Taking the risk out of giving birth

African countries have taken to the
Carmma initiative. It has been launched in
over 30 countries so far.
(Image: www.pbs.org )

AU commissioner for social affairs
Bience Ganawas with Ugandan first lady
Janet Museveni at the launch in that
country in 2010.
(Image: Flickr)

South African Ministry of Health
+27 12 395 9165
AU Directorate of Women, Gender
and Development

Litha Musyimi-Ogana
+251 11 551 77 00 Ext 220

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Valencia Talane

The problem of maternal deaths stopped long ago being about women’s health and care facilities – it is a power issue, between men and women, and will not be resolved until men realise it is very much their problem too.

This was the firm assertion of Bience Gawanas, AU Commissioner for Social Affairs, at the 2009 launch of the Campaign for Accelerated Reduction of Maternal Mortality in Africa (Carmma) in Tunisia.

“Women need to claim their power in society, to make sure they can live better lives for themselves and their children,” said Ganawas.

The Carmma programme has just been launched in South Africa.

How Carmma came about

Carmma was established three years earlier, when ministers of health from over 40 African countries gathered in 2006 to discuss a way forward in developing a strategy to curb the occurrence of maternal deaths.

The campaign was born out of what is now known as the Maputo Plan of Action, a document agreed upon at the same meeting held in the capital of Mozambique.

South Africa’s launch of the campaign came only recently – Friday 4 May was the date set for the big event, on the eve of the annual international day for midwives.

Health minister Aaron Motsoaledi did the honours in KwaZulu-Natal province at an event that was attended by, among others, senior government officials, leaders in the health fraternity, delegates from the AU and the UN, and members of NGOs.

The theme of the campaign is Africa Cares: No woman should die while giving life, which Motsoaledi quoted as a way of kicking off the proceedings.

“It is important to note that maternal mortality is not just the death of a women – it is death of a woman because she dared fall pregnant!” he went on to say.

Keeping MDGs in check

One of eight Millennium Development Goals (MDGs) established by UN member countries in 2000, maternal health has been a tough challenge for health authorities in African governments for decades.

The objective, in terms of the MDG, is to reduce, by 75%, the maternal mortality ratio from what it was in 1990 (430 per 100 000 women died in the world) by a set deadline of 2015. Additionally, the point is to also increase access for mothers to antenatal care that should be provided during pregnancy and delivery, as well as to the standard duration of postnatal care.

Four of the top five countries with the highest prevalence of maternal mortality are in Africa, so it was not by accident that a programme of accelerated proportions was deemed extremely necessary for the continent.

Seven years after its inception, the campaign has been incorporated into the reproductive health programmes of over almost all of the 40 countries present at its establishment.

Part of basic human rights

The right to health is a basic human right that every woman should enjoy, yet every day hundreds of women die in pregnancy and childbirth worldwide, according to the UN.

Every year, eight-million women suffer serious pregnancy-related illnesses and disabilities, such as obstetric fistula, and two-million babies don’t survive the first 24 hours of their lives.

A major cause of these tragedies is lack of access to maternity services, including the care of midwives or others with midwifery skills at childbirth.

The maternal mortality ratio in South Africa is estimated to have increased from 150 to 310 deaths per 100 000 live births between 1990 and 2008.

Abuse of maternity patients in health facilities can have an indelible psychological effect and drive women away from seeking care, leading to delayed diagnosis and treatment, and increased morbidity and mortality.

According to the Patient’s Rights Charter as determined by South Africa’s national Department of Health, all patients have the right to a positive disposition displayed by health care providers that demonstrate courtesy, human dignity, patience, empathy and tolerance.

However, according to a Human Rights Watch (HRW) article published in August 2011, pregnant women with complications experience problems with referrals to higher levels of care and with accessing emergency transport, like ambulances, when they need it.

This is despite the country having enough resources to improve care substantially.

HRW research further revealed that many women in South Africa don’t believe they’ll receive good treatment if they seek medical help in a clinic or hospital during childbirth. And if they do receive poor treatment, many don’t believe the doctors or nurses will be held accountable.

South Africa’s dilemma

The HRW’s Stop Making Excuses Report is based on research gleaned from visits between August 2010 and July 2011 to health care facilities providing maternity service, and interviews with patients, medical staff, health officials, and experts in the Eastern Cape.

The report finds the government is not addressing recurrent health system failures that contribute to poor maternal health outcomes. It also fails to be accountable for the implementation of existing reproductive and sexual health-related laws and policies that could greatly improve maternal health care and overcome abuses documented here and elsewhere.

However, HRW acknowledges that the government has made a genuine commitment to address these problems. Since the end of apartheid in 1994, for example, South Africa has passed important sexual and reproductive health-related laws and policies, and a constitutional guarantee of the right to health.

Acknowledging that maternal deaths are unacceptably high, the government has identified the decrease in maternal and child mortality as a national priority, and stated that this mission is one of four “strategic outputs” that the health sector must achieve by 2014.

Today, 92% of South African women attend antenatal care, almost 87% deliver in health facilities, and South Africa is one of the few African countries where maternity care is free, abortion is legal, and there is a system of confidential inquiries to assess levels, causes of, and contributors to maternal deaths.

All hope is not lost

Minister Motsoaledi, in his launch speech, outlines eight strategy points that South Africa will be following. They are:

• Addressing inequity through targeting of under-served areas;
• Development of a comprehensive and coordinated framework for the provision of Maternal, Neonatal, Child and Women’s Health (MNCWH) & Nutrition services;
• Strengthening community-based MNCWH & Nutrition interventions;
• Strengthening provision of key MNCWH & Nutrition interventions at PHC and district levels;
• Strengthening provision of key MNCWH & Nutrition interventions at district hospital level;
• Strengthening the capacity of the health system to support the provision of MNCWH & Nutrition services;
• Strengthening human resource capacity for delivery of MNCWH & Nutrition services;
• Strengthening systems for monitoring and evaluation of MNCWH & Nutrition interventions and outcomes.

The following are the key components of the Carmma strategy:

a) Strengthening access to comprehensive sexual and reproductive health services and rights, with specific focus to family planning services;
b) Advocacy and promotion of early antenatal care attendance/ booking;
c) Allocation of obstetric ambulances to every facility where deliveries are conducted;
c) Establishment of maternity waiting homes, where necessary and facilities for lactating mothers and for Kangaroo Mother Care;
d) Strengthening human resources for maternal and child health through:

• Training on essential steps in management of obstetric emergencies for doctors and midwives;
• Strengthening midwifery education and training.