal care. But training staff to improve “cultures of kindness” and to “listen and make sure women are heard” will not be enough to fully address the complex causes of these disparities in black maternal health.</p>
<p>Current NHS strategies such as <a href="https://onlinelibrary.wiley.com/doi/10.1111/1467-9566.13414">hiring more diverse staff</a> and rethinking <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8162667/">research priorities</a> are one step in the right direction. By having staff from more diverse backgrounds, there’s a greater likelihood they will be able to sympathise with patients and understand their experiences. Moreover, having more research which has included black patients will help healthcare staff better respond to the specific health needs of these patients.</p>
<p>But such strategies risk falling short if they are not explicitly aimed at <a href="https://www.weahsn.net/news/black-maternity-matters-pilot-evaluation">targeting systemic racism</a> and prejudice in the NHS. </p>
<p>For maternal mortality, midwifery training needs to directly challenge the racist stereotypes that drive some healthcare staff to deny the credibility of others’ testimonies. Gynaecology and obstetric researchers must proactively include black women in their studies to ensure their distinctive needs and concerns are met. This may in turn improve medical care for <a href="https://committees.parliament.uk/publications/38989/documents/191706/default/">women from all backgrounds</a>.</p><img src="https://counter.theconversation.com/content/204709/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian James Kidd does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A recent report found that black women are four times more likely to die while pregnant or just after childbirth, compared with white women.Ian James Kidd, Assistant Professor of Philosophy, University of NottinghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2029772023-04-19T14:16:04Z2023-04-19T14:16:04ZRahima Moosa: South Africa’s only mother and child hospital is falling apart - a veteran doctor reflects on why<figure><img src="https://images.theconversation.com/files/520758/original/file-20230413-28-483g5a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source"> Papi Morake/ Gallo Images via Getty Images</span></span></figcaption></figure><p><em>South Africa’s health ombudsman <a href="https://healthombud.org.za/wp-content/uploads/2023/03/Investigation-Report-into-allegations-against-Rahima-Moosa-Mother-and-Child.pdf">recently published</a> the findings of an investigation into Rahima Moosa Mother and Child Hospital. The investigation followed the publication of a <a href="https://www.news24.com/news24/SouthAfrica/News/watch-pregnant-women-sleeping-on-the-floor-at-joburg-hospital-20220402?s=08">video</a> showing pregnant women lying on the hospital floor, as well as complaints by patients’ family members. The ombudsman’s investigation produced shocking findings, including severe overcrowding and staff shortages at the facility. There haven’t been any substantial upgrades to the hospital since it was built 80 years ago.</em> </p>
<p><em>Laetitia Rispel has been researching health policy and systems for over 20 years. She asked <a href="https://www.thepresidency.gov.za/national-orders/recipient/prof-yosuf-%E2%80%9Cjoe%E2%80%9D-veriava">Professor Emeritus Yosuf “Joe” Veriava</a> – who has been involved in South Africa’s healthcare system for more than half a century and is a recipient of the Order of Luthuli in silver for his contribution to the medical profession in South Africa – about the report.</em></p>
<hr>
<p><strong>Laetitia Rispel:</strong> What did you find most disturbing about the report? Who should be held accountable? </p>
<p><strong>Yosuf Veriava:</strong> I spent most of my student or training years there in the late 1960s. Seeing the problems that are occurring now is very sad. </p>
<p>What I found particularly disturbing is the failure in providing appropriate, effective and efficient leadership. </p>
<p>At first glance I thought the only person to blame was the CEO. But the Gauteng provincial department of health is just as responsible. The department was involved in the appointment of the CEO. It was also the department that gave the CEO permission to work from home. I find this very problematic because the CEO of a hospital cannot work from home. The CEO could be needed at any time during working hours.</p>
<p>The CEO herself should be held responsible. And the Gauteng department of health must take some responsibility.</p>
<p><strong>Laetitia Rispel:</strong> In your opinion, what factors have contributed to the hospital’s current state?</p>
<p><strong>Yosuf Veriava:</strong> There are many. </p>
<p>First of all, it is the heavy patient burden. The hospital has a <a href="https://healthombud.org.za/wp-content/uploads/2023/03/Investigation-Report-into-allegations-against-Rahima-Moosa-Mother-and-Child.pdf#page=18">large catchment area</a>. And within it, many of the people are of a lower social economic group and clearly their disease profile is not of the best. </p>
<p>This is the only mother and child hospital in South Africa, providing care for a very large number of women and children. In theory the hospital should be treasured, but the large patient numbers and high burden of care have a negative impact on the hospital.</p>
<p>Rahima Moosa Hospital delivers around 15,000 babies every year, which is the second highest number of babies in the country after Chris Hani Baragwanath Hospital (which is known as <a href="https://www.chrishanibaragwanathhospital.co.za/">Africa’s biggest hospital</a>). But the total staff complement is 1,200, and health professionals (doctors, nurses, pharmacists and rehabilitation therapists) account for 65% (780). Hence, the staff-to-patient ratio is low, even when compared to hospitals of a similar size. </p>
<p>Another aspect is the age of the hospital. The hospital <a href="https://www.youtube.com/watch?v=OYDhTpC6V-w">is as old</a> as I am – 80.</p>
<p>When I was at Coronation (the hospital’s old name) it was in reasonable shape. Not as good as the hospitals catering for white patients. But it was well kept. </p>
<p>When you have such an old hospital, there is a natural process of decay and this was not catered for. This points to the public works department failing to keep up with the decaying processes, and the maintenance of the hospital. </p>
<p><strong>Laetitia Rispel:</strong> What should be done to turn the situation around?</p>
<p><strong>Yosuf Veriava:</strong> It is the government that should be doing something about sorting this out. There are in fact recommendations that come out of the ombud’s report. These need immediate attention. </p>
<p>There have been concerns about public sector hospitals in general. And there have been various types of interventions.</p>
<p>In 2013, when I was professor emeritus of medicine at the University of the Witwatersrand, I was involved in a legal intervention to make a difference. We wanted to take the then health minister, Dr Aaron Motsoaledi, to court to compel him to take action. </p>
<p>While we were trying to bring the challenge to court, the minister said we should have discussions. These were held with the university as well as the minister’s office. The discussions resulted in an agreement on a turnaround strategy.</p>
<p>While this was positive and helped sort out the university-linked hospitals, it did nothing for the other state hospitals. </p>
<p>The other hospitals have received quite a bit of <a href="https://www.iol.co.za/pretoria-news/news/disturbing-number-of-public-hospital-patients-have-died-due-to-negligence-e623f9b9-4801-446f-af91-51246800ae77">publicity</a>.</p>
<p>There have been other attempts at interventions. One includes the drawing up of the <a href="https://www.gov.za/speeches/president-cyril-ramaphosa-signing-presidential-health-compact-25-jul-2019-0000">Presidential Health Compact</a>. While there was a lot of hype about the meeting with the president and the health compact, nothing much has happened and the hospitals remain the way they were. </p>
<p>So things get raised, but we don’t have any action. </p>
<p><strong>Laetitia Rispel:</strong> What should be done to ensure a capable and functional public healthcare system in South Africa?</p>
<p><strong>Yosuf Veriava:</strong> We can sort out all the hospitals. But the outcomes aren’t just going to improve suddenly.</p>
<p>Without sorting out the marked inequity in our country we will not make any major gains in improving health outcomes. There are many experts who believe that without sorting out various social and economic determinants we won’t have a very healthy society. So that’s the first point to make.</p>
<p>We are sending students to Cuba to try to facilitate the establishment of a health system based on primary healthcare. But our infrastructure here is not conducive to that. Hence, we should improve the primary healthcare system to cater for illnesses that can be seen at that level, which would take some of the extreme load from public sector hospitals.</p>
<p>We can look at improving hospitals but we also need to look at how to improve health outcomes.</p><img src="https://counter.theconversation.com/content/202977/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laetitia Rispel holds a SARChI Chair at Wits University and receives funding from the National Research Foundation.
</span></em></p>Rahima Moosa Hospital caters for a very large number of women and children. The large patient numbers and high burden of care have a negative impact on the hospital.Laetitia Rispel, Professor of Public Health and DST/NRF Research Chair., University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2005562023-03-16T14:48:24Z2023-03-16T14:48:24ZKenya introduced free maternal health services a decade ago - it’s been a success, saving lives<figure><img src="https://images.theconversation.com/files/515113/original/file-20230314-3891-vmz4q8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Kenya has seen an overall improvement in maternal and newborn health outcomes.</span> <span class="attribution"><span class="source">Belen B Massieu/Shutterstock</span></span></figcaption></figure><p>Maternal and newborn deaths are a major public health problem in Kenya. <a href="https://www.who.int/publications/i/item/9789240068759">In 2020 the maternal mortality ratio was 530 deaths per 100,000 live births</a>. This is much higher than the <a href="https://www.who.int/publications/i/item/9789240068759">global average of 223 maternal deaths per 100,000 live births</a>. The ratio of babies who die in the first month of life (neonatal deaths) is also higher than the global average. <a href="https://dhsprogram.com/pubs/pdf/PR143/PR143.pdf">Kenya’s neonatal death rate is 21 deaths per 1,000 live births</a>. The <a href="https://data.unicef.org/topic/child-survival/neonatal-mortality/">global rate</a> is 18 deaths per 1,000. </p>
<p>Most of these deaths can be prevented if women receive maternal health services. These include care during pregnancy and skilled attendants during childbirth. The World Health Organization has recognised that user fees are a major barrier to care like this.</p>
<p>To provide more women with healthcare during pregnancy and childbirth, Kenya introduced free maternity health services in 2013. The programme – known as <a href="https://www.nhif.or.ke/wp-content/uploads/2021/09/Linda_Mama_Brochure.pdf"><em>Linda mama</em></a> – consists of a package of benefits. The benefits include antenatal care, attended delivery and outpatient care for infants up to nine months. This programme is a step towards universal health coverage for Kenya. </p>
<p>Pregnant women can use these services at a range of healthcare facilities including those run by the government, faith-based organisations, nongovernmental organisations, or private providers. Women with alternative medical insurance are excluded from the service.</p>
<p>In our <a href="https://link.springer.com/article/10.1007/s10198-023-01575-w">recent study</a> we wanted to show the impact of this policy. We focused on: neonatal deaths; skilled birth attendants; and children born with low birth weight. Further, we presented the cost-benefit analysis of the free maternity policy. Estimating the policy’s contribution is important to guide its sustainable funding through budgeting.</p>
<p>We found an overall improvement in maternal and newborn health outcomes. More women – especially poor women – are now able to access maternal care. And the net benefits of the policy were much greater than the costs. Further investment into the free maternity policy could potentially avert even more maternal and neonatal deaths. </p>
<h2>Our study</h2>
<p>We used data from Kenya’s demographic health survey to evaluate the impact of the free maternity care policy on a key set of indicators. We compared the rates before and after the start of the policy. The indicators we focused on were: </p>
<ul>
<li><p><strong>early neonatal mortality (dying within the first seven days of life):</strong>
Our study showed that the probabilities of birth resulting in early neonatal mortality after the implementation of the policy were significantly reduced by 21 percentage points from <a href="https://dhsprogram.com/pubs/pdf/fr308/fr308.pdf">22 deaths per 1,000 live births</a> in the period before the policy was implemented to <a href="https://link.springer.com/article/10.1007/s10198-023-01575-w">approximately 17.4 deaths per 1,000 live births after the policy was implemented</a>. This reduction shows the investments in public health initiatives (such as free maternity care and possibly free primary care), improved access to water and sanitation are bearing fruits. </p></li>
<li><p><strong>neonatal mortality (dying within the first 28 days of life):</strong> The probabilities of birth resulting in neonatal mortality were significantly reduced by 20 percentage points. As with early neonatal mortality, this contributed to the reduction from <a href="https://dhsprogram.com/pubs/pdf/fr308/fr308.pdf">22 deaths per 1,000 live births</a> in the period before the policy was implemented to <a href="https://link.springer.com/article/10.1007/s10198-023-01575-w">approximately 17.6 deaths per 1,000 live births after the policy was implemented</a>. </p></li>
<li><p><strong>skilled birth attendance:</strong> Our study shows that the probability of skilled birth attendance increased by 16 percentage points. This was not statistically significant because while some of the improvements could have been due to the free maternity policy, the remainder of the effect is possibly attributed to other mechanisms such as quality of care (neonatal and maternal), availability of antenatal care and identification of possible complications earlier on in pregnancy, which need to be explored in the future. Though not significant, it also plausibly shows that many women who were not accessing maternal care before the policy could consequently be accessing it as a result. In the five years before the free maternity policy <a href="https://dhsprogram.com/pubs/pdf/fr308/fr308.pdf">61.8% of all births</a> were attended by a skilled health professional. <a href="https://dhsprogram.com/pubs/pdf/PR143/PR143.pdf">Currently, 89.3% of all births now have skilled birth attendance</a>. </p></li>
<li><p><strong>low birth weight:</strong> Our study shows that the probability of a child having low weight at birth increased by 4.4 percentage points. This was also not statistically significant. The prevalence of newborn babies with <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0248417">low birth weight prior to the free maternity policy was 6.89%.</a>.</p></li>
</ul>
<p>We also did a limited cost–benefit analysis to assess the net social benefit of the free maternity policy. We used the most appropriate cost-effectiveness indicators (cost vis-a-vis effectiveness) and compared the annual cost of implementing the policy to the average annual per neonatal death averted. </p>
<p>With the policy shown to have resulted to on average 4,015 fewer neonatal deaths after its implementation, the cost-to-benefit ratio of the policy was 21.22. The net benefits received from the policy were 21 times higher than the cost. This shows that the free maternity policy is associated with a high return to the country. Policymakers need to look at ways of further expanding and sustainably funding the free maternity policy for even better outcomes.</p>
<h2>Way forward</h2>
<p>The reduction in early neonatal and neonatal mortality and increase in skilled delivery brought on by the policy can be maintained if more women are encouraged to give birth in health facilities. This can be done by promoting awareness of the policy and the benefits package. </p>
<p>The government must address the health system challenges that could hamper the policy’s positive impact. The challenges include health worker shortages, increased workload and shortages of drugs. </p>
<p>In addition, more facilities should be accredited to provide free maternity services. This will address the issue of people having to travel long distances to access the free maternity benefits.</p><img src="https://counter.theconversation.com/content/200556/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Boniface Oyugi works for/consults to the World Health Organisation Regional Office for Africa.</span></em></p>User fees is a major barrier to healthcare, including maternal and newborn care in Kenya.Boniface Oyugi, Health Policy and Health Economics researcher and a Honorary Researcher at the Centre for Health Services Studies, University of KentLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1939092022-11-30T13:35:39Z2022-11-30T13:35:39ZMore than 4 in 5 pregnancy-related deaths are preventable in the US, and mental health is the leading cause<figure><img src="https://images.theconversation.com/files/498087/original/file-20221129-14-ezp753.jpg?ixlib=rb-1.1.0&rect=27%2C27%2C4524%2C3064&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">According to the CDC's latest numbers, 65% of pregancy-related deaths occur in the first year following childbirth.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/a-young-woman-holds-her-newborn-baby-in-a-safety-royalty-free-image/834822152">Petri Oeschger/Moment via Getty Images</a></span></figcaption></figure><p>Preventable failures in U.S. maternal health care result in far too many pregnancy-related deaths. Each year, approximately <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/preventing-pregnancy-related-deaths.html#">700 parents die from pregnancy and childbirth complications</a>. As such, the U.S. maternal mortality rate is <a href="https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries">more than double </a> that of most other developed countries.</p>
<p>The Department of Health and Human Services declared maternal deaths a <a href="https://www.hhs.gov/sites/default/files/call-to-action-maternal-health.pdf">public health crisis</a> in December 2020. Such calls to action by the U.S. Surgeon General are reserved for only the most serious of public health crises.</p>
<p>In October 2022, the Centers for Disease Control and Prevention released new data <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html">gathered between 2017 and 2019</a> that further paints an alarming picture of maternal health in the U.S. The report concluded that a staggering <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/docs/pdf/Pregnancy-Related-Deaths-Data-MMRCs-2017-2019-H.pdf">84% of pregnancy-related deaths are preventable</a>. </p>
<p>However, these numbers don’t even reflect how widespread this problem could be. At present, only 39 states have <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/docs/pdf/Pregnancy-Related-Deaths-Data-MMRCs-2017-2019-H.pdf">dedicated committees in place</a> to review maternal deaths and determine whether they were preventable; of those, 36 states were included in the latest CDC data.</p>
<p>I am a <a href="https://www.adler.edu/programs/rachel-diamond/">therapist and scholar</a> specializing in mental health during the perinatal period, the time during pregnancy and postpartum. Research has long demonstrated <a href="https://www.mmhla.org/wp-content/uploads/2020/07/MMHLA-Main-Fact-Sheet.pdf">significant mental health risks</a> associated with pregnancy, childbirth and the year following childbirth. The CDC’s report now makes it clear that mental health conditions are an important factor in many of these preventable deaths.</p>
<h2>A closer look at the numbers</h2>
<p>The staggering number of preventable maternal deaths – 84% – from the CDC’s most recent report represents a 27% increase from the agency’s previous report, <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/mmr-data-brief_2019-h.pdf">from 2008 to 2017</a>. Of these pregnancy-related deaths, 22% occur during pregnancy, 13% during childbirth and 65% during the year following childbirth.</p>
<p>This raises the obvious question: Why are so many preventable pregnancy-related deaths occurring in the U.S., and why is the number rising?</p>
<p>For a pregnancy-related death to be <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/docs/pdf/Pregnancy-Related-Deaths-Data-MMRCs-2017-2019-H.pdf">categorized as preventable</a>, a maternal mortality review committee must conclude there was some chance the death could have been avoided by at least one reasonable change related to the patient, community, provider, facility or systems of care. </p>
<p>The <a href="https://www.cdcfoundation.org/sites/default/files/upload/pdf/MMRIAReport.pdf">most commonly identified factors</a> in these preventable deaths have been those directly related to the patient or their support networks, followed next by providers and systems of care. While patient factors may be most frequently identified, they are often dependent on providers and systems of care.</p>
<p>Take, for instance, the example of a new mother dying by suicide from a mental health condition, such as depression. Patient factors could include her lack of awareness about the warning signs of clinical depression, which she may have mistaken for difficulties with the transition to parenthood and perceived personal failures as a new parent. </p>
<p>As is often the case, these factors would have directly related to the inaction of health care providers, such as a failure to screen for mental health concerns, delays in diagnosis and ineffective treatment. This type of breakdown – which is common – would have been made worse by poor coordination of care between providers across the health care system.</p>
<p>This example illustrates the complexities of the failures and preventable outcomes in the maternal health care system. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/ARNKVrWFDvc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The U.S. has a far higher rate of pregnancy-related deaths than other developed nations.</span></figcaption>
</figure>
<h2>The role of mental health</h2>
<p>In the CDC’s latest report, mental health conditions are the overall <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html">most frequent cause of pregnancy-related death</a>. Approximately 23% of deaths are attributed to suicide, substance use disorder or are otherwise associated with a mental health condition. The next two leading causes are hemorrhage and cardiac conditions, which combined contribute to only slightly more deaths than mental health conditions, at about 14 and 13%, respectively.</p>
<p>Research has long shown that <a href="https://doi.org/10.1001/jamapsychiatry.2013.87">1 in 5 women</a> suffer from mental health conditions during pregnancy and the postpartum period, and that this is also a time of <a href="https://doi.org/10.1016/j.ajog.2016.03.040">increased risk for suicide</a>. Yet, mental illness – <a href="https://doi.org/10.1542/peds.2010-2348">namely, depression</a> – is the most underdiagnosed obstetric complication in America. Despite some promising reductions in U.S. suicide rates in the general population over the last decade, <a href="https://doi.org/10.1001/jamapsychiatry.2020.3550">maternal suicide has tripled</a> during this same time period.</p>
<p>As it relates to maternal substance use, this issue is also worsening. In recent years, almost all deaths from drug overdose during pregnancy and the postpartum period involved opioids. A review from 2007 to 2016 found that pregnancy-related deaths <a href="https://doi.org/10.1016/j.ajog.2018.09.028">involving opioids more than doubled</a>. </p>
<p>Many of these issues stem from the fact that up to 80% of women with maternal mental health concerns are <a href="https://www.themotherhoodcenter.com/blogindex/2022/6/23/what-are-perinatal-mood-and-anxiety-disorders-pmads#">undiagnosed or untreated</a>. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1596594644309012480"}"></div></p>
<h2>Barriers to care</h2>
<p>In 2021, the first national data set of its kind showed that <a href="https://www.2020mom.org/blog/2022/11/14/us-maternal-depression-screening-rates-released-for-the-first-time?emci=d266ca19-ae66-ed11-ade6-14cb65342cd2&emdi=726c140a-d666-ed11-ade6-14cb65342cd2&ceid=8668229">less than 20% </a> of prenatal and postpartum patients were screened for depression. Only half of those who screened positive received follow-up care.</p>
<p>Research has long demonstrated widespread <a href="https://www.issuelab.org/resources/40013/40013.pdf">barriers and gaps</a> in maternal mental health care. Many health care providers do not screen for mental health concerns because they do not know where to refer a patient or how to treat the condition. In addition, only about <a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care">40% of new mothers</a> even attend their postpartum visit to have the opportunity for detection. Non-attendance is more common among <a href="https://web.s.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=0&sid=aa757e01-7bbb-4387-9f50-ee7cfd726f00%40redis">higher-risk populations of postpartum women</a>, such as those who are socially and economically vulnerable and whose births are covered by Medicaid. </p>
<p>Medicaid covers around <a href="https://www.cdc.gov/nchs/products/databriefs/db387.htm#section_3">4 in 10 births</a>. Through <a href="https://americanpregnancy.org/healthy-pregnancy/planning/medicaid-for-pregnant-women/">Medicaid benefits</a>, pregnant women are covered for care related to pregnancy, birth and associated complications, but only up to 60 days postpartum. Not until 2021 did the <a href="https://www.kff.org/policy-watch/postpartum-coverage-extension-in-the-american-rescue-plan-act-of-2021/">American Rescue Plan Act</a> begin extending Medicaid coverage up to one year postpartum. </p>
<p>But as of November 2022, only <a href="https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/">27 states</a> have adopted the Medicaid extension. In the other states, new mothers lose postpartum coverage after just 60 days. This matters a great deal because low-income mothers are at a <a href="https://doi.org/10.1542/peds.2010-2348">greater risk for postpartum depression</a>, with reported rates as high as 40% to 60%. </p>
<p>In addition, the recent CDC report showed that 30% of preventable pregnancy-related deaths happened between 43 and 365 days postpartum – which is also the time frame <a href="https://www.cdcfoundation.org/sites/default/files/upload/pdf/MMRIAReport.pdf">suicide most commonly occurs</a>. Continued Medicaid expansion would reduce the number of uninsured new parents and <a href="https://ccf.georgetown.edu/wp-content/uploads/2021/09/maternal-health-and-medex-final.pdf">rates of maternal mortality</a>. </p>
<p>Another challenging barrier to addressing maternal mental health is the criminalization of substance use during pregnancy. If seeking care exposes a pregnant person to the <a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2011/01/substance-abuse-reporting-and-pregnancy-the-role-of-the-obstetrician-gynecologist">possibility of criminal or civil pentalties</a> – including incarceration, involvement with child protective services and the prospect of separation from their baby – it will naturally dissuade them from seeking treatment. </p>
<p>At this time, 24 states consider <a href="https://www.guttmacher.org/state-policy/explore/substance-use-during-pregnancy">substance use during pregnancy to be child abuse</a>, and 25 states require health care professionals to report suspected prenatal drug use. Likewise, there are also tremendous barriers in the postpartum period for mothers seeking substance use treatment, due in part to the lack of <a href="https://doi.org/10.1111/famp.12501">family-centered options</a>. </p>
<p>With all these barriers, many pregnant and new mothers may make the difficult decision to not engage in treatment during a critical window for intervention.</p>
<h2>Looking ahead</h2>
<p>While the information described above already paints a dire picture, the CDC data was collected prior to two major events: the COVID-19 pandemic and the <a href="https://theconversation.com/roe-overturned-what-you-need-to-know-about-the-supreme-court-abortion-decision-184692">fall of Roe v. Wade</a>, which overturned nearly 50 years of abortion rights. Both of these events have <a href="https://www.axios.com/2022/07/05/maternal-mortality-death-abortion-ban-roe">exacerbated existing cracks</a> in the health care system and, subsequently, worsened the <a href="https://www.gao.gov/assets/730/723432.pdf">maternal health in the U.S.</a> </p>
<p>In my view, without radical changes to maternal health care in the U.S., starting with how mental health is treated throughout pregnancy and postpartum, it’s likely parents will continue to die from causes that could otherwise be prevented.</p><img src="https://counter.theconversation.com/content/193909/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachel Diamond does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many of the preventable pregnancy-related deaths documented by the CDC are directly attributable to failures and barriers in the maternal care system.Rachel Diamond, Clinical Training DIrector and Assistant Professor of Couple and Family Therapy, Adler UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1865742022-07-18T13:49:42Z2022-07-18T13:49:42ZNigeria’s large, youthful population could be an asset or a burden<figure><img src="https://images.theconversation.com/files/473194/original/file-20220708-21-ts9vsb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nigeria's large population of young people may become a burden if not healthy and well educated.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/vendor-carries-nigerian-national-flags-on-october-1-2015-as-news-photo/490811636?adppopup=true">Pius Utomi Ekpei/AFP via Getty Images </a></span></figcaption></figure><p>With a population estimated at <a href="https://guardian.ng/business-services/industry/nigerias-population-now-206m-says-npc/">206 million in 2020</a>, Nigeria is the most populous country in Africa and <a href="https://www.worldometers.info/world-population/">seventh in the world</a>.</p>
<p>The country’s <a href="https://drive.google.com/file/d/1_LqDbc249sq_bo_Cmpa8VSZBmk8fHJSj/view">population is growing at 2.6% a year</a>, one of the fastest rates globally. At this rate, Nigeria’s population could double within the next 25 to 30 years. </p>
<p>Nigeria’s population structure is potentially an economic asset. The country has the largest <a href="https://www.worldometers.info/world-population/nigeria-population/">population of youth</a> in the world, with a median age of 18.1 years. <a href="https://www.worldometers.info/world-population/nigeria-population/">About</a> 70% of the population are under 30, and 42% are under the age of 15. </p>
<p>The size and youthfulness of the population offer great potential to expand Nigeria’s capacity as the regional economic hub of Africa and globally. A young, large population could be an economic asset because population growth and urbanisation go together and <a href="https://blogs.worldbank.org/africacan/can-rapid-population-growth-be-good-for-economic-development">economic development is closely correlated with urbanisation</a>. Population growth increases density and, together with rural-urban migration, creates higher urban agglomeration. This can help companies in producing goods in larger numbers and more cheaply, serving a larger number of low-income customers. </p>
<p>But the potential needs to be properly harnessed. Leaders must invest (through health and education) and adopt strong policies to create an environment where this human resource is used optimally. Such was the case among the Asian Tiger countries, which invested massively in technology, infrastructure and education.</p>
<p>Nigeria is, by every measure of socioeconomic progress, failing to develop its endowment of young people. Millions of young people have a poor quality of life, including a lack of education, low living standards and poor health outcomes. </p>
<p>Nigeria is not reaping the benefits of its current population structure and must do more to mitigate the negatives. A large population of unskilled, economically unproductive, unhealthy and poorly educated young people is also a burden to society.</p>
<h2>Poor human development</h2>
<p>Nigeria was ranked 158 of 185 countries in the <a href="https://hdr.undp.org/sites/default/files/Country-Profiles/NGA.pdf">2019 Human Development Index</a>. A <a href="https://www.worldbank.org/en/news/press-release/2022/03/21/afw-deep-structural-reforms-guided-by-evidence-are-urgently-needed-to-lift-millions-of-nigerians-out-of-poverty#:%7E:text=According%20to%20the%20report%2C%20which,below%20the%20national%20poverty%20line.">2022 World Bank report</a> also says about 40% of Nigerians live below the national poverty line of U$1.90 per day and about 95.2 million are in poverty. About <a href="https://www.premiumtimesng.com/agriculture/agric-news/516720-19-4-million-nigerians-to-face-food-insecurity-by-august-2022-fao.html">19.4 million Nigerians</a> are likely to face food insecurity in 2022. </p>
<p>According to <a href="https://www.unicef.org/nigeria/education">UNICEF</a>, Nigeria accounts for 20% of the world’s children who are out of school. In absolute terms, about 10.5 million children, the majority of whom are girls, do not have access to education in Nigeria.</p>
<p><a href="https://nigerianstat.gov.ng/elibrary/read/856">Unemployment is high at 33.3%</a>. Most of those who are unemployed are women and young people. Of those with jobs, over 20% are underemployed as they don’t earn enough.</p>
<h2>Health indicators</h2>
<p>Most of the health indicators in Nigeria are disturbing. Health is key for human development and this means that Nigeria is lagging behind in development.</p>
<p>Health facilities are at sub-optimal levels. Nigerians <a href="https://www.thelancet.com/action/showPdf?pii=S0140-6736%2821%2902488-0">currently</a> have a lower life expectancy (54 years) than many of their neighbours. The country’s burden of chronic and infectious diseases is high. While infectious diseases remain the primary causes of death in the country, <a href="https://www.afro.who.int/news/nigeria-fulfils-commitment-launches-plan-prevention-and-control-non-communicable-diseases">non-communicable diseases account for 3 out of every 10 deaths</a>.</p>
<p>While Nigeria is failing to develop her human capital, Nigerians are making more babies, adding to the potential burden.</p>
<h2>Fertility</h2>
<p>The national fertility rate stands at <a href="https://dhsprogram.com/pubs/pdf/SR264/SR264.pdf">about</a> 5 children per woman. There are regional variations. It is also lower in urban areas (4.5) than in rural areas (5.9); lower in the Southwest (3.9) than in the Northwest (6.6). In other words, poorer households are worse off, particularly those in the rural areas. Also, poor women and those with no or low education are disproportionately affected.</p>
<p>There were <a href="https://www.dhsprogram.com/pubs/pdf/FR359/FR359.pdf">20 adolescent mothers (aged 15-19) among every 100 adolescent girls </a> in Nigeria, with <a href="https://archpublichealth.biomedcentral.com/articles/10.1186/s13690-022-00789-3">wide variations</a> across states and regions. This is <a href="https://www.tandfonline.com/doi/full/10.3402/gha.v8.29745">among the highest in the world</a> and is associated with high risk births, adverse social-economic consequences, limited opportunities and a likely pathway to <a href="http://www.ghheadlines.com/agency/ghana-news-agency/20191112/132518617/adolescent-parenthood-escalates-generational-poverty-nigerian-professor">intergenerational poverty</a>. </p>
<p>The unmet need for modern contraception has been estimated at <a href="https://dhsprogram.com/pubs/pdf/SR264/SR264.pdf">over 20%</a>. Modern contraceptives help to prevent unwanted pregnancy. This is imperative for improving maternal and child health. A lack of access to contraception perpetuates the high maternal and infant mortality, and high fertility in the country.</p>
<p>Currently, the infant mortality <a href="https://data.unicef.org/country/nga/#/">is 72 deaths per 1,000 live births</a>. Maternal mortality is estimated at 512 maternal deaths per 100,000 live births. The national target is to reduce maternal mortality to 72 per 100,000 live births and zero deaths by 2030. </p>
<h2>High dependency</h2>
<p>Nigeria has a relatively high and growing population of dependants. This could put a strain on those who provide for them. Young people account for a bigger share of the dependants, a situation which will get worse unless there is a deliberate public policy to address high fertility.</p>
<p>The age structure of the population suggests that for every 100 people in the economically active age group (15-64), there are 86 dependants (under 15 and over 64). This compares with the <a href="https://www.worldeconomics.com/Country-Data/">78.1 average</a> for the African continent, 52 for South Africa.</p>
<p>There are <a href="https://data.worldbank.org/indicator/SP.POP.65UP.TO?end=2021&locations=NG&start=2021&view=bar">about 6 million people aged over 65</a>. Though this equates to only 3% of population, it is numerically larger than the population of some states in Nigeria. In 2020, <a href="https://www.statista.com/statistics/1203462/dependency-ratio-in-nigeria/#:%7E:text=In%202020%2C%20the%20elderly%20dependency,(15%20to%2064%20years).">the elderly dependency ratio in Nigeria stood at 5.1</a>. This means that there were about five people aged 65 years and older that depend on every 100 people of working age (15 to 64 years). This number of dependants, in addition to children, can reduce the capacity of the working age population to save and invest. </p>
<p>Other groups with high dependency in Nigeria are those with disabilities and the displaced. </p>
<p>The percentage of disabled Nigerians stands at <a href="https://drive.google.com/file/d/1_LqDbc249sq_bo_Cmpa8VSZBmk8fHJSj/view">about</a> 2.3%, comparable to <a href="https://www.tandfonline.com/doi/full/10.1080/09687599.2018.1556491">Ghana’s 3%</a>, but far less than <a href="https://www.google.com/search?q=percentage+of+disability+in+south+africa+population&oq=percentage+of+disability+in+south+africa+population&aqs=chrome..69i57.13625j0j7&sourceid=chrome&ie=UTF-8">South Africa’s 7.5%</a>. But Nigeria <a href="https://www.scidev.net/sub-saharan-africa/features/facts-figures-disabilities-in-developing-countries-1/">doesn’t have plans</a> for addressing the needs of its disabled.</p>
<p>The country is also home to <a href="https://data.unhcr.org/en/country/nga#_ga=2.105709184.2034587582.1657237059-239904064.1657237059">over 3 million internally displaced people</a> and <a href="https://data.unhcr.org/en/country/nga#_ga=2.105709184.2034587582.1657237059-239904064.1657237059">over 82,000 international refugees</a>, mostly from neighbouring countries.</p>
<h2>Demographic dividend</h2>
<p>Nigeria needs to balance population growth with economic prosperity. This makes it possible to achieve a demographic dividend – faster economic growth arising from a favourable population age structure and favourable social and economic policies. </p>
<p>Some countries in Asia including <a href="https://www.un.org/en/development/desa/population/events/pdf/expert/9/wang.pdf">China</a>, <a href="https://www.cgdev.org/blog/what-comes-after-demographic-dividend-east-asia-finding-out">Hong Kong</a>, <a href="https://www.files.ethz.ch/isn/99030/2005_06_East_Asian_Economic.pdf">South Korea</a> and <a href="https://www.files.ethz.ch/isn/99030/2005_06_East_Asian_Economic.pdf">Singapore</a> have benefited substantially from this. Nigeria should aim to make a transition to low birth and death rates. Government at all levels must invest towards addressing high fertility and mortality. </p>
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<strong>
Read more:
<a href="https://theconversation.com/nigerias-2022-census-is-overdue-but-preparation-is-in-doubt-177781">Nigeria's 2022 census is overdue but preparation is in doubt</a>
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<p>Nigerians need to embrace family planning and address some of the root causes of high fertility, including sociocultural factors. A reduction in fertility by one child per childbearing woman <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(12)60827-7.pdf">would lead to a 13% increase</a> in Nigeria’s GDP per capita in 20 years or a 25% increase over 50 years.</p>
<p>As stated in the <a href="https://drive.google.com/file/d/1_LqDbc249sq_bo_Cmpa8VSZBmk8fHJSj/view">population policy document</a>, Nigeria should aim to reduce fertility from the current 5.3% to 4.3% by 2030. Family planning should be available to all and there should be no maternal deaths by 2030.</p>
<p>Education is key to good health, empowerment, employment and peaceful societies. It offers the best return on investment. Graduates in sub-Saharan Africa earn <a href="https://documents1.worldbank.org/curated/en/442521523465644318/pdf/WPS8402.pdf">21% more than</a> those without tertiary education.</p>
<p>Nigeria must prioritise investment in education, health and infrastructure to harness the opportunities of its huge population. But Nigerians have a role to play too. They must make rational decisions and choices. These include choices about investment in quality of life, healthy living, fertility reduction and the empowerment of young people.</p><img src="https://counter.theconversation.com/content/186574/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>There is nothing to disclose.</span></em></p><p class="fine-print"><em><span>Akanni Ibukun Akinyemi does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Nigeria must prioritise investment in education, health and infrastructure to harness the opportunities of its huge population.Akanni Ibukun Akinyemi, Professor of Demography and Social Statistics., Obafemi Awolowo UniversityJacob Wale Mobolaji, Lecturer, Demography and Social Statistics, Obafemi Awolowo UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1812822022-05-04T14:32:01Z2022-05-04T14:32:01ZMost maternal deaths are preventable: how to improve outcomes in South Africa<figure><img src="https://images.theconversation.com/files/459322/original/file-20220422-22-egvfdt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Maternal care should be respectful and dignified.</span> <span class="attribution"><span class="source">GettyImages</span></span></figcaption></figure><p><em>The past 20 years have seen a significant decline in maternal mortality rates <a href="https://data.unicef.org/topic/maternal-health/maternal-mortality/#:%7E:text=From%202000%20to%202017%2C%20the,reduction%20of%202.9%20per%20cent">from 342 deaths to 211 per 100,000 globally </a>. But every day, more than <a href="https://data.unicef.org/topic/maternal-health/maternal-mortality/">800 women</a> around the world die from complications of pregnancy and childbirth, up to 42 days after delivery. Most of these deaths are preventable. For every maternal death, another <a href="https://data.unicef.org/topic/maternal-health/maternal-mortality/">20 women</a> suffer serious injuries, infections and disabilities related to pregnancy. Professors Salome Maswime and Lawrence Chauke explain the state of maternal health in South Africa and how it can be improved.</em> </p>
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<h2>How South Africa compares to other countries</h2>
<p>In low-income countries the maternal mortality rate in 2017 was 462/100,000 compared to <a href="https://www.who.int/news-room/fact-sheets/detail/maternal-mortality">11/100,000</a> in high-income countries. In Western Europe rates are as low as five deaths per 100,000 births. Sub-Saharan Africa has 533 deaths per 100,000 births. </p>
<p>The risk of a woman dying from pregnancy-related complications was one in 5,400 in high-income countries, compared to <a href="https://www.who.int/news-room/fact-sheets/detail/maternal-mortality">one in 45</a> in low-income countries. </p>
<p>In West and Central Africa the maternal mortality rate is 674 per 100,000.
In South Sudan it is <a href="https://data.unicef.org/topic/maternal-health/maternal-mortality/#:%7E:text=Sub%2DSaharan%20Africans%20suffer%20from,maternal%20deaths%20per%20year%20worldwide.">1,150</a> and 1,140 in Chad.</p>
<p>South Africa has one of the lowest rates in Africa (113/100,000) but far higher than the UK (7/100,000). The rate in South Africa has declined from 150 deaths per 100,000 births in 1998 to 113 per 100,000 in 2019, according to the South African <a href="https://dhsprogram.com/publications/publication-fr131-dhs-final-reports.cfm">Demographic and Health Survey</a> and the National Confidential Enquiries for Maternal Deaths.</p>
<h2>Drivers of maternal mortality in South Africa</h2>
<p>The three leading causes of maternal deaths in South Africa are HIV-related infections, obstetric haemorrhage and hypertensive disorders of pregnancy.</p>
<p>Pre-existing medical conditions also account for a high proportion of pregnancy related complications in South Africa. Most deaths are still deemed as preventable. </p>
<p>A significant number of <a href="https://www.statssa.gov.za/?p=13100">South African women</a> attend at least four antenatal clinics (76%) and deliver in healthcare facilities (96%) under the care of a skilled birth attendant (97%).
Ideally these figures should translate into a much lower maternal
mortality rate. This means that there are still gaps and more work still needs to be done.</p>
<p>The biggest challenge is still late booking. Only <a href="https://www.statssa.gov.za/?p=13100">47%</a> of women booked during the first trimester in 2016. Between 2017-2019, 72% of the women who died had attended antenatal care. But only <a href="https://www.knowledgehub.org.za/system/files/elibdownloads/2021-06/SA%20MPNH%20Policy%2023-6-2021%20signed%20Web%20View%20v2.pdf">half</a> had booked before 20 weeks. </p>
<p>Delays in seeking antenatal care have been associated with a higher likelihood of having adverse pregnancy outcomes. </p>
<p>A very high percentage (90%) <a href="https://www.opensaldru.uct.ac.za/bitstream/handle/11090/613/2013_97.pdf?sequence=1">of South Africans live within 7km</a> of a health facility and 67% live within 2km of a healthcare facility. Despite this proximity women struggle to get timely transport to healthcare facilities. The situation is even worse for rural women due to poor road infrastructure and poor emergency referral systems. </p>
<p>Healthcare facilities offer different levels of care. <a href="https://www.hst.org.za/publications/District%20Health%20Barometers/DHB%202019-20%20Section%20A,%20chapter%201%20-%20Reproductive,%20maternal,%20newborn%20and%20child%20health.pdf#page=21">Most</a> deaths occur in district hospitals in South Africa, where specialist, critical care or efficient emergency medical services may not be readily available. Patients with complications don’t reach higher levels of care in good time. </p>
<p>Even when they have access to higher levels of care women face possible shortage of specialist, medical and nursing personnel in
addition to overcrowding. </p>
<p>A report done covering <a href="https://www.knowledgehub.org.za/system/files/elibdownloads/2021-06/SA%20MPNH%20Policy%2023-6-2021%20signed%20Web%20View%20v2.pdf">2017 to 2019</a> found that 80% of women who died, received substandard care at district hospitals. The figure was 60% for community healthcare centres and regional hospitals. Poor quality of care is therefore a major problem within the country’s healthcare system. The same report identified overcrowding, lack of resources, including shortage of nursing and medical personnel among the key drivers for the poor quality care. </p>
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<strong>
Read more:
<a href="https://theconversation.com/what-drives-abuse-of-women-in-childbirth-we-asked-those-providing-the-care-134465">What drives abuse of women in childbirth? We asked those providing the care</a>
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<p>Disrespectful maternal care is an issue too. The abuse in South African maternity services was described as <a href="http://www.samj.org.za/index.php/samj/article/view/9582/6634">“one of the world’s greatest disgraces”</a> in 2015. It included verbal and physical abuse, non-consensual care, non-confidential care, neglect and abandonment. In some facilities women <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-017-0411-5">said</a> they expect to be shouted at, beaten and neglected. </p>
<p>Maternal mortality is an indicator of access to care and quality of care. It is also indirectly linked to socioeconomic factors. Women who have access to education, proper housing and job opportunities are more likely to have good health outcomes compared to those who are not. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/the-role-of-bias-in-how-women-are-treated-during-childbirth-a-kenyan-case-study-152775">The role of bias in how women are treated during childbirth: a Kenyan case study</a>
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<p>Socio-demographic variables such as
“race” have also been <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-019-0729-2">linked</a> to how women are treated. </p>
<p>The attitudes of the healthcare workers towards patients has an impact on women’s health-seeking behaviour and delivery
of care by the healthcare workers (to the extent of delaying and withholding care).</p>
<h2>What can be done to improve outcomes?</h2>
<p>The first step is to meet the need for contraception to avoid unwanted and unplanned pregnancies. In 2012, 215 million women globally were estimated to have an <a href="https://www.prb.org/resources/unmet-need-for-contraception-fact-sheet/#:%7E:text=What%20Is%20Unmet%20Need%3F,are%20potential%20users%20of%20contraception.">unmet need for contraception</a>. </p>
<p>Health education and promotion at community level would encourage women to attend antenatal clinics and give birth in a health facility in the care of a skilled attendant.</p>
<p>Maternal care should be respectful and dignified.</p>
<p>Efficient transport and emergency medical services are needed so that women receive timely and appropriate care.</p>
<p>Stronger health systems would improve access to high quality obstetric care. Women survive complications of pregnancy and childbirth in <a href="https://www.sciencedirect.com/science/article/pii/S002072921630159X">functional health systems</a>, with efficient referral systems. There is an urgent need for a responsive healthcare system that takes into consideration population and disease trends. </p>
<p>There is also an urgent need to address the imbalance between demand and supply of healthcare services; improve the
social and economic status of women in society as well as the quality of maternal and reproductive healthcare services, to win the battle against maternal deaths.</p><img src="https://counter.theconversation.com/content/181282/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Salome Maswime receives funding from the South African Medical Research Council and UNICEF. </span></em></p><p class="fine-print"><em><span>Lawrence Chauke receives funding from SAMRC and Global Health Fund as part of research collaboration. </span></em></p>For every maternal death, there are about an additional 20 women who suffer serious injuries, infections and disabilities related to pregnancy.Salome Maswime, Professor of Global Surgery, University of Cape TownLawrence Chauke, Adjunct professor, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1676102021-09-22T12:55:59Z2021-09-22T12:55:59ZStudy shows an abortion ban may lead to a 21% increase in pregnancy-related deaths<figure><img src="https://images.theconversation.com/files/420920/original/file-20210913-25-107aakk.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1024%2C683&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Banning abortion can have health consequences for pregnant people.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/woman-carries-a-sign-declaring-abortion-a-part-of-news-photo/1235196693">Jordan Vonderhaar/Stringer via Getty Images News</a></span></figcaption></figure><figure class="align-center ">
<img alt="White text on green background stating '21%: Estimated increase in pregnancy-related deaths by the second year of a nationwide abortion ban in the US.'" src="https://images.theconversation.com/files/422479/original/file-20210921-25-1k8bj57.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/422479/original/file-20210921-25-1k8bj57.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=255&fit=crop&dpr=1 600w, https://images.theconversation.com/files/422479/original/file-20210921-25-1k8bj57.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=255&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/422479/original/file-20210921-25-1k8bj57.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=255&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/422479/original/file-20210921-25-1k8bj57.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=321&fit=crop&dpr=1 754w, https://images.theconversation.com/files/422479/original/file-20210921-25-1k8bj57.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=321&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/422479/original/file-20210921-25-1k8bj57.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=321&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p>A <a href="https://www.texastribune.org/2021/09/01/texas-abortion-clinic-follow-new-law/">new Texas law</a> bans nearly all abortions, and other states have indicated that they likely will <a href="https://www.nbcnews.com/news/us-news/just-beginning-after-texas-victory-anti-abortion-rights-activists-could-n1278492">follow suit</a>. But the research is clear that people who want abortions but are unable to get them can suffer a slew of <a href="https://www.ansirh.org/research/ongoing/turnaway-study">negative consequences for their health and well-being</a>. </p>
<p>As a <a href="https://scholar.google.com/citations?user=YTK30lUAAAAJ&hl=en&oi=ao">researcher who measures the effects of contraception and abortion policy on people’s lives</a>, I usually have to wait years for the data to roll in. But sometimes anticipating a policy’s effects before they happen can suggest ways to avoid its worst consequences.</p>
<p>In my forthcoming peer-reviewed paper, <a href="https://doi.org/10.31235/osf.io/sb5f2">currently available as a preprint</a>, I found that if the U.S. ends all abortions nationwide, pregnancy-related deaths will increase substantially because carrying a pregnancy to term can be deadlier than having an abortion.</p>
<h2>Pregnancy is riskier than abortion</h2>
<p>Banning abortion does not stop people from trying to end their pregnancies. But it won’t result in a return to the kinds of unsafe abortion that <a href="https://www.washingtonpost.com/politics/2019/05/29/planned-parenthoods-false-stat-thousands-women-died-every-year-before-roe/">killed hundreds of women per year</a> before the Supreme Court’s ruling Roe v. Wade legalized abortion in the U.S. </p>
<p>Recent advances in <a href="https://www.kff.org/womens-health-policy/fact-sheet/the-availability-and-use-of-medication-abortion/">medication abortion</a>, which relies on prescription drugs rather than a procedure, have made safer abortions outside of clinics possible. They set the stage for organizations like <a href="https://www.plancpills.org">Plan C</a> to help pregnant people safely <a href="https://www.plannedparenthood.org/learn/abortion/the-abortion-pill">manage their own abortions with pills</a> if they want or need to.</p>
<p>Staying pregnant, on the other hand, carries a greater risk of death for the pregnant person than having an abortion. Abortion is incredibly safe for pregnant people in the U.S., with <a href="http://dx.doi.org/10.15585/mmwr.ss6907a1">0.44 deaths per 100,000 procedures from 2013 to 2017</a>. In contrast, <a href="https://www.cdc.gov/nchs/data/hestat/maternal-mortality-2021/E-Stat-Maternal-Mortality-Rates-H.pdf">20.1 deaths per 100,000 live births occurred in 2019</a>. In the U.S., pregnancy-related deaths occur for <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm">many reasons</a>, including cardiovascular conditions, infections and hemorrhage caused or worsened by being pregnant or giving birth.</p>
<h2>One possible future with an abortion ban</h2>
<p>Policies like the <a href="https://news.trust.org/item/20201231112641-qfynt/">abortion bans sweeping the U.S.</a> may affect pregnancy-related deaths in several ways. In <a href="https://doi.org/10.31235/osf.io/sb5f2">my study</a>, I estimated a portion of the additional deaths that would be caused by a nationwide ban on all abortions.</p>
<p>To do this, I used published U.S. pregnancy and abortion death rates to project how many deaths would occur if all pregnancies that currently end in abortion were instead continued to miscarriage or term. My conservative estimate found that the annual number of pregnancy-related deaths would <a href="https://osf.io/preprints/socarxiv/sb5f2/">increase by 21% overall</a>, or 140 additional deaths, by the second year after a ban. </p>
<p>Among non-Hispanic Black woman, this percentage would increase 33%, causing 78 additional deaths and exacerbating the ongoing U.S. <a href="https://www.hsph.harvard.edu/magazine/magazine_article/america-is-failing-its-black-mothers/">Black maternal health crisis</a>. The pregnancy-related death rate for non-Hispanic Black women is about <a href="https://www.cdc.gov/nchs/data/hestat/maternal-mortality-2021/E-Stat-Maternal-Mortality-Rates-H.pdf">three times higher</a> than for non-Hispanic white women and Hispanic or Latino women, likely because of <a href="https://doi.org/10.1089/jwh.2020.8882">structural racism</a>, <a href="https://doi.org/10.1186/s12978-019-0729-2">biases in health care provision</a> and disparities in health care access, among other reasons.</p>
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<p>In reality, these figures could be higher. They do not account for the fact that <a href="https://doi.org/10.1363/46e0414">people having abortions</a> are on average <a href="https://doi.org/10.1097/AOG.0b013e31823fe923">less advantaged than people having births</a> and at a higher risk of pregnancy-related death. Nor do they include the risks of using less safe abortion methods.</p>
<h2>This possible future does not have to come true</h2>
<p>Projections always rely on assumptions about how the future will unfold – they are warnings, not predictions. My estimates describe how deaths would increase if everyone who currently has abortions instead carries their pregnancy to term.</p>
<p>But the federal government, other states and nongovernmental organizations could make state abortion bans less deadly. </p>
<p>The assumptions behind my projections show us how to prevent what I warn could happen. For example, effectively addressing the <a href="https://doi.org/10.26099/411v-9255">maternal health crisis</a> could make pregnancy safer and reduce pregnancy-related deaths. Helping people <a href="https://www.nbcnews.com/think/opinion/texas-abortion-crisis-proves-abortion-pill-needs-be-every-drug-ncna1278829">access safe medication abortion</a> and <a href="https://www.npr.org/sections/health-shots/2021/08/02/1022860226/long-drives-costly-flights-and-wearying-waits-what-abortion-requires-in-the-sout">travel across state lines</a> to get to an abortion clinic would reduce pregnancy-related deaths. And not banning abortion in the first place would reduce pregnancy-related deaths the most.</p><img src="https://counter.theconversation.com/content/167610/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amanda Jean Stevenson receives funding from the William and Flora Hewlett Foundation and the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Her statements do not represent those of her funders.</span></em></p>Carrying a pregnancy to term is riskier than having an abortion, especially for non-Hispanic Black women.Amanda Jean Stevenson, Assistant Professor of Sociology, University of Colorado BoulderLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1669912021-09-06T19:44:28Z2021-09-06T19:44:28ZHow Google Maps can help with efforts to tackle delays in accessing critical maternal health services<p>Every year, <a href="https://www.unfpa.org/sites/default/files/pub-pdf/Maternal_mortality_report.pdf">295,000 women die</a> from preventable causes related to pregnancy and childbirth globally. Nigeria accounts for an enormous <a href="https://www.unfpa.org/sites/default/files/pub-pdf/Maternal_mortality_report.pdf%20">23% of these deaths</a>. Each one is a needless tragedy, and preventing them should be a global priority.</p>
<p>How can we do so? Research has shown that prompt access to nine critical maternity services, together known as <a href="https://doi.org/10.1016/j.ijgo.2004.11.026">emergency obstetric care</a>, can reduce deaths of pregnant women by 15-50% and the deaths of their unborn children by 45-75%.</p>
<p>Pregnant women have a <a href="https://www.sciencedirect.com/science/article/pii/0277953694902267">higher risk of dying if they experience any of three delays</a> in accessing this care when they need it. These include a delay in deciding to seek care, a delay travelling to appropriate health facilities, or a delay in receiving the care they need when they get there.</p>
<p>In Nigeria, it’s the delay in travelling to receive care that is often the most deadly, with many women left to travel to health facilities either on their own or with support of their relatives, without professional help. This journey is thought of as a <a href="https://doi.org/10.1186/s12978-020-00996-7">“black box”</a> because unravelling what happened during their travel, including delays experienced while en route, can only be analysed after it is already too late.</p>
<h2>The promise of Google Maps</h2>
<p>What if we could <a href="https://gh.bmj.com/content/6/1/e004318">use Google Maps</a>, the most popular navigation app on earth, to help understand these delays? In a recently <a href="https://doi.org/10.1093/heapol/czab099">published study</a>, my colleagues and I assessed travel time to care for pregnant women in emergency situations using data from Google Maps.</p>
<p>We used the travel time estimates we found to assess the coverage of critical maternity services in Nigeria’s most urbanised state and the largest city in sub-Saharan Africa – Lagos.</p>
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<img alt="A satellite view of Lagos on Google Maps" src="https://images.theconversation.com/files/418913/original/file-20210901-17-2szf3p.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418913/original/file-20210901-17-2szf3p.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=451&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418913/original/file-20210901-17-2szf3p.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=451&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418913/original/file-20210901-17-2szf3p.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=451&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418913/original/file-20210901-17-2szf3p.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=567&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418913/original/file-20210901-17-2szf3p.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=567&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418913/original/file-20210901-17-2szf3p.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=567&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Google Maps data can help us understand pregnant women’s journeys to hospital for emergency care.</span>
<span class="attribution"><span class="source">Google Maps</span></span>
</figcaption>
</figure>
<p>Our results showed that for women who travelled directly to a hospital, travel time ranged from 2 to 240 minutes. For those who went there after a referral, travel time ranged from 7 to 320 minutes. Total travel time was within 60 minutes for 80% of pregnant women. The time of day and having been referred were both associated with travelling more than 60 minutes.</p>
<p>We identified three hotspots from which pregnant women travelled more than 60 minutes to public hospitals in Lagos. These areas were Alimosho/Ifako-Ijaiye, Eti-Osa and Ijanikin/Morogbo. In cases when a referral was required, we identified a fourth hotspot in the north of Ikorodu, where pregnant women required more than 60 minutes to arrive at a hospital that could provide the care they need.</p>
<h2>Eliminating hotspots</h2>
<p>Our findings indicate that these hotspots require government intervention to reduce delays in women accessing care. The Lagos state government already appears to be addressing one of these hotspots by <a href="https://businessday.ng/health/article/lagos-targets-1m-mothers-children-as-110-bed-mcc-opens-in-eti-osa/">building the Eti-Osa Maternal and Child Care Centre</a>.</p>
<p>Similar action is needed to address the Ijanikin/Morogbo hotspot, as there is currently no public hospital for about 30 km to the east and west of this cluster.</p>
<p>For Alimosho/Ifako-Ijaiye and north of Ikorodu, there are established public hospitals within these areas already and it appears the challenge might be their relative inaccessibility. In these areas, road expansion and repair and the improvement of referral systems could be effective ways to minimize travel time.</p>
<p>Our research reinforces existing evidence that <a href="https://doi.org/10.1186/s12978-020-00996-7">pregnant women face significant challenges</a> in accessing emergency care. Even in places that are expected to have the so called “urban advantage”, pregnant women in urgent situations still have to face traffic congestion, poor roads and slow referral systems.</p>
<p>For a pregnant woman in an emergency situation, delay can be a matter of life and death. If we are going to make progress in reducing maternal mortality, targeted actions that respond to local area-specific challenges like those recommended in our study will go a long way.</p><img src="https://counter.theconversation.com/content/166991/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Aduragbemi Banke-Thomas a reçu des financements de AXA Research Fund.</span></em></p>Using data from the popular navigation app, researchers have pinpointed the areas of Lagos, Nigeria, where emergency obstetric care is most needed.Aduragbemi Banke-Thomas, Research Fellow, London School of Economics and Political ScienceLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1639042021-07-09T10:13:31Z2021-07-09T10:13:31ZWhy Nigeria’s weak health system affects women and girls the most<figure><img src="https://images.theconversation.com/files/410383/original/file-20210708-13-1ep073o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Mothers wait with their babies to receive treatment at a dispensary .</span> <span class="attribution"><span class="source">ISSOUF SANOGO/AFP via Getty Images</span></span></figcaption></figure><p>Nigeria’s healthcare service delivery is very poor. It ranks among the worst globally in terms of access and quality. In 2018 it was ranked 142 out of 195 countries by the general medical journal, the <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30994-2/fulltext">Lancet</a>. The World Bank <a href="https://data.worldbank.org/indicator/SH.UHC.SRVS.CV.XD">ranks</a> it 42 on a scale of 100 in its universal coverage index, which indicates the availability of essential healthcare services in the participating countries.</p>
<p>Some of the reasons for the sub-optimal healthcare delivery are linked to the country’s <a href="https://worldpopulationreview.com/countries/nigeria-population">rapid population growth</a> from 122.2 million in 2000 to 211.4 million.</p>
<p>Other factors include poor funding – <a href="https://www.devex.com/news/sponsored/2-decades-on-nigeria-falls-short-of-landmark-health-pledge-99555">the government spends less than 5%</a> of its annual budget on health – and high attrition and <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-017-0205-4">migration of health workers</a>. </p>
<p>There is also inefficiency within the health system and systemic neglect of rural areas. A poor reward system and a trade union crisis – including prolonged industrial actions by health workers – and corruption complete the list. </p>
<p>Women, young girls and children are the <a href="https://dhsprogram.com/pubs/pdf/FR359/FR359.pdf">worst affected</a> by the poor health services. This is particularly true for those living in rural areas where the burden of disease is disproportionately high. </p>
<p>Some of the health indicators are very frightening. Nigeria <a href="https://www.who.int/reproductivehealth/maternal-health-nigeria/en/">accounts</a> for nearly 20% of global maternal deaths. It is also among the <a href="https://apps.who.int/iris/bitstream/handle/10665/327596/WHO-RHR-19.23-eng.pdf?sequence=13&isAllowed=y">five countries</a> with the highest maternal deaths. </p>
<p>The reasons for this state of affairs are threefold. The first is that there are major hurdles to accessing care, which has a knock-on effect on women accessing decent family planning services. The other major contributor is that the opportunities for girls to attend school are massively curtailed, particularly in northern Nigeria. Extended years in school have been shown to make a marked difference to the choices girls make in later life.</p>
<h2>Hurdles to accessing healthcare</h2>
<p>The average Nigerian woman or child faces a host of hindrances in accessing health services. </p>
<p>The first is cost. Although the country’s national healthcare policy provides a framework for access to basic healthcare, most Nigerians are still faced with out-of-pocket payment for health services. This is a major hindrance for most women from poor households. </p>
<p>The second is the patriarchal system that operates in Nigeria. This restricts women’s ability to make decisions about what money should be spent on, and also about their healthcare and that of their children. </p>
<p>Thirdly, women are also plagued with issues like <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-020-05700-w">transport, distance to health facilities</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/29669538/">poor health literacy and poverty</a>.</p>
<p>Fourth are bureaucracy delays within the health facilities and referral systems for those at high risk to access essential healthcare. </p>
<p>Fifth, there is the <a href="https://pubmed.ncbi.nlm.nih.gov/29669538/">poor attitude of health workers, and frequent industrial action</a>.</p>
<p>Sixth, there is a lack of essential drugs and equipment. </p>
<p>Seventh, corruption and poor infrastructure. </p>
<p>And lastly, inadequate capacity. <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-017-0205-4">There aren’t enough human resources to deliver essential health services</a>. There are only about two health workers available for every 1,000 people. </p>
<p>This inability to access healthcare has resulted in women not being able to access adequate family planning services. </p>
<h2>Having babies</h2>
<p>There is <a href="https://www.who.int/news-room/fact-sheets/detail/family-planning-contraception">overwhelming evidence</a> that if women access family planning services there are improvements in maternal and child health. It also <a href="https://www.prb.org/resources/family-planning-improves-the-economic-well-being-of-families-and-communities/">increases</a> the wellbeing of individuals, families and communities. </p>
<p>For example, family planning promotion has been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4642363/">identified</a> as a very important factor in addressing high-risk births.</p>
<p>But only about <a href="https://www.pmadata.org/sites/default/files/data_product_results/PMA2020-Nigeria-National-R3-FP-Brief.pdf">one-fifth</a> of Nigerian women are currently using a modern method of contraceptive and <a href="https://www.pmadata.org/sites/default/files/data_product_results/PMA2020-Nigeria-National-R3-FP-Brief.pdf">about 23%</a> said they had unmet needs for family planning while <a href="https://www.pmadata.org/sites/default/files/data_product_results/PMA2020-Nigeria-National-R3-FP-Brief.pdf">only 38%</a> were satisfied with the family planning method they used.</p>
<p>Over a quarter of childbearing mothers in Nigeria <a href="https://www.pmadata.org/sites/default/files/data_product_results/PMA2020-Nigeria-National-R3-FP-Brief.pdf">considered</a> their last birth as a product of unwanted pregnancy. </p>
<p>Nigeria also has a very large number of births among adolescent girls. It’s estimated that about one-fifth of adolescent girls have begun to have children. The adolescent fertility rate is <a href="https://dhsprogram.com/pubs/pdf/FR359/FR359.pdf">estimated</a> at 123 births per 1,000 for girls aged 15-19. <a href="https://dhsprogram.com/pubs/pdf/FR308/FR308.pdf">Kenya</a>’s comparative number is below 85.</p>
<p>The consequences are reflected in high-risk birth, intergenerational poverty and poor life skills. It is also <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-018-1859-1">reflected</a> in limited opportunities for the mothers and children.</p>
<h2>Education for girls</h2>
<p>Education is one of the major <a href="https://www.oecd.org/dac/gender-development/44843817.pdf">indicators</a> of women’s empowerment, particularly secondary school education. It enhances women’s health literacy skills and has been <a href="https://onlinelibrary.wiley.com/doi/10.1111/sifp.12156">identified</a> as a major factor in the uptake of family planning and child health care.</p>
<p>Only about 65% of girls compared with 71% of boys have a primary education. And only 39% of girls <a href="https://education.gov.ng/nigeria-digest-of-education-statistics/">completed junior secondary school</a> while 29% completed senior secondary school.</p>
<p>These indicators vary widely across the country and disproportionately affect those in the rural areas, particularly in northern Nigeria. </p>
<p>Some reasons for this gender disparity in educational attainment are poverty, gender apathy and discrimination against women. Others are religion, cultural factors and lack of government’s commitment to girl-child education.</p>
<p>Girl-child education is a fundamental human right, entrenched in the <a href="https://sdgs.un.org/goals/goal5">Sustainable Development Goals</a>. It enhances the socioeconomic status of the individual girls, family, and society at large. <a href="https://onlinelibrary.wiley.com/doi/10.1111/sifp.12156">Studies</a> have shown <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6320680/">that education improves</a> health literacy, decision making and childcare practices among women. </p>
<h2>Next steps</h2>
<p>The Nigerian government has made a <a href="https://www.familyplanning2020.org/nigeria">policy commitment</a> to achieve a modern contraceptive prevalence rate of 27% among all women by 2024. But this will only be achievable with more political commitment at the federal and sub-national levels. </p>
<p>A reduction in fertility of one child per woman in Nigeria <a href="https://pubmed.ncbi.nlm.nih.gov/22784535/">would lead</a> to a 13% increase in GDP per capita in 20 years, and 25% in 50 years. Current estimates by the Guttmacher Institute and Nigeria Family Planning Blueprint (2020-2024) say if <a href="https://www.guttmacher.org/fact-sheet/adding-it-up-contraception-mnh-nigeria">all unmet needs for modern contraception were met</a>, it would prevent 1.9 million unintended pregnancies, 685,000 unplanned births, 1.01 million unsafe abortions in Nigeria, 42,000 maternal deaths and 217,000 infant deaths per annum.</p>
<p>The government has made a commitment to strengthen collaboration with states, donors and other stakeholders on implementing an effective health insurance scheme to make household family planning expenditures reimbursable. </p>
<p>But there is a need for more financial commitment to increase the annual allocation for contraceptives by government at all levels. And there is the need to target adolescents with vulnerable socio-demographic profiles, particularly those in the rural areas in the northeastern and northwestern part of the country. </p>
<p>The government also needs to do a great deal more when it comes to educating Nigerian girls. Efforts to improve school attendance have been made, including the implementation of <a href="http://www.fao.org/faolex/results/details/en/c/LEX-FAOC169078/">Home-Grown School Feeding</a>. But there are limited – or no – government interventions at the national level to improve gender parity in education. </p>
<p>At sub-national level, there are some intervention programmes towards improving girl-child education, particularly in <a href="https://centreforgirlseducation.org/programs">Kaduna</a>, <a href="https://www.girlchildconcerns.org/education-sensitization/">Borno</a> and <a href="https://www.vanguardngr.com/2019/08/girl-child-education-a-cheery-intervention-by-maritime-academy/">Edo</a> States. However, their impact is minimal and further impaired by insecurity, political instability and corruption.</p>
<p>Investing in girls’ education will substantially contribute to increasing women’s contraceptive use, prevent unwanted pregnancies and improve maternal and child health.</p><img src="https://counter.theconversation.com/content/163904/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Akanni Ibukun Akinyemi does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The average Nigerian woman or child faces a host of hindrances in accessing health services.Akanni Ibukun Akinyemi, Professor of Demography and Social Statistics., Obafemi Awolowo UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1554932021-03-08T15:19:32Z2021-03-08T15:19:32ZSouth Africa needs to change direction on maternal health to solve child malnutrition<figure><img src="https://images.theconversation.com/files/387728/original/file-20210304-15-1plejga.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Children are eating too much poor nutrient quality food and too little of good nutrient quality food.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>When we think about nurturing healthy children, we need to adopt a life course approach to maternal nutrition. In other words, a woman’s health for the benefit of herself and her child must be prioritised early in life.</p>
<p>We know that poor nutrition during pregnancy and infancy has <a href="https://pubmed.ncbi.nlm.nih.gov/17200031/">long-term consequences</a> for that generation of infants – malnourished mothers, birth malnourished infants. Health and nutrition during this critical window has far-reaching consequences and casts a long shadow of the increased risk of ill-health such as diabetes, hypertension and cardio-vascular disease.</p>
<p>At a <a href="https://pubmed.ncbi.nlm.nih.gov/23541370/">public health level</a>, good health, mainly through good nutrition, contributes to the economic productivity and development of society by decreasing the costs of ill-health and ensuring a good healthy workforce.</p>
<p>So how healthy are South Africa’s children?</p>
<p>South Africa is classified as a <a href="https://data.worldbank.org/?locations=ZA-XT">middle-income country</a> and has high <a href="https://data.worldbank.org/indicator/SH.XPD.CHEX.PC.CD?locations=ZA">per capita spending</a> on health. Yet the nutritional status of South Africa’s children is deteriorating. While the number of children going hungry has reportedly <a href="http://www.ci.uct.ac.za/sites/default/files/image_tool/images/367/Child_Gauge/South_African_Child_Gauge_2020/ChildGauge_2020_screen_final.pdf">decreased</a>, access to energy-dense but low micronutrient-dense food is fuelling an increase in child overweight and obesity. </p>
<p>In 2018, 11% of children (2.1 million) lived in households that <a href="http://www.ci.uct.ac.za/sites/default/files/image_tool/images/367/Child_Gauge/South_African_Child_Gauge_2020/CG2020_CC_child%20nutrition.pdf">reported</a> child hunger. More than a quarter (27%) of children in South Africa are stunted – the most common manifestation of malnutrition.</p>
<p>Children are eating too much poor nutrient quality food and too little of good nutrient quality food. This profile illustrates the concept of hidden hunger or poor nutrition-security and demonstrates the insidious corruption that malnutrition meets out on children’s health and lives, now and into their futures.</p>
<p>If the country wants to change this, it needs to implement health and nutrition policies in girlhood and in the teen years.</p>
<p>Our <a href="http://www.ci.uct.ac.za/sites/default/files/image_tool/images/367/Child_Gauge/South_African_Child_Gauge_2020/CG2020_ch4_food%20and%20nutrition%20security%20of%20unborn%20child.pdf">paper</a>, written for an annual status report on South Africa’s children produced by the Children’s Institute at the University of Cape Town, argues that a child-centric food systems would reap benefits for society and for future generations. This food system would need to focus on food security and good nutrition. It would require multisectoral changes to the food system as well as the way in which healthcare services work.</p>
<h2>The risks and mitigation strategies</h2>
<p>Women who are either overweight or obese before conceiving a child or gain excessive weight during pregnancy are more likely to develop <a href="https://pubmed.ncbi.nlm.nih.gov/17200031/">gestational diabetes</a>. These women are also at higher risk of developing diabetes after childbirth. And babies born to women who are obese are more likely to be born large for their age and are at higher risk of being an obese child.</p>
<p>The mother’s weight isn’t the only potential risk to a child. When pregnant women experience nutrient deficiencies, it also affects the baby. For example, <a href="https://journals.sagepub.com/doi/abs/10.1177/1753495X20932426">iron deficiency in pregnancy</a> has negative effects on the development of the foetus’s brain.</p>
<p>Nutrient deficiencies also contribute to the <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60937-X/fulltext">high incidence</a> of noncommunicable diseases in low- and middle-income countries.</p>
<p>The International Federation of Gynaecology and Obstetrics has set out some helpful guidelines for policy makers. These call for:</p>
<ul>
<li><p>Increased awareness of the impact of women’s nutrition on their health and the health of future generations.</p></li>
<li><p>Greater attention to the links between poor maternal nutrition and increased risk of later non-communicable diseases in the offspring as a core component of meeting global health goals.</p></li>
<li><p>Action to improve nutrition among adolescent girls and women of reproductive age.</p></li>
<li><p>Public health measures to improve nutritional education, particularly for adolescents, girls and young women.</p></li>
<li><p>Greater access to preconception services for women of reproductive age to assist with planning and preparation for healthy pregnancies and healthy children.</p></li>
</ul>
<p>In addition, we argue that the government needs to adopt a comprehensive package of interventions that extends social assistance to pregnant women to improve their nutrition and mental health, and the health, care and development of their children. For example, the child support grant could start in pregnancy. </p>
<p>This package of interventions could prioritise food and nutrition at every point of contact for a mother and her infant. </p>
<p>South African policy is moving forward long these lines but policies need to be accelerated.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-tracked-soweto-mothers-to-be-to-find-out-more-about-diet-and-obesity-patterns-138989">We tracked Soweto mothers-to-be to find out more about diet and obesity patterns</a>
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<p>The interventions would be delivered beyond health and would require a multisectoral approach to ensure the optimal health and development of children from birth to age two years or older. This would also need to include early child development programmes which have seen a steady increase in utilisation over the past few years. </p>
<p>Healthy growing children are not only a moral and legal obligation but children remain a sustainable investment into a country’s future. To achieve this South Africa can draw lessons from other countries such as Brazil, Rwanda and Bangladesh. All have prioritised child nutrition and have reduced childhood stunting. Healthier children are healthier parents. </p>
<p>These countries have prioritised child nutrition by investing in general public nutrition literacy campaigns and have enforced legislation to protect children from the marketing of unhealthy foods. They have also ensured the scale up and implementation of a proven set of evidenced based interventions like maternity protection, promotion and protection of breastfeeding and the promotion and support for affordable localised diversified diets.</p><img src="https://counter.theconversation.com/content/155493/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chantell Witten is the Chairperson of the Child Health Priorities Association and the Nutrition Lead for the South African Civil Society for Women's, Adolescents' and Children's Health (SACSoWACH).</span></em></p><p class="fine-print"><em><span>Shane Norris receives funding from South African Medical Research Council, South African Department of Science and Innovation and National Research Foundation, UK Medical Research Council, Joint Global Health Trials (UK), National Institutes of Health, International Atomic Energy Agency and the National Institutes of Health Research (UK).</span></em></p>Malnutrition during the first 1000 days of life can cast a long shadow over a person’s life.Chantell Witten, Lecturer, University of the Free StateShane Norris, Director, DSI-NRF Centre of Excellence in Human Development, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1527752021-01-27T15:12:54Z2021-01-27T15:12:54ZThe role of bias in how women are treated during childbirth: a Kenyan case study<figure><img src="https://images.theconversation.com/files/379524/original/file-20210119-17-pk4i92.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">GettyImages</span></span></figcaption></figure><p>Global maternal mortality is unacceptably high. Around <a href="https://www.who.int/news-room/fact-sheets/detail/maternal-mortality">810 women</a> die every day from preventable causes related to pregnancy and childbirth. </p>
<p>A number of factors drive maternal mortality. In <a href="https://www.who.int/news-room/fact-sheets/detail/maternal-mortality">developing countries</a> it is often due to women not having access to basic health-care during pregnancy and when they give birth. </p>
<p>Another contributory factor is the way in which women are treated when they seek care. </p>
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Read more:
<a href="https://theconversation.com/what-drives-abuse-of-women-in-childbirth-we-asked-those-providing-the-care-134465">What drives abuse of women in childbirth? We asked those providing the care</a>
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<p>Studies in poor <a href="https://pubmed.ncbi.nlm.nih.gov/30554766/">countries</a> have highlighted disparities in respectful and responsive care during childbirth based on women’s socioeconomic status and other characteristics. Yet few studies have explored factors that may underlie these disparities. </p>
<p>My colleagues and I <a href="https://pubmed.ncbi.nlm.nih.gov/33491086/">conducted a study</a> into the biases – implicit and explicit – in the perceptions of providers based on the socioeconomic status of women seeking care during childbirth. We conducted the study with maternity care providers in western Kenya to understand how their personal biases might influence the way they treat their patients. </p>
<p>We found a complex and contradictory web of perceptions among maternity care providers. Some of the considerations shared by the providers included the educational level of women, their economic status and their appearance. These perceptions affected the kind of maternity care given.</p>
<p>We also found evidence of both explicit and implicit bias among maternity care providers towards women giving birth. </p>
<h2>How biases show up in patient care</h2>
<p>The providers told us about a variety of ways bias affected the care patients receive.</p>
<p>Some of the providers said the treatment they meted out to women was sometimes based on their appearance. When women appeared well-dressed and clean, they were treated better than those who were dirty and unkempt. One provider told us:</p>
<blockquote>
<p>Mostly you will find yourself not treating them equally. You will see the clean one to be special than the other one. </p>
</blockquote>
<p>Providers said their attitudes were also affected by assumptions they made about who was knowledgeable about their health and who was likely to cooperate. Providers perceived more educated women as having a better understanding of information about their care. This, in their view, made them easier to deal with. Uneducated women from the village were assumed to lack understanding. One provider put it this way:</p>
<blockquote>
<p>If you explain and they do not do what you explained, then you become angry because the mother and baby can die.</p>
</blockquote>
<p>Another said. </p>
<blockquote>
<p>So when you explain and they don’t cooperate, it will force you to apply some pressure to cooperate because if you become too soft, the result will be poor.</p>
</blockquote>
<p>Another factor was a person’s level of education. More educated women were thought to know what was right and were treated with caution.</p>
<p>Some providers also said that they gave better care to people who they assumed had higher expectations and could fend for themselves. Women of higher social and economic status were perceived as having higher expectations about the care they received. They were therefore more likely to demand higher-quality care. </p>
<p>Women who knew someone who could hold the provider accountable were said to be more likely to get good care. A provider shared: </p>
<blockquote>
<p>Maybe she is related to an MP or somebody who works at the county… and will always feel that she is right and whatever she said is what is important.</p>
</blockquote>
<p>Another factor at play was whether a woman could pay for care. Those that could were given more timely care. Providers acknowledged giving more timely care to women who were able to bring – or pay – for supplies such as gloves and cotton wool. Those able to pay for needed tests and medications also received more timely care. </p>
<p>Providing better care didn’t necessarily mean a provider preferred that patient. </p>
<p>Providers’ preferences for women who could understand their instructions sometimes conflicted with their preference for women to be cooperative. High status women were more likely to understand, but also more likely to challenge providers. </p>
<p>Providers valued obedience and preferred cooperation over knowledge. </p>
<p>We also heard concerning ideas that conflicted with treating patients with dignity. Nearly half of the providers said that they assumed that women had already given their consent to examination and treatment by the mere fact that they had come to the facility. They therefore felt no need to ask for approval for procedures from the women.</p>
<p>About a third agreed that women were likely to be uncooperative when it is time to push and would need to be physically restrained.</p>
<h2>How to fix this problem</h2>
<p>Providers’ biases can contribute to maternity care being poor. This is true for both low and high socioeconomic status women. </p>
<p>Working directly with providers to recognise both implicit and explicit biases could help reduce disparities.</p>
<p>Structural changes are also needed to prevent those biases from influencing care. One step would be to empower women so that they were able to articulate what they needed, and to make demands. Another would be to train providers and companions to serve as advocates for patients.</p>
<p>Making lasting change will require a shift in thinking about what makes a good patient-provider encounter. We need to help providers embrace a model where all women are encouraged to be active participants in their care. These changes are essential to ensuring that women get the quality, dignified maternity care they deserve, and that can save lives.</p><img src="https://counter.theconversation.com/content/152775/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patience Afulani receives funding from National Institutes of Health</span></em></p>Studies in poor countries have highlighted disparities in respectful and responsive care during childbirth based on women’s socioeconomic status and other characteristics.Patience Afulani, Assistant Professor, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1367832020-04-26T06:47:14Z2020-04-26T06:47:14ZResponsive and respectful maternity care needs protection during COVID-19 crisis<figure><img src="https://images.theconversation.com/files/329801/original/file-20200422-47815-kwo0vn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">One of the first babies born on 1 January 2020 in Lagos, Nigeria.</span> <span class="attribution"><span class="source">Olukayode Jaiyeola/NurPhoto via Getty Images</span></span></figcaption></figure><p>COVID-19 is sweeping the world, and the burden on healthcare facilities is growing. <a href="https://blogs.scientificamerican.com/observations/covid-19-is-no-reason-to-abandon-pregnant-people/">Stories</a> have begun to emerge from higher-resource countries, mainly in the US and Europe, about poor experiences for women giving birth in these circumstances. Some have been denied companions such as husbands or partners during childbirth, or have had their baby taken away from them afterwards. Some may have been neglected or not given information. </p>
<p>As the pandemic reaches into more low-resource settings, including African countries, it is likely that more women will face similar experiences. Often, in these settings, maternity care is already not what it should be: centred on people.</p>
<p>Person-centred maternity care refers to care that is respectful and responsive to women and their families’ preferences, needs <a href="https://pubmed.ncbi.nlm.nih.gov/25057539/">and values</a>. It includes aspects like communication and dignity. Unfortunately, disrespectful and neglectful treatment of women during childbirth, including verbal, physical and emotional abuse, is not uncommon. </p>
<p>The drivers of poor care are likely to be exaggerated in times of crisis. This is why person-centred care needs to be emphasised as part of provider training to respond to the pandemic. </p>
<h2>Putting people first</h2>
<p>Person-centred maternity care is a <a href="https://www.who.int/reproductivehealth/topics/maternal_perinatal/statement-childbirth-rights/en/">fundamental human right</a>. Everyone is entitled to dignified and respectful care, and that includes during childbirth. </p>
<p>Negative health care experiences lead to lack of trust and poor perceptions of the quality of care in health facilities. This discourages women from <a href="https://pubmed.ncbi.nlm.nih.gov/25238684/">seeking health care</a>. When even a few women in a community don’t get person-centred care, it discourages others from delivering in health facilities. That may make them more likely to <a href="https://www.who.int/news-room/fact-sheets/detail/maternal-mortality">die of pregnancy complications</a>.</p>
<p>Person-centred care also has direct effects on women and their newborn babies by improving clinical decision-making and communication between the birthing woman and the healthcare provider. Women are more likely to follow treatments and do well. </p>
<p>In contrast, when care is <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31472-6/fulltext">delayed, inadequate or unnecessary</a>, mothers and babies suffer.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/subtle-abuse-affects-women-during-childbirth-120789">Subtle abuse affects women during childbirth</a>
</strong>
</em>
</p>
<hr>
<p>Despite recognition of the importance of person-centred maternity care, research has highlighted gaps worldwide. A recent <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6853169/">study</a> in Ghana, Guinea, Myanmar and Nigeria found that more than one-third of women experienced some form of mistreatment. <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30403-0/fulltext">Research</a> in Kenya, Ghana and India highlighted communication gaps, lack of respect for women’s autonomy and unsupportive care. Over half of women reported that providers did not explain the purpose of exams or procedures or ask permission before performing them. About half of the women in the <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30403-0/fulltext">urban Kenya and Ghana</a> studies didn’t have someone with them throughout their labour. </p>
<h2>COVID-19</h2>
<p>Most of the drivers of poor care are likely to be exaggerated in the pandemic, as has been seen in other pandemics, such as <a href="https://www.jstage.jst.go.jp/article/hedn/5/1/5_2016-0014/_article/-char/ja/">Ebola</a>.</p>
<p>One key area is visitors and support at the facility during childbirth. There is already evidence of institutional policies limiting <a href="https://blogs.scientificamerican.com/observations/covid-19-is-no-reason-to-abandon-pregnant-people/">visitors</a> such as birth companions. </p>
<p>In many low-resource settings women are routinely being denied companions because of lack of privacy in open, overcrowded wards or <a href="https://pubmed.ncbi.nlm.nih.gov/29747593/">distrust of companions</a>. This is even when they are needed to provide practical help to women during labour. Hearteningly, in an effort to improve person-centred care, this was beginning to change. But with COVID-19, facilities may start restricting visitors even more stringently. This may leave women unsupported and alone when they deliver, with potential adverse impacts on <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6483123/">emotional and physical health</a>.</p>
<p><a href="https://www.who.int/mediacentre/news/releases/2013/health-workforce-shortage/en/">Health worker shortages</a> are already high in low-resource settings. As new COVID-19 cases continue to increase, so will the demands on health systems and the risk of infections <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(20)30074-8/fulltext">in health workers</a>. This will increase the chance that women will not receive the care that they need.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-drives-abuse-of-women-in-childbirth-we-asked-those-providing-the-care-134465">What drives abuse of women in childbirth? We asked those providing the care</a>
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</em>
</p>
<hr>
<p>Providers will be more stressed, given the increased workload from potential COVID-19 infections, inadequate personal protective equipment and an overstretched health system. Stressed providers have been shown to be more likely to verbally and physically <a href="https://academic.oup.com/heapol/advance-article/doi/10.1093/heapol/czaa009/5802543">abuse women</a>. Poor communication and stress are likely to lead to situations where providers perceive women as <a href="https://academic.oup.com/heapol/advance-article/doi/10.1093/heapol/czaa009/5802543">difficult</a>. Difficult situations are going to be exaggerated, with verbal and physical abuse likely to increase, as providers feel helpless and resort to these reactive behaviours as a means of gaining compliance.</p>
<p>Prior <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30403-0/fulltext">research</a> has highlighted that poor communication and lack of respect for women’s autonomy is widespread.</p>
<p>It has also been related to women’s ability to demand or command effective communication and respect for <a href="https://www.researchgate.net/publication/340819043_Providers'_perceptions_of_communication_and_women's_autonomy_during_childbirth_A_mixed_methods_study_in_Kenya#fullTextFileContent">their autonomy</a>. During a pandemic, communication may worsen because providers are even more overstretched. Women’s autonomy may be restricted to keep people “safe” from COVID-19 infections. These challenges arise at a time when clear communication is even more important, as women need to understand what is happening to and around them.</p>
<h2>What can be done?</h2>
<p>Person-centred maternity care is a priority for women, as highlighted by responses from nearly 1.2 million women in the “<a href="https://www.whatwomenwant.org/">What Women Want</a>” global campaign. </p>
<p>This is even more important in a pandemic when anxiety and risks are high. To prevent worsening quality of care, it needs to remain high on the agenda along with efforts to control COVID-19. Both person-centred maternity care and safety precautions are needed to prevent the spread of infection. Women are more likely to comply if they understand what is happening to them and trust that providers have their interest at heart. This can only happen if providers take time to talk to women.</p>
<p>Person-centred care needs to be emphasised as part of provider training to respond to the pandemic. Training needs to include self-care for providers to develop positive coping mechanisms. They also need personal protective equipment, which will reduce their anxiety and prevent them from projecting such anxiety to birthing women. Promoting person-centred maternity care should be part of institutional maternal and child health policies for pandemic response.</p><img src="https://counter.theconversation.com/content/136783/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patience Afulani receives funding from NICHD and Gates Foundation.</span></em></p><p class="fine-print"><em><span>Nadia Diamond-Smith receives funding from NICHD, The David and Lucile Packard Foundation, and the Bill and Melinda Gates Foundation. </span></em></p>Unfortunately, disrespectful and neglectful treatment of women during childbirth, including verbal, physical and emotional abuse is not uncommon.Patience Afulani, Assistant Professor, University of California, San FranciscoNadia Diamond-Smith, Assistant Professor, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1355282020-04-14T12:20:29Z2020-04-14T12:20:29ZIgnaz Semmelweis, the doctor who discovered the disease-fighting power of hand-washing in 1847<figure><img src="https://images.theconversation.com/files/327549/original/file-20200413-177903-6l8e8z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A simple, low-tech way to get rid of germs.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/medical-personnel-hand-washing-dressed-in-medical-royalty-free-image/1212821218"> FatCamera/E+ via Getty Images</a></span></figcaption></figure><p>One of the front-line defenses individuals have against the spread of the coronavirus can feel decidedly low-tech: <a href="https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html">hand-washing</a>.</p>
<p>In fact, it was 19th-century Hungarian physician Ignaz Semmelweis who, after observational studies, first advanced the idea of “hand hygiene” in medical settings.</p>
<p>The <a href="https://www.cdc.gov/handwashing/index.html">simple act of hand-washing</a> is a critical way to prevent the spread of germs. Here’s how Semmelweis, working in an obstetrics ward in Vienna in the 19th century, made the connection between dirty hands and deadly infection.</p>
<h2>Benefits of cleanliness, symbolic and real</h2>
<p>The <a href="https://doi.org/10.4103/2008-7802.201923">history of hand-washing</a> extends back to ancient times, when it was largely a faith-based practice. The Old Testament, the Talmud and the Quran all mention hand-washing in the context of ritual cleanliness.</p>
<p>Ritual hand-washing appears to have come with public health implications. During the Black Death of the 14th century, for instance, the Jews of Europe had a distinctly lower rate of death than others. Researchers believe that hand-washing prescribed by their religion <a href="https://doi.org/10.1016/j.ijid.2004.05.005">probably served as protection during the epidemic</a>.</p>
<p>Hand-washing as a health care prerogative did not really surface until the mid-1800s, when a young Hungarian physician named Ignaz Semmelweis did an important observational study at Vienna General Hospital.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/327551/original/file-20200413-177938-r4kf7z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/327551/original/file-20200413-177938-r4kf7z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/327551/original/file-20200413-177938-r4kf7z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=837&fit=crop&dpr=1 600w, https://images.theconversation.com/files/327551/original/file-20200413-177938-r4kf7z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=837&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/327551/original/file-20200413-177938-r4kf7z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=837&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/327551/original/file-20200413-177938-r4kf7z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1052&fit=crop&dpr=1 754w, https://images.theconversation.com/files/327551/original/file-20200413-177938-r4kf7z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1052&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/327551/original/file-20200413-177938-r4kf7z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1052&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ignaz Philip Semmelweis (1818-1865)</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/ignaz-philip-semmelweis-hungarian-obstetrician-discovered-news-photo/113444168">Universal Images Group via Getty Images</a></span>
</figcaption>
</figure>
<p>After becoming disillusioned with the study of law, Semmelweis moved to the study of medicine, graduating with a medical degree from the University of Vienna in 1844. Having graduated from this prestigious institution, he believed he would be able to pursue a choice practice. He applied for positions in pathology and then medicine, but received rejections in both.</p>
<p>Semmelweis then turned to obstetrics, a relatively new area for physicians, previously dominated by midwifery, which was less prestigious and where it was easier to obtain a position. <a href="https://wwnorton.com/books/9780393326253">He began working in the obstetrics division</a> of the Vienna Hospital on July 1, 1846.</p>
<p>The leading cause of maternal mortality in Europe at that time was <a href="https://doi.org/10.1017/s0025727300000119">puerperal fever</a> – an infection, now known to be caused by the streptococcus bacterium, that killed postpartum women.</p>
<p>Prior to 1823, about 1 in 100 women died in childbirth at the Vienna Hospital. But after a policy change mandated that medical students and obstetricians perform autopsies in addition to their other duties, the mortality rate for new mothers suddenly jumped to 7.5%. What was going on?</p>
<p>Eventually, the Vienna Hospital opened a second obstetrics division, to be staffed entirely by midwives. The older, First Division, to which Semmelweis was assigned, was staffed only by physicians and medical students. Rather quickly it became apparent that the mortality rate in the first division was much higher than the second.</p>
<p>Semmelweis set out to investigate. He examined all the similarities and differences of the two divisions. The <a href="https://doi.org/10.1128/9781555817220">only significant difference</a> was that male doctors and medical students delivered in the first division and female midwives in the second.</p>
<h2>Washing away germs from the dead</h2>
<p>Remember that at this time, the general belief was that bad odors – miasma – transmitted disease. It would be two more decades at least before germ theory – the idea that microbes cause disease – gained traction.</p>
<p>Semmelweis cracked the puerperal fever mystery after the death of his friend and colleague, pathologist Jakob Kolletschka. Kolletschka died after receiving a scalpel wound while performing an autopsy on a woman who’d died of puerperal fever. His autopsy revealed massive infection from puerperal fever.</p>
<p>Contagiousness now established, Semmelweis concluded that if his friend’s</p>
<blockquote>
<p>“general sepsis arose from the inoculation of cadaver particles, <a href="https://wwnorton.com/books/9780393326253">then puerperal fever must originate from the same source</a>. … The fact of the matter is that the transmitting source of those cadaver particles was to be found in the hands of students and attending physicians.”</p>
</blockquote>
<p>No midwives ever participated in autopsies or dissections. Students and physicians regularly went between autopsies and deliveries, rarely washing their hands in between. <a href="https://doi.org/10.1080/08998280.2010.11928658">Gloves were not commonly used</a> in hospitals or surgeries until late in the 19th century.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/327550/original/file-20200413-177903-5qhytd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/327550/original/file-20200413-177903-5qhytd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/327550/original/file-20200413-177903-5qhytd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=312&fit=crop&dpr=1 600w, https://images.theconversation.com/files/327550/original/file-20200413-177903-5qhytd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=312&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/327550/original/file-20200413-177903-5qhytd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=312&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/327550/original/file-20200413-177903-5qhytd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=392&fit=crop&dpr=1 754w, https://images.theconversation.com/files/327550/original/file-20200413-177903-5qhytd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=392&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/327550/original/file-20200413-177903-5qhytd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=392&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ignaz Semmelweis washing his hands in chlorinated lime water before attending to patients.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/ignaz-semmelweis-washing-his-hands-in-chlorinated-lime-news-photo/517403466">Bettmann via Getty Images</a></span>
</figcaption>
</figure>
<p>Realizing that chloride solution rid objects of their odors, Semmelweis mandated hand-washing across his department. Starting in May 1847, anyone entering the First Division had to wash their hands in a bowl of chloride solution. The incidence of puerperal fever and death <a href="https://doi.org/10.1128/9781555817220">subsequently dropped precipitously</a> by the end of the year.</p>
<p>Unfortunately, as in the case of his contemporary John Snow, who discovered that cholera was transmitted by water and not miasma, Semmelweis’ work <a href="https://doi.org/10.1017/S0025727300043738">was not readily accepted by all</a>. The obstetrical chief, perhaps feeling upstaged by the discovery, refused to reappoint Semmelweis to the obstetrics clinic.</p>
<p>Semmelweis’ refusal to publish his work may have also contributed to his downfall. With little recognition during his lifetime, he <a href="https://wwnorton.com/books/9780393326253">eventually died from injuries</a> sustained in a Viennese insane asylum.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/327552/original/file-20200413-132830-9emais.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/327552/original/file-20200413-132830-9emais.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/327552/original/file-20200413-132830-9emais.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/327552/original/file-20200413-132830-9emais.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/327552/original/file-20200413-132830-9emais.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/327552/original/file-20200413-132830-9emais.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/327552/original/file-20200413-132830-9emais.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/327552/original/file-20200413-132830-9emais.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Coronavirus has launched hand-washing into the spotlight.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/woman-walks-past-a-coronavirus-public-information-campaign-news-photo/1206349532">SOPA Images/LightRocket via Getty Images</a></span>
</figcaption>
</figure>
<h2>Taking an old lesson to heart</h2>
<p>Although Semmelweis began the charge for hand hygiene in the 19th century, it has not always fallen on receptive ears.</p>
<p>The medical field now recognizes that soap and running water are the best way to <a href="https://doi.org/10.1097/00002727-200407000-00007">prevent, control and reduce infection</a>. But regular folks and <a href="https://doi.org/10.1016/j.ajic.2005.05.025">health care workers</a> still <a href="https://doi.org/10.7326/0003-4819-141-1-200407060-00008">don’t always follow</a> <a href="https://doi.org/10.1071/ah980238">best practice guidelines</a>.</p>
<p>Hand-washing appears to get a bump in compliance in the wake of disease outbreaks. Take the example of the first major outbreak of SARS, which occurred in the Prince of Wales Hospital in Hong Kong in March 2003. Health authorities advised the public that hand-washing would help prevent spread of the disease, caused by a coronavirus. After the SARS outbreak, medical students at the hospital were much more likely <a href="https://doi.org/10.1016/j.ajic.2005.05.025">to follow hand-washing guidelines</a>, according to one study.</p>
<p>I suspect the current pandemic of COVID-19 will change the way the <a href="https://globalhandwashing.org">public thinks about hand hygiene</a> going forward. In fact, White House coronavirus advisor and NIAID Director Anthony Fauci has said “<a href="https://thehill.com/homenews/administration/491917-fauci-i-dont-think-we-should-shake-hands-ever-again">absolute compulsive hand-washing</a>” for everyone must be part of any eventual return to pre-pandemic life.</p>
<p>[<em>Get facts about coronavirus and the latest research.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=upper-coronavirus-facts">Sign up for The Conversation’s newsletter.</a>]</p><img src="https://counter.theconversation.com/content/135528/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Leslie S. Leighton does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A Hungarian obstetrician was the first to nail down the importance of handwashing to stop the spread of infectious disease.Leslie S. Leighton, Visiting Lecturer of History, Georgia State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1244402019-11-28T14:12:09Z2019-11-28T14:12:09ZHow better information will reduce maternal and child deaths<figure><img src="https://images.theconversation.com/files/303972/original/file-20191127-112489-1lq8c8p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Countries need to have the capacity to interrogate their health data to address maternal and child health challenges.</span> <span class="attribution"><span class="source">APHRC</span></span></figcaption></figure><p><em>At least two-thirds of all annual maternal and child deaths worldwide occur in sub-Saharan Africa. Despite recent improvements, significant inequities persist across countries and regions and within countries. An initiative by the <a href="https://aphrc.org/">African Population and Health Research Centre</a>, <a href="http://countdown2030.org">Countdown to 2030</a>, seeks to accelerate coverage and access to reproductive, maternal, newborn, child, and adolescents’ health and nutrition services by providing evidence that informs decision making for policy, programming and financing. Cheikh Mbacke Faye explains.</em></p>
<p><strong>Why the focus on maternal and child health?</strong></p>
<p>There has been substantial progress in reducing maternal and child deaths globally. This is due to increased investment in good infrastructure, the use of vaccines and other factors. Between 1990 and 2015, maternal and under-five mortality <a href="https://data.unicef.org/resources/trends-maternal-mortality-2000-2017/">declined</a> by 44% and 58% respectively globally. But maternal mortality remains unacceptably high, especially in developing countries. At least <a href="https://data.unicef.org/topic/maternal-health/maternal-mortality/">two-thirds of all annual maternal and child deaths worldwide</a> occur in sub-Saharan Africa. </p>
<p><strong>How does the Countdown 2030 initiative hope to change this?</strong></p>
<p>This initiative aims to equip country health data experts to provide deep analyses of inequalities from existing data sources such as the District Health Information System and the Demographic Health Surveys. Evidence like this should help improve equity in maternal and child health as <a href="https://www.who.int/sdg/targets/en/">stipulated</a> in the Sustainable Development Goals. The overall aim is to reach all populations with essential health services of good quality. </p>
<p>The analysis aims to show the inequities by sub-national level, socioeconomic status and the rural-urban divide. When governments have evidence, they are better placed to develop policies and programmes that provide equitable coverage of effective health interventions for women, children and adolescents. The project is anchored on the use of evidence to promote increased coverage and access to reproductive, maternal, newborn, child, and adolescents’ health and nutrition services to all people. </p>
<p>For example, in Uganda, working with Makerere University School of Public Health, we did an analysis to understand the rate of under-five mortality in different regions of Uganda. The analysis identified the six regions in Uganda with the highest child mortality rates. This evidence was shared at a meeting in Kampala with stakeholders in government and civil society organisations to facilitate a discussion of health system challenges in these regions. </p>
<p>In addition, the initiative seeks to ensure that disadvantaged groups are not left behind. This is because inequities in access and coverage of reproductive health and nutrition services for these target groups persist. Knowing the inequities is the first step to identifying the challenges and how to address them. </p>
<p><strong>How do you plan to bring change in just over a decade?</strong> </p>
<p>Strengthening the evidence base and country analytical capacity is key. Countries need to have the capacity to interrogate properly the health data that is collected. Investigating what the data means will lead to its use in informing targeted action to address maternal and child health challenges. </p>
<p>The initiative is, therefore, training health data specialists at country level. They are trained on which analyses to do, how to do them and how to share the evidence. As a result, it is expected that there will be more demand for evidence. On top of this, the institutions with data analysis capacity will be considered as technical partners of government. Other actors can provide evidence on a needs basis. </p>
<p>This evidence can inform decision making for policy, programming and financing. Already <a href="http://countdown2030.org/country-and-regional-networks/country-profiles">country analyses</a> have revealed the disparities in the coverage between the poor and wealthy, those living in urban and rural areas, and other strata. </p>
<p>The initiative is also highlighting the data collected in interesting ways that are easy to read, understand and use. These include equity profiles, country profiles and dashboards that are accessible for free. </p>
<p>Related to this are technical analyses and support for countries to define priority areas and activities for their participation and funding through the Global Financing Facility. This brings together partners focusing on women, children and adolescents to agree on priorities and country-led plans to implement. It is a catalyst for domestic financing as country funding commitments are matched through Trust Fund grants by the World Bank. </p>
<p>The initiative collaborates with the facility at country level to ensure priorities are informed by evidence. </p>
<p>The other element is building national capacity for the collection, quality assessment, analysis and use of data related to their policies and programmes. For example, the initiative trains people in each country to collect, analyse and share the data in consistent and useful ways to inform decision making for women’s children and adolescents’ health.</p>
<p>Finally, the initiative will support decision makers, civil society representatives, governments and advocates with evidence for effective advocacy efforts.</p>
<p><strong>What are the measures of success?</strong></p>
<p>At the top level is the creation of global public tools like country profiles. They help the monitoring and measurement of coverage, quality and equity. </p>
<p>At the regional level, the initiative is enhancing cross-country learning and sharing of best practices. It is also enhancing regional networks and multi-country monitoring, learning and evaluation. This will make it easier for regions and countries to track their progress in enhancing equity in the health outcomes of women, children and adolescents. </p>
<p>At national level, strengthened country-led data analysis and generation of evidence can be used to inform decision making for policy and programming. This will mean that countries will have more relevant information to plan and make effective decisions to address health system challenges. </p>
<p>Finally, improved communication and use of evidence on progress and performance will make it easier for anyone to see what progress is being made in preventing maternal, child and adolescent deaths.</p><img src="https://counter.theconversation.com/content/124440/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>When governments have evidence, they are better placed to develop health policies and programmes.Cheikh Mbacke Faye, Associate Research Scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1273772019-11-25T14:51:01Z2019-11-25T14:51:01ZAntenatal care in Kenya needs improvement<figure><img src="https://images.theconversation.com/files/302907/original/file-20191121-467-7o5mdt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Maternal and neonatal mortality has remained high in low-resource settings despite progress in recent years. The estimated maternal mortality ratio in Kenya is <a href="https://data.unicef.org/topic/maternal-health/maternal-mortality">342 per 100,000 live births</a>, a startling 18 times the rate in the United States.</p>
<p>High quality prenatal care can address these high levels of mortality. High quality prenatal care means women receive all the recommended services needed to ensure a successful pregnancy. But it’s not just about receiving services; the woman’s experience matters. High quality care is person-centred, meaning that it is respectful and responsive to the woman’s needs and preferences.</p>
<p>This kind of care can prevent or identify and manage complications or pre-existing conditions that could cause problems during the pregnancy. Receiving quality prenatal care can also make it more likely that women will go to a facility for skilled care during birth, which is critical for managing complications at birth to prevent morbidity and mortality.</p>
<p>Kenya’s national guidelines for obstetrics and perinatal care <a href="https://uasingishureproductivehealth.files.wordpress.com/2015/08/national-guidelines-for-quality-obstetrics-and-perinatal-care-2012.pdf">recommend</a> four comprehensive and targeted prenatal care visits. The guidelines also urge providers to treat each visit as though it may be the only one to ensure patients are getting thorough care. </p>
<p>The guidelines say:</p>
<blockquote>
<p>Antenatal care should be simpler, safer, friendly and more accessible. Women are more likely to seek and return for services if they feel cared for and respected by their providers.</p>
</blockquote>
<p>A recent Bixby Center study <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-019-4476-4">surveyed</a> around 1,000 women in a rural county in western Kenya, to see how the prenatal care they received measured up. It is one of few studies to look at both provision of services and women’s experiences of care. The study found gaps in both provision of services and women’s experiences of care, indicating that women are not reaping the full benefits of prenatal care. </p>
<h2>Gaps in quality care</h2>
<p>The study found that most women received basic services like blood pressure monitoring and urine tests at least once during pregnancy. However, it found that they were not receiving them consistently at every visit as recommended by the guidelines. </p>
<p>The situation is even more dire for advanced services like ultrasounds, which fewer than one in five women received. Women with complications – for whom ultrasound is recommended – were not more likely to have one. Young women 15-19 years old were less likely to get an ultrasound, in addition to being less likely to have a good prenatal care experience. Given that this group has a high risk of complications, poor quality care may be playing a big role in their outcomes as complications may not be identified early or at all. </p>
<p>Women from the wealthiest households and those with college educated partners, however, had about two times higher odds of receiving an ultrasound than women from the poorest households and those with partners with primary education or less.</p>
<p>In the provision of person-centred care, the major gap was in communication. Only around two-thirds of women understood the purposes of tests performed or medicines received most or all of the time. Less than two-thirds felt they were able to ask questions and only half were consistently asked if they had questions. Most women felt respected by providers and felt they were treated in a friendly manner, which was encouraging. </p>
<p>But there is still room for improvement – one in 10 women didn’t feel that way. A significant number of women also said they never got the opportunity to discuss issues in private. <a href="https://doi.org/10.1186/s12978-017-0446-7">Prior research</a> shows that women sometimes experience verbal and physical abuse during prenatal care.</p>
<p>As in many areas of health care, the most disadvantaged and disempowered women received the lowest quality care – both in terms of services provided and their experiences of care. Women who received all their prenatal care in lower level facilities, however, had better experiences than those who received some prenatal care in higher level facilities.</p>
<p>Some women may get better treatment because they are able to access facilities that offer higher quality care, are able to pay for higher quality care or have the knowledge and ability to advocate for themselves. Structural factors and provider attitudes could also contribute to the low quality of care. Providers simply aren’t able to take weight and blood pressure measures or do blood and urine tests if they don’t have the right equipment and laboratories. They can’t give out medication if it’s not in stock.</p>
<p>The need for supplies and equipment has an obvious connection to providing services, but it can also have an impact on person-centred care if it manifests as frustration in providers’ interactions with women. Poor communication could be due to time constraints – it takes less time to just provide services than to talk to women and answer their questions. But that means that women might not adhere to treatment and recommendations for further tests because they don’t understand why it’s important.</p>
<h2>What next</h2>
<p>While it’s important to get women to health facilities, much more is needed to achieve the full benefits of prenatal care. A lot of work remains to improve both dimensions of quality prenatal care. And the momentum behind improving person-centred care during childbirth should spread to prenatal care. </p>
<p>There must be special attention to disparities based on demographic factors, social status and facility type to move towards the sustainable development goal of “no woman left behind”. </p>
<p>As countries like Kenya update their national guidelines, they must consider how to strengthen providers’ ability to provide person-centred care to all women in all types of facilities and hold them accountable for providing it.</p><img src="https://counter.theconversation.com/content/127377/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patience Afulani receives funding from NICHD and Gates Foundation. </span></em></p><p class="fine-print"><em><span>Rebecca Griffin does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Most women feel they are unable to ask health professionals questions. And only half were consistently asked if they had questions.Patience Afulani, Assistant Professor, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1142052019-04-09T13:26:08Z2019-04-09T13:26:08ZNigerian trial shows how universal home visits can help reduce maternal risks<figure><img src="https://images.theconversation.com/files/265548/original/file-20190325-36264-1gn7yge.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Home visit trials strongly encouraged spouses to get involved.</span> <span class="attribution"><span class="source">Anne Cockroft</span></span></figcaption></figure><p>Nigerian women are at high risk of death related to pregnancy and child birth. Accurate figures are hard to come by, but the World Health Organisation estimates there are <a href="https://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2015/en/">more than</a> 800 maternal deaths for every 100,000 live births in Nigeria. That’s about 100 times higher than rates in Canada or the United Kingdom. </p>
<p>Most maternal deaths happen in low and middle-income countries, over half of them in sub-Saharan Africa. The rate <a href="https://www.who.int/news-room/fact-sheets/detail/maternal-mortality">is highest</a> among very poor women living in rural areas, and among adolescent mothers who are younger than 15. This is <a href="https://www.dhsprogram.com/pubs/pdf/FR293/FR293.pdf">the situation</a> for many women in northern Nigeria.</p>
<p>The <a href="https://apps.who.int/iris/bitstream/handle/10665/250796/9789241549912-eng.pdf;sequence=1">standard approach</a> to reducing maternal mortality is to encourage women to attend health facilities for antenatal care and to <a href="https://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf?sequence=1&isAllowed=y">deliver</a> their babies in health facilities. </p>
<p>But, in places with high maternal mortality and poor health services, simply advising a woman to seek routine antenatal care during pregnancy is not the answer. </p>
<p>The very disadvantages that increase a woman’s risk in pregnancy and child birth – like poverty or lack of education – also make her less likely to be able to attend health facilities. For those who do go to health facilities during their pregnancy, the standard of care is <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-015-0081-0">often poor</a> and could be compromised further if the overstretched facilities had to cope with increased demand. </p>
<p>Previous <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007754.pub3/abstract">studies</a> indicate that home visits to women during pregnancy and after delivery, as part of community-based schemes, <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-14-129">can improve</a> the health of mothers and babies. But in most of these home visit schemes, the visitors encouraged women to visit health facilities and coverage of households was far from universal. </p>
<p><a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3319-z">We undertook</a> a trial to test the impact of universal home visits – carried out by trained female and male “home visitors” – in Bauchi, a state in northern Nigeria. </p>
<p>These were different from other home visits because they covered all households and pregnant women in an area, ensured that the most marginalised women were reached, and were based on local evidence about risks – like heavy work or domestic violence during pregnancy – that households themselves could tackle. They also included men. Male visitors shared the same evidence about risks with the pregnant women’s spouses. </p>
<p>The trial was a success. The visits improved the health of mothers without changing their use of health facilities, or the services provided by them. These are important findings for other countries with similar maternal health challenges. </p>
<h2>Bauchi trial</h2>
<p>A <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-11-S2-S7">previous study</a> in Bauchi found that women were more likely to have complications in pregnancy and childbirth if they continued heavy work throughout their pregnancy, experienced domestic violence, did not communicate with their spouse about pregnancy and child birth, and if they did not know the danger signs in pregnancy or delivery. </p>
<p>The Bauchi state Primary Health Care Development Agency, Federation of Muslim Women Association of Nigeria, and Community Information and Epidemiological Technologies/Participatory Research at McGill <a href="https://www.mcgill.ca/familymed/research/projects/ciet">CIET/PRAM</a>, in the department of Family Medicine, worked together to implement the Bauchi trial. </p>
<p>In the trial, the home visitors provided pregnant women and their spouses with information about the risk factors and what could be done to avoid them. This allowed them to reduce the risks themselves. The visitors shared information either through conversations or short video clips, in the style of locally popular soap operas. </p>
<p>The home visitors used android handsets to record interview responses and share the video clips. The GPS enabled handsets also allowed remote monitoring to ensure the visitors had actually visited the households. </p>
<h2>The results</h2>
<p>After one year of the intervention, we compared outcomes over four areas, which we call <em>wards</em>. Two which had received visits – totalling 1,837 women who had given birth – and two which hadn’t, with a total of 1,853 women who had recently had their babies. </p>
<p>Through questionnaires given to the women, we found that the home visits produced <a href="https://gh.bmj.com/content/4/1/e001172">clear benefits</a>. Women in the visited wards had less complications of pregnancy and less infections related to childbirth. The visits also reduced targeted risk factors. The women in the visited wards undertook less heavy work in pregnancy, experienced less domestic violence, and communicated better with their spouses. They were also much better informed about danger signs in pregnancy and delivery. </p>
<p>This all happened without an increase in use of health services in the visited wards, suggesting that the improvement in the targeted risk factors led to the improvements in maternal outcomes. The households themselves took action to reduce these risks.</p>
<p>All too often, special programmes implemented on a trial basis show promise, but cannot continue once a separately funded project is over. In Bauchi, officers from the Primary Health Care Development Agency, involved in implementing the home visits from the beginning, have now taken over the financial and technical management of the visits in two of the wards. The Primary Health Care Development Agency has planned and budgeted to roll out home visits in this model to the rest of the local government authorities in the state, and the research team are training government officers to run the programme.</p><img src="https://counter.theconversation.com/content/114205/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anne Cockcroft received funding from Global Affairs Canada, Canadian Institutes of Health Research (CIHR), and International Development Research Centre (IDRC), Canada </span></em></p><p class="fine-print"><em><span>Neil Andersson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Home visits as part of community-based schemes to women during and after pregnancy can improve the health of mothers and babies.Anne Cockcroft, Associate Professor, McGill UniversityNeil Andersson, Professor of Family Medicine, McGill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1139572019-03-25T13:57:34Z2019-03-25T13:57:34ZThe death rate for mothers having C-sections is 50 times higher in Africa<figure><img src="https://images.theconversation.com/files/265282/original/file-20190322-36248-1we4te1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Maternal mortality is much higher in Africa than in high-income countries.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The in-hospital maternal mortality rate following a Caesarean delivery in Africa may be 50 times higher than in high-income countries. These were the findings of the <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30036-1/fulltext">African Surgical Outcomes Study</a> that followed more than 3500 mothers from 22 African countries during a week of surgery in 2016.</p>
<p>The study found that maternal mortality rate was 5.43 per 1 000 operations, compared to 0.1 per 1000 operations in the UK. And one in six women developed complications following Caesarean delivery, which is nearly <a href="https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.13523">three times</a> the rate in the US. Bleeding in the period shortly before, during, and immediately after giving birth, was the most common complication. And it had the highest attributable risk for maternal mortality. </p>
<p>Although the complication rate was three times that of a high-income country, mortality was 50 times that of a high-income country. This suggests that a lot more complications result in death in Africa. When a complication results in death, this is known as “failure to rescue”. Mothers in Africa appear to be particularly susceptible to it, when compared to high-income countries.</p>
<p>Unfortunately, it isn’t only the mothers who are suffering in Africa. The in-hospital mortality of babies after Caesarean delivery was double that of high-income countries. There were indicators that the risk of subsequent <a href="https://www.bmj.com/content/360/bmj.k207">cerebral palsy or epilepsy</a> for the babies who survived Caesarean delivery, are between two and 11 times higher in Africa when compared to a high-income country.</p>
<p>These findings tell a sad story of life in Africa. Many families are incomplete, as a result of either a mother or child who died in childbirth, and for those children who survive a Caesarean delivery, a number of them will have long-term morbidity.</p>
<p>So what can be done to improve this situation? Unfortunately, there will be no “quick-fix”, as this is a complex, multifactorial problem. It speaks to a number of problems that need to addressed in Africa, if we are to improve outcomes for mothers and their children.</p>
<h2>Where the problems lie</h2>
<p>The first problem is poor access to Caesarean deliveries. In Africa, the Caesarean section rate is too low. There is a minimum threshold of the number of Caesarean sections per population to ensure optimal obstetric care. Most countries in Africa don’t reach this threshold. The result is that many mothers who would benefit from Caesarean section don’t have this option.</p>
<p>Secondly, access to surgical care is limited. This is reflected in the observation that <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30036-1/fulltext">3 out of 4 mothers</a> presenting for Caesarean deliveries present as emergencies. This may partly reflect the limitations in the current antenatal services available. </p>
<p>The role of antenatal care is to monitor and identify both mothers and babies at risk. Early identification of those at risk could result in an elective Caesarean section in a more controlled environment. This, in turn, would lead to better outcomes for the mother and the baby.</p>
<p>But it appears that in the current antenatal environment in Africa a number of mothers at risk aren’t identified early enough in the community.</p>
<p>Another contributing factor is that there are limited skilled human resources to provide safe obstetric care in Africa. It’s generally accepted that to provide a safe Caesarean section, at least <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60160-X/fulltext">20 specialists</a> (obstetricians, surgeons and anaesthetists) are required per 100 000 population. In the African cohort it was found to be <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30036-1/fulltext"><1 specialist per 100 000</a> population.</p>
<p>This creates a stressful and dangerous working environment. The majority of mothers are sick and present as emergencies, yet there is insufficient skilled staff to deal with the workload. </p>
<p>Finally, it’s clear that mothers are dying predominantly secondary to bleeding around the time of delivery. This may be for many reasons; bleeding may not be identified early enough (both before and after surgery) due to limited human resources (resulting in “failure to rescue”). This could also be due to insufficient resources, such as limited drugs to stop bleeding or limited access to blood products. </p>
<h2>Reason for hope</h2>
<p>Is there reason for hope? I believe there is. The <a href="http://www.asos.org.za">African Surgical Outcomes Study network</a>, which produced the study, is a group of over 1000 clinician investigators who now span over 30 African countries. They are committed to improving surgical outcomes in Africa. </p>
<p>The group is looking towards large pragmatic trials of simple interventions designed to improve outcomes in resource constrained environments. To this end it will be running a large trial across the continent this year that will focus on identifying and managing high-risk patients in the perioperative period with the aim of preventing the progression of complications. The trial hopes to decrease “failure to rescue” in African surgical patients. </p>
<p>Next year, the group hopes to conduct another large trial across Africa which will aim to decrease maternal bleeding. The hope is that this will also help bring down the numbers of mothers dying at a result of childbirth.</p>
<p>The network aims to extend its footprint into the community to ensure that “at-risk” patients are identified early, and high-risk patients are followed adequately after surgery. Improving maternal and surgical outcomes in Africa certainly demands a large collaborative effort.</p><img src="https://counter.theconversation.com/content/113957/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bruce M Biccard received funding from Medical Research Council (MRC) South Africa for ASOS. </span></em></p>Research shows that women in Africa are more likely to die as a result of complications related to C-sections.Bruce M Biccard, Professor and Second Chair at Groote Schuur Hospital , University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1081822019-01-23T14:35:24Z2019-01-23T14:35:24ZEducation quality and the youth skills gap are marring progress in Africa<figure><img src="https://images.theconversation.com/files/248757/original/file-20181204-34154-pwp7wz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Education has a bearing on prospects for sustainable economic opportunities as it feeds the market.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The <em><a href="http://s.mo.ibrahim.foundation/u/2018/10/28235917/2018-IIAG-Press-Release.pdf">Ibrahim Index of African Governance</a></em> measures and monitors Africa’s governance performance. It produces an impartial picture of governance performance in every country on the continent. David E Kiwuwa, associate professor of international studies at the University of Nottingham, asked <strong>Mandipa Ndlovu</strong>, a Zimbabwean academic, researcher and 2017/18 Ibrahim Scholar to unpack some of the findings from the 2018 report.</p>
<p><strong>Where do you see progress in Africa in terms of good governance and leadership over the past decade?</strong></p>
<p>The Index defines governance as the provision of the political, social and economic goods and services that every citizen has the right to expect from their government. Governments have a responsibility to deliver these services to their citizens.</p>
<p>The 2018 Index shows that countries that have done well in overall governance have also seen improvements in transparency and accountability. These improvements fall under the broad category of “safety and rule of law”. Here, the continent is in a better position than it was five years ago. For this trend to continue national security needs to be reinforced.</p>
<p>The health measure has improved in 47 countries over the past ten years. Countries like Nigeria, the Democratic Republic of Congo and Burkina Faso have taken great strides. This is thanks to improvements in several areas like the provision of antiretroviral treatment, a drop in child mortality and better management of communicable diseases. Maternal mortality rates have also stabilised and immunisation has become more common.</p>
<p>In spite of this progress, Africans are not satisfied with their governments’ handling of basic health services.</p>
<p><strong>Where is progress slowest?</strong></p>
<p>Gender is one area of concern. The 2018 report notes that gender representation in leadership had the largest improvement over the last five years. However, the empowerment of women in general registered the biggest slowdown. Gender representation therefore, must not be conflated with gender empowerment.</p>
<p>The data also shows that policies and representation do not always translate into action. South Africa, for example, continues to face high rates of femicide and patriarchal ideals within its judicial structures. This is despite its liberal constitution.</p>
<p>While the country shows great improvements under “women’s political participation” and “representation of women in the judiciary” there is a decline in “women’s political empowerment”. Women are well represented in the country’s cabinet, for instance, but there’s been a marked deterioration in how empowered ordinary women feel to participate in politics.</p>
<p>Such disconnects are concerning.</p>
<p>However, countries like Rwanda must be commended for their deliberate inclusion of women in places of influence. Interventions like these are still too rare on the continent.</p>
<p>Also worrying is the lack of progress under “sustainable economic opportunity”, the worst performing measure. Almost half of the continent’s citizens (43.2%) live in a country that’s seen a decline of sustainable economic opportunities in the last 10 years.</p>
<p><strong>Why have African governments struggled to translate economic growth into improved sustainable economic opportunities for their citizens?</strong></p>
<p>Trends indicate that transparency and accountability are vital for sustainable economic opportunity in the long term. Greater accountability and transparency is needed on national expenditure, for example. Protectionist systems that allow for the abuse of power and inhibit the levelling out of socio-economic disparities must be exposed. Only then can these systems be reformed to open up more opportunities for all.</p>
<p>Increasing access to sustainable economic opportunities improves human development. This in turn allows for innovation in health, technology and other spaces that increase the overall functionality of good governance.</p>
<p><strong>What role can education play in improving governance?</strong></p>
<p>The gaps in African governance are twofold: socio-economic inclusion and education. It is important to focus on both areas to bring about overall improvement. Although improvements have been recorded in the sub-category of “participation” in the last 10 years, student and youth resistance movements belie the progress.</p>
<p>The rise of populist movements coupled with the lack of voter registration within the youth dividend must not be misconstrued as political apathy.</p>
<p>In South Africa for example – where the 2018 index was launched – there is a critical skills gap that has not been adequately addressed. The quality of education in South Africa is worrying.</p>
<p>Also in South Africa, as well as the rest of the continent, youth enrolment in schools is improving. But “education quality”, “satisfaction with education provision”, and “alignment of education with market needs” are persistent causes for concern.</p>
<p>Education has a great bearing on sustainable economic opportunities because skilled workers feed the market. Africa is currently experiencing a skills gap deficit. With 27 countries registering deteriorating education scores in the last five years there is a further decline to already fragile sustainable economic opportunities.</p>
<p><em>The opinions expressed in this article are solely those of the author. They do not reflect the opinions or views of the Mo Ibrahim Foundation.</em></p><img src="https://counter.theconversation.com/content/108182/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David E Kiwuwa does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The gaps in African government are twofold: governance and education. It is important to focus on both areas to bring about overall improvements.David E Kiwuwa, Associate Professor of International Studies, University of NottinghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1082062019-01-02T09:11:52Z2019-01-02T09:11:52ZWhy improving access to surgery in childbirth makes economic sense<figure><img src="https://images.theconversation.com/files/251276/original/file-20181218-27758-j579lr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pregnant women waiting to see a doctor at a hospital in Uganda. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Maternal mortality remains high around the world, with more than <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)00838-7/fulltext">303,000</a> women dying in pregnancy, childbirth or shortly afterwards. The majority (99%) of these deaths occur in developing countries. More than half of these deaths are in sub-Saharan Africa. </p>
<p>A major reason for this is that women in developing countries have no real access to proper medical care and therefore miss out on the help required for difficult births. About <a href="http://apps.who.int/iris/bitstream/handle/10665/255760/9789241565493-eng.pdf?sequence=1">15%</a> of all women experience severe complications when giving birth. Most of these cases require major intervention, including surgery. In developed countries, emergency surgery ensures that women and their babies survive childbirth, and mothers are spared the severe physical and emotional trauma that often follows a complicated birth.</p>
<p>One potentially devastating complication in childbirth is <a href="https://www.who.int/reproductivehealth/topics/maternal_perinatal/fistula/en/">obstetric fistula</a>. This usually happens during a protracted or obstructed labour that isn’t given sufficient attention. A hole develops in the birth canal between the vagina and rectum or between the vagina and bladder. An estimated <a href="https://www.who.int/reproductivehealth/topics/maternal_perinatal/fistula/en/">50 000 to 100 000 women </a>in sub-Saharan Africa develop fistula every year. </p>
<p>If women don’t have access to quality emergency obstetric care, the fistula can cause long term damage. This can include incontinence. In turn this can lead to women being stigmatised and isolated from their families and communities among other socio-economic losses.</p>
<p>While conducting <a href="https://www.ncbi.nlm.nih.gov/pubmed/27918334">research</a> in East Africa, I personally witnessed the profound lack of safe anaesthesia. This meant that there was a delay in access to safe and immediate caesarean sections. The lack of access was due to a number of issues. These include few anaesthetists, lack of equipment and emergency drugs, shortage of blood supply and failed referral systems.</p>
<p>In my more <a href="https://academic.oup.com/heapol/article/33/9/999/5106382">recent research</a> I conducted a cost evaluation to see if it made sense to provide women with fistula repair surgery. We looked at it both from the point of view of the long-term cost to women as well as the financial cost. </p>
<p>Our study found that fistula surgery is cost-effective and can significantly reduce disability in women of childbearing age in Uganda.</p>
<p>Our findings were consistent with a previous modelled analysis on the issue in low- and middle-income countries. Increasing access to high quality obstetric and fistula surgery could improve the health of many women in resource-limited settings. </p>
<h2>What we found</h2>
<p>Our study is the first publication on the cost-effectiveness of obstetric fistula repair in the East African region. </p>
<p>We built a model to estimate the cost-effectiveness of vesico-vaginal and recto-vaginal fistula surgery versus no surgery to Uganda’s national health system. </p>
<p>We assessed long-term disability outcomes based on a lifetime Markov model. This involved mapping a sequence of possible events in which the probability of each event depended only on the state attained in the previous event. Surgical costs were estimated by micro-costing local Ugandan health resources. Disability weights associated with vesico-vaginal, recto-vaginal fistula, and mortality rates in the general population in Uganda were based on published sources.</p>
<p>We estimated that the cost of providing fistula repair surgery in Uganda was $378 per procedure. For a hypothetical 20-year-old woman, surgery was estimated to decrease the number of years lost to disability from 8.53 to 1.51. </p>
<h2>What is needed</h2>
<p>Our model found obstetric fistula surgical repair to be the optimal strategy for management of this condition, and one that is highly cost-effective in Uganda. Our study provides data for policy makers to prioritise implementation of this procedure in developing countries. </p>
<p>But this will require significant social and economic attention. The lack of action to date has been because of insufficient political commitment, the low numbers of skilled healthcare providers and the inability to retain skilled birth attendants in priority areas. </p>
<p>Three vital ways to prevent obstetric fistula are to provide access to skilled care during delivery, to closely monitor progress during labour, and to provide emergency caesarean sections. But low and middle-income countries lack sufficient surgeons and resources to treat patients with obstetric fistula. </p>
<p>While the current estimates of the unmet need for fistula surgical repair in low-income countries are not well documented, 10 years ago it was estimated to be as high <a href="https://obgyn.onlinelibrary.wiley.com/doi/full/10.1016/j.ijgo.2007.06.011">as 99%</a>. Therefore, there is an urgent need to strengthen care in low income countries for better maternal and neonatal outcomes. </p>
<p>All this needs to change if countries are going to achieve the goal of making sure that every citizen – whatever their income – has access to universal health care. And priority must be given to investing in medical facilities that are able to provide adequate prenatal care as well as healthy deliveries. Strengthening the option for women to have safe surgery during birth complications would decrease maternal and neonatal morbidity and move closer to the goal of safe motherhood.</p><img src="https://counter.theconversation.com/content/108206/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Isabella Epiu received funding from USA National Institute of Health, World Federation of Societies of Anaesthesiologists, University of California Global Health Institute - Center for Expertise in Women, SONKE Gender Justice.</span></em></p>If women don’t have access to quality emergency surgery, they can develop dibilitating complications such as fistula.Isabella Epiu, MD PhD, Postdoctoral Fellow Global Health, University of California Global Health Institute (UCGHI), Makerere UniversityLicensed as Creative Commons – attribution, no derivatives.