Doing More: Linking Governance and Positive Maternal Health Outcomes

By Derek Langford, Program Assistant for the Africa Program

Sub-Saharan Africa is perhaps the riskiest place for a woman to give birth.  According to the United Nations Population Fund (UNFPA), African women comprise approximately 56 percent of the maternal deaths and 91 percent of HIV-related maternal deaths worldwide every year.  In order to bring life into this world, women in Africa literally must put their own lives on the line.  This is alarming, yet not surprising.  For some time African governments, healthcare professionals, and the international community have been acutely aware of the scope of this problem in Africa and its ramifications for the continent.  It is well understood that healthy women give birth to, and rear, healthy children who then, in turn, are able to positively impact society. Conversely, a motherless child is 10 times more likely to die prematurely than children who grow up with a maternal figure. What is shocking, but gets very little news coverage, is that we know how to impact this situation for the better – good governance is essential for positive maternal health outcomes. Governance is generally understood as the means, procedures, and institutions through which a society manages its affairs.  In the developing world, including in sub-Saharan Africa, government too often conducts itself as though it and it alone, has the exclusive right to manage societal affairs.  This narrow approach to governance is misguided.  It stifles innovation from civil society and the private sector, and is insufficient to respond to development deficits. Indeed, governance ought to be broadened to include civil society, non-profit and private sectors so that myriad stakeholders can be empowered to develop solutions and participate fully in decision-making processes.

In the case of maternal health outcomes in Africa, this notion of expansive governance must include citizen engagement, advocacy, and participation in policy discussion, formulation, and implementation.  It is hardly a coincidence that in 2010 countries with democratic veneers and questionable approaches to governance like Zimbabwe, Sudan, Democratic Republic of the Congo, Cameroon, Central African Republic, Guinea-Bissau, and Chad averaged no less than 550 maternal deaths per 100,000 live births, among the highest and most distressful levels on the continent.  That is not to say that there are not other factors driving the numbers, that there are not anomalies, such as Rwanda, or that the aforementioned governments do not honestly care about the health, well-being, and pre- and antenatal care of the women whose lives are in jeopardy when giving birth in their countries.  But, that is not at issue.  The point is whether or not the countries suffering from inadequate maternal health support in Africa can summon the will to redefine their management of societal affairs and allow the space necessary to chart a new course with respect to maternal health outcomes.

Nigeria is one such African country that provides an interesting dichotomy of disquieting data and hopeful inventiveness. Nigeria has an abysmal record in terms of maternal health.  According to statistics furnished by the World Bank in 2010, approximately 630 Nigerian women die for every 100,000 births – countries like Afghanistan and Haiti outperform Nigeria in this regard.  When Nigeria is juxtaposed with its sub-Saharan counterparts, a woman is almost one full percentage point more likely to die in childbirth.  All told, the country ranks an uninspiring 10th place among world nations with the highest maternal mortality rate.

Fortunately, this is not the whole story.  The leadership in the southwest Ondo State has been experimenting with a pilot project on maternal health care that focuses on critical areas of access, quality, and governance.  The Abiye program, which translated from Yoruba means "safe motherhood," recognizes key obstacles inhibiting Nigeria's progress in this area. With an eye toward evidence-based policy reform, incentives, and accountability, as well as program efficiency and sustainability, Ondo's project offers a potential model for rolling back maternal mortality.  Through statewide surveys and analysis of community needs and healthcare providers, and perhaps most importantly, a strategic response to the concerns of Ondo women, Abiye is addressing the delays in the provision of pre- and antenatal care, the inaccessibility of health facilities, the knowledge and skills shortcomings of healthcare workers, and the lack of available emergency care.  Notably, the Abiye program trains and dispatches "health rangers" to, a cohort of about 25 expectant mothers, to bring basic services and information regarding nutrition and family planning to the community at-large.  As it functions, the health rangers are trained health liaisons who visit the homes of their cohort population about 4 times during pregnancy, transport the women to the health facility, and do postnatal follow up.  The Ondo government has passed a law requiring that all maternal deaths, without exception, are to be reported to authorities within 48 hours. In addition, the government is investing in modernizing existing health centers in each of the state's administrative counties, and is incentivizing hospitals to increase the number of state-funded childbirths that occur within their walls.  Furthermore, an oversight committee comprised of women, community leaders, and religious figures has been established to monitor Abiye on a local level and instill a sense of ownership.  The Abiye program is engendering an essential confidence in the healthcare system that had been sorely missing and it is producing results.

The safe delivery of every African child and the health of his or her mother ought to be treated by policymakers as an integral part of a country's economic future and a matter of national security.  Since Abiye was implemented in 2009, Ondo women are receiving record levels of pre- and antenatal care and access to health facilities.  Indeed, within two and a half months of the program's implementation, one health center in the state, the Akure Mother and Child Hospital, witnessed a spike in patient registration (60 percent, whereas in years past a mere 16 percent of women received pre- and antenatal care) and performed 13,000 deliveries and 2,000 caesarian sections free of charge. To be sure, this is a positive development, but it is not without its pitfalls.  Hospitals, like Akure, can be overwhelmed by the surge in enthusiasm, while local health clinics that are equally capable of treating these women are passed over because they are not always aware of the services they can receive from local clinics that are less well reputed.  However, Abiye is a testament to how good governance can and must play a role in addressing maternal health outcomes.  Let leaders pledge that not another woman will die needlessly in childbirth due to healthcare incapacity or a lack of political will.