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Santé maternelle et des nouveaux-nés

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Contents

Analytical summary

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Most maternal deaths occur during or after childbirth, and most are preventable. The lifetime risk for maternal mortality in African women is 1 in 26, compared with 1 in 7300 in the developed world. Leading causes are bleeding (haemorrhage), hypertension, abortion-related problems and sepsis. Other risks are due to undernutrition, anaemia, tuberculosis, malaria and HIV/AIDS.

Percentage of births by caesarean section in the WHO African Region, 2000–2010

The WHO African Region is making little progress in reducing maternal mortality, although to achieve Millennium Development Goal 5 requiring a reduction in maternal mortality of three quarters by 2015, a decline of at least 5.5% a year is needed. The Region has the highest rate of newborn deaths in the world at 41:1000 live births.

Almost 60% of all adults living with HIV/AIDS in sub-Saharan Africa are women. A total of 1.4 million pregnant women are infected and 90% of children with HIV/AIDS become infected through mother-to-child transmission.

Factors influencing maternal and newborn mortality include weak health infrastructure, human resource shortages, lack of drugs and limited laboratory capacity.

However, there is an increase in the numbers of women obtaining tests for HIV and 45% of pregnant women are now receiving antiretroviral therapy to prevent mother-to-child transmission.

Malaria poses a serious threat to pregnant women, as 90% of all malaria occurs in Africa. Malaria in pregnancy contributes to anaemia and low birth weight, as well as to other health conditions. Coinfection with HIV exacerbates malaria in pregnancy.

Other maternal and newborn risks include poor nutrition, especially in adolescent pregnancy. Perinatal mortality rates are twice as high when the mother is under the age of 20 years. The continuing low availability and uptake of contraceptives in all age groups compounds the problems, as 32% of maternal deaths could be prevented if women had unlimited access to contraceptives.

Antenatal care services are weak and inadequate, with only eight countries in the Region having an average of skilled birth attendance over 80%, the rate required to significantly reduce maternal mortality.

Political commitment has been made and policies are in place in a significant number of countries. However, implementation remains varied and inequitable and women continue to face geographical, financial, physical and health systems barriers to care.



Disease burden

Percentage of births attended by skilled health personnel in the African Region, 2000–2010

Maternal mortality in the African Region is estimated at 900:100 000 live births, compared to 28:100 000 in Europe and 11:100 000 live births in Northern America. The lifetime risk of maternal death is 1 in 26 in Africa, as opposed to 1 in 7 300 in developed regions[1].

Most maternal deaths occur during or immediately after childbirth, and from preventable causes. New WHO global estimates show maternal deaths from haemorrhage (34%), hypertension (19%), abortion (9%), and sepsis (9%). Other direct causes of maternal death globally total 12%, and include ectopic pregnancy, embolism and anesthesia-related causes. Indirect causes amount to 17%.

In sub-Saharan Africa, maternal undernutrition, severe anemia, TB, malaria and HIV/AIDS increase the risk of maternal death at birth, and are associated with at least 20 % of maternal mortality.

Maternal Mortality Rate (MMR) estimates for 2005 show that the WHO African Region had made no progress towards achieving this target. Only 13 countries[2] had a maternal mortality ratio of less than 550:100 000 live births. Thirty-one countries had very high maternal mortality rates, equal to or more than 550:100 000. Of these, 12 countries[3] had maternal mortality ratios of 1 000 or more per 100 000 (Figure 1).

Figure 1: Progress Towards Achieving MDG 5 Goal of Reducing Maternal Mortality in the WHO African Region

Fig20section46MNHfig1.png


Between 1990 and 2005, maternal mortality in sub-Saharan Africa declined only by 0.1%, although to achieve MDG 5 on reducing maternal mortality by three quarters by 2015, a decline of at least 5.5% per year is required. Progress towards increasing access to essential interventions, such as access to skilled birth attendance and emergency obstetric care, has also been very slow in the African Region.

Perinatal mortality rate

Perinatal mortality comprises stillbirth combined with early neonatal mortality rates. The majority of countries, however, report on neonatal mortality rather than perinatal mortality. Demographic and Health Surveys reported on perinatal mortality rate in only 17 countries’... This ranges from 29/1 000 live births in Swaziland, to 50/1 000 live births in Mali.

Neonatal and post-neonatal mortality rate

The African Region has the highest newborn mortality rate in the world, estimated at 45/1 000 live births. This compares with 34:1 000 in Asia, 17/1 000 in Latin America, and 5/1 000 in developed countries. Every year, one million babies in sub-Saharan Africa are stillborn, of which at least 300 000 die during labour. A further 1.2 million babies die in their first month of life, with up to half these deaths occurring on the first day[4]. The major causes of neonatal deaths are the following.

  • Preterm births (29%)
  • Infections including pneumonia/ septicemia (28%)
  • Birth asphyxia and trauma (27%)
  • Neonatal tetanus (2%)
  • Congenital abnormalities (7%)
  • Diarrhoeal diseases (2%)
  • Other neonatal causes (5%).

HIV in pregnancy

The availability of rapid HIV testing with return of results on the same day has been very helpful. By 2008, 25 countries in sub-Saharan Africa had implemented rapid HIV/AIDS testing with same day results in at least 75% of their antenatal facilities.

In sub-Saharan Africa, women now account for almost 60% of the adults living with HIV/AIDS, and in 2008 1.4 million pregnant women were living with HIV/AIDS[5]. Of these, 70% were concentrated in eastern and southern Africa. Among the 20 countries with the highest estimated numbers of pregnant women living with HIV/AIDS, 19 are in sub-Saharan Africa. More than 90% of children living with HIV/AIDS in these countries are infected through Mother To Child Transmission.

Despite international and Head of State commitments to ensuring that 80% of pregnant women gain access to comprehensive Prevention of Mother-to-Child Transmission (PMTCT) treatment by 2010, countries are still facing challenges. These include weak infrastructure in primary health centers, the shortage of trained health workers, stock-out of antiretroviral drugs due in most countries to inadequate coordination among national authorities and partners, the limited capacity of laboratories, and lack quality assurance all slow national progress towards the MDG Target objectives.

Progress has been made and good practices identified in some countries. In sub-Saharan Africa, the percentage of pregnant women who received an HIV/AIDS test increased from 17% in 2007 to 28% in 2008. Countries such as Kenya, Malawi, Mozambique, South Africa, the United Republic of Tanzania and Zambia have reached testing coverage of around 60-80%.

The percentage of HIV-positive pregnant women who received antiretroviral treatment to prevent mother-to-child transmission reached 45% in 2008. Eastern and southern Africa made substantial progress, with coverage increasing from 46% in 2007 to 58% in 2008.

Cote d’Ivoire and Lesotho have documented rapid acceleration in coverage, increasing from 13% in 2007 to 41% in 2008, and 27% in 2007 to 57% in 2008, respectively.

Malaria in pregnancy

Malaria in pregnancy (MIP) poses a serious threat to pregnant women and their newborns, especially in Africa where 90% of the world’s malaria cases occur. In sub-Saharan Africa, malaria infection is estimated to cause 400 000 cases of severe maternal anemia and 75 000–200 000 infant deaths annually. Maternal anemia contributes significantly to maternal mortality, causing an estimated 10 000 deaths annually. In malaria-endemic areas, MIP contributes to a number of health problems.

  • 2–15% of maternal anemia
  • 8–14% of low birth weight
  • 8–36% of preterm births
  • 13–70% of intrauterine growth restriction
  • 3–8% of infant death.

In addition, the burden of malaria in pregnancy is exacerbated by co-infection with HIV. Sub-Saharan Africa bears the brunt of this co-morbidity, where approximately 25 million pregnant women are at risk of Plasmodium falciparum infection every year, and 13.5 million of the world’s HIV/AIDS infected women reside. The use of insecticide-treated nets (ITN) among pregnant women is very uneven, varying from only 1% in Cameroon and Swaziland to 60% in Rwanda. The uptake of intermittent preventive treatment (IPT) is also very low, ranging from 3 to 60%.

Risk factors/vulnerability

Factors contributing to the poor health status of mothers include inadequate availability of essential health care, or the inability of many mothers and their children to access it; high levels of maternal undernutrition and poor feeding practices; insufficient maternal education, and limited access to contraception contributing to unplanned and unwanted pregnancies.

Proportion of rural births

In most sub-Saharan African countries, the majority of births occur in rural areas. Thirty-three out of 36 countries reported more than half of all births occurring in rural areas[6]. But the majority of skilled health care personnel, especially midwives, work in urban settings. Maternity care services are frequently not available where women need them.

Low birth weight

In sub-Saharan Africa, more than 14% of babies are born with low birth weight (LBW) each year. The proportion of low birth weight (less than 2.5 kg at birth) varies from country to country. The 2005 Demographic and Health Survey (DHS) in Ethiopia reported a rate of 0.4%, Rwanda reported 1.7%, Senegal reported 6.3%, the Congo reported 10.4%, and Sierra Leone reported 24%[7]. In sub-Saharan Africa, low birth weight is often due to malaria and malnutrition in pregnancy. Malaria in pregnancy also leads to premature delivery. All these conditions are risk factors for neonatal death and impaired cognitive development. Other causes of low birth weight, such as infection, alcohol and tobacco, are much less frequent in African countries.

Nutrition

The health and nutritional status of pre-pregnant and pregnant women are critical determinants of outcomes of pregnancy, such as the birth weight of the baby. The growth of the fetus depends on the net deposition of tissue, which requires the constant availability of energy and nutrients. Nutrient availability also depends on the nature and size of maternal reserves, and her metabolic capability to establish a nutrient environment suitable for each particular stage of development of the growing fetus. A pregnant woman’s ability to meet her fetus’s growing nutritional needs is determined by the extent to which concurrent demands compete for the same nutrients.

In the African Region, exposure to infections and infestations, hard physical labour including carrying of heavy loads, short intervals between pregnancies, and mental and emotional stresses, are potential risk factors known to increase the nutritional requirements of pregnant women[8]. Poverty and hunger associated with household food insecurity is one of the major factors hindering the availability and improvement of dietary intake. Poor maternal nutrition in African countries is reflected in the high rates of low birth weight babies. In an effort to address this problem, the African Regional Consultation on Integrated Approaches to Promote Optimal Fetal Growth and Development was held in 2006. The consultation emphasized household food security and essential nutrition actions, highlighting interventions that could facilitate the integration of optimal fetal growth and development into maternal and child health programmes at country level.

Fertility

The average total fertility rate in the African Region has declined from 6.2 children per woman in 1990 to 4.9 in 2008. However, there is a significant variation, ranging from 1.8 to 7.1 children per woman, depending on the country and the sub-region. The level of adolescent fertility over the period 2000–2007 stands at 118 births per 1 000 adolescent girls aged 15–19 years, which is the highest in the world. Adolescents contribute to the high maternal mortality in the African Region, accounting for up to 40% of all maternal deaths in some countries[9].

Teenage pregnancy

The highest rate of teenage pregnancy in the world occurs in sub-Saharan Africa. In general, African women marry at much earlier ages than women elsewhere, leading to earlier pregnancies. On average, 26% of total maternal deaths occur during adolescence [10], with perinatal deaths estimated to be twice as high when the mother is under 20 years of age. The unsafe abortion rate is higher among girls aged 15–19 years, and one African girl out of four in this age group is affected.

Intervention coverage

Family planning

Pregnancies that are too early, too closely spaced, too late, or too many are among the main determinants of maternal deaths. In spite of this evidence, access to and use of contraceptives have not been widely successful in African countries. The regional average of contraceptive prevalence among married women in sub-Saharan Africa is 24.3%. Data available during 2000–2008 indicate that 24% of women wanting to delay or stop childbearing were not using a family planning method. Among other factors, traditional beliefs, religious barriers, lack of male involvement, and inappropriate health services, especially for adolescent girls, contribute to continuing unmet need for family planning.

As one of the pillars of safe motherhood and an essential component of primary health care, family planning could play a key role in reducing maternal and newborn morbidity and mortality. It is estimated that 32% of maternal deaths could be prevented if women who wish to stop or delay childbearing were able to use effective contraception[11].

Antenatal care

Antenatal care attendance in the African Region is 73% for one visit, rising to a maximum of only 44% for four visits. This low uptake is mainly due to the poor quality of services provided in maternity units, including the negative attitude of health workers. The new WHO approach[12] now being implemented in many African countries seeks to improve the quality of antenatal care provided to women, particularly in low-resource settings. Also described as focused antenatal care (FANC), this new approach is based on the following principles:

  • Quality of care rather than quantity of care
  • Four comprehensive visits for women with normal pregnancy
  • Individualized care, client-centered care
  • Disease detection and not risk categorization
  • Evidence based practices during antenatal care provision
  • Birth and emergency preparedness.

In many low resource settings, client friendliness is often needlessly sacrificed in the face of severe human and financial resource challenges. For example, shortage of midwives in some settings has led to a “factory assembly line” system of care, in which pregnant women are processed in a long queue through various clinical stations such as weighing, blood pressure, and palpation. This approach results in poor quality care, defeating the very goals antenatal care wishes to achieve.

The antenatal clinic has also, in many low resource settings, become an important vehicle for providing integrated care, in an effort to address the multiple health challenges facing pregnant women. In sub-Saharan Africa, for example, the HIV/AIDS pandemic and the malaria scourge has necessitated the development of special care packages, and inserting them into antenatal care approaches. Family planning and nutrition packages are also being introduced. Inserting these into routine antenatal care is challenging, and requires innovative clinic management to maintain client friendliness and high quality care.

Skilled Birth Attendant at delivery

Although all women and newborns need access to a skilled birth attendant, overall coverage remains insufficient and uneven. The percentage of births attended by skilled personnel is still very low, standing at 46.5% in sub-Saharan Africa[13]. Twenty-eight countries have at least 50% of births attended by skilled personnel[14]. Only eight countries have an average of skilled birth attendance above 80%, which represents the rate required to significantly reduce maternal mortality. Two countries, namely Burkina Faso and Rwanda, gained more than 20 percentage points between 2000 and 2008. There is an urgent need to increase human resources in maternity units in order to effectively assist pregnant women at delivery.

Place of delivery

More than half of all deliveries in sub-Saharan Africa occur at home without the assistance of skilled personnel. Mainly due to geographical, transport, and financial barriers, pregnant women do not have the access they need to existing maternity services[15]. In Ethiopia, Chad, Niger and Sierra Leone, where maternal mortality is very high, the percentage of home delivery is greater than 80%.

C-section

Africa has the lowest rate of caesarean section anywhere, with an average rate of only 3.40% compared to 13.9% globally[16]. Where maternal mortality is high, the rate of caesarean section tends to be low, especially in rural areas. The rate varies from 0.4% in Chad to 37% in Mauritius. Most countries have a caesarean section average rate below 5%, whereas an average of 5–15% is an average requirement.

Equity

In the African Region, inequities in coverage and access to proven interventions remain challenges. Women still face geographical, financial, physical and health systems barriers to care. Poor women in the region are especially vulnerable to the following shortcomings:

Gaps in care where it is most needed

In most African countries maternal, newborn and child deaths occur at home, often due to delays in reaching the care they need. Only 12% of pregnant women requiring Emergency Obstetric Care (EmOC) receive it.

Gaps in availability of essential interventions such as skilled birth attendance

Postnatal care and family planning, as well as skilled attendance at birth reached, only half the women and babies in the 68 countries that were monitored during the Count Down 2010 Initiative. Although more mothers and babies die at and near the time of birth than at any other time, care is then at its lowest. This calls for intensified efforts to scale up priority interventions to improve access to, and availability of, skilled attendance. The importance of postnatal care for both mothers and babies has only recently been fully recognized.

Quality gap and missed opportunities.

Antenatal services in particular have been used as points of entry for the delivery of various preventive care services, for example for PMTCT, IPT and ITN against malaria, and protection against neonatal tetanus. This practice should be increased.

Policies

Political momentum is now building globally to address the question of high maternal and child deaths, together with their leading causes. Recently, the May 2009 launch of a Continental Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA), under the slogan “Africa Cares: No Woman Should Die While Giving Life”, and the World Health Assembly’s decision to make maternal and child health a major theme for the Fifteenth Ordinary Session of the African Union Summit in July 2010, also demonstrate the commitment now accorded to reducing high maternal, newborn and child mortality.

Forty-two of the 46 countries in the African Region have developed a strategic plan or Road Map to accelerate the reduction of maternal and newborn mortality. This Road Map serves as a framework to support maternal and newborn health activities. Countries are currently in the process of moving from strategic to costed operational plans at national and district levels.

Among other policies and strategies, the Family and Reproductive Health Cluster and its partners have developed a ten-year framework for accelerated action to reposition family planning on national agendas[17]. This was adopted at the Fifty-fourth Session of the WHO Regional Committee for Africa. However, the African Region is experiencing reduced donor support for family planning, and fragmentation of various interventions. In this context, the proposed development of the Regional Agenda for Accelerating Universal Access to Sexual and Reproductive Health in the African Region will serve as a clear roadmap on how governments and all development partners would work together, united around one common agenda.

Systems

Financial flows remain too low to achieve the needs identified. Only 31% of all official development assistance for health was allocated to maternal, newborn and child health in 2007. Despite the Abuja commitment to allocate 15% of the national budget to health, only 6 countries have reached the target (Botswana, Burkina Faso, Malawi, Niger, Rwanda and Zambia).

State of surveillance

Evidence shows that maternal death review (MDR) is an effective means of improving quality of care and accountability of health services, and thereby reducing maternal mortality and severe morbidities. The primary objective of conducting an MDR is to facilitate national, regional and local actions based on analysis of causes and avoidable factors causing maternal death and severe disabilities. The successful experience of South Africa since 1997 in conducting national confidential enquiry into maternal death has encouraged other countries in Africa to take up a similar approach.

Since 2003, WHO, UNICEF and UNFPA have promoted the institutionalization of MDR in health systems. Twenty-seven African countries have now received orientation in this process. Progress has been made in some countries in setting up national and local MDR committees, developing guidelines, training health professionals, undertaking regular MDR and analysis, and taking appropriate action to improve services. In most countries, however, MDR is still limited to a small number of hospitals or districts, demonstrating the need for significant scaling up in this area.

Endnotes: sources, methods, abbreviations, etc.

List of Tables and figures

Figure 1: Progress Towards Achieving MDG 5 Goal of Reducing Maternal Mortality in the WHO African Region

Atlas Figure 89: Percentage of low-birthweight newborns in the African Region, by country, 2000 – 2008.

Atlas Figure 91: Percentage of births attended by skilled health personnel in the African Region, 2000-2008

References


1. Maternal mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA and the World Bank, 2007. WHO, Geneva. http://www.who.int/reproductivehealth/publications/maternal_mortality_2005/index.html (accessed on 29/10/08)

2. Opportunities for Africa's newborns: Practical data, policy and programmatic support for newborn care in Africa. The Partnership for Maternal, Newborn and Child Health. WHO (YEAR?)

3. Towards universal access – scaling up priority HIV interventions in the health sector. Progress Report 2009. WHO, Geneva.

4. Cleland J, Bernstein S, Ezeh A, Faundes A, Glasier A, Innis J, 2006. Family planning: the unfinished agenda. Lancet 368 (9549):1810-27.

5. World Health Organization. Antenatal Care Randomized Trial: Manual for the Implementation of the New Model, 2003. WHO, Geneva.

6. Resolution AFR/RC54/R2: Repositioning family planning in reproductive health services: framework for accelerated action, 2005-2014. WHO Regional Office for Africa, Brazzaville, 2005

7. World Health Organization, UNFPA, UNICEF and AMDD Monitoring Emergency Obstetric Care: a Handbook, 2009. WHO, Geneva.

8. World Health Organization, Department of Making Pregnancy Safer, Country Profiles, 2008. WHO, Geneva.

9. Promoting optimal fetal development : report of a technical Consultation, 2003. WHO, Geneva. http://www.who.int/nutrition/publications/fetal_dev_report_EN.pdf (accessed on 16/08/10)

10. Resolution AFR/RC51/R3: Adolescent heath: A strategy for the African Region, 2001. WHO Regional Office for Africa, Brazzaville.

11. World Health Statistics 2010. WHO, Geneva.

References

  1. Maternal mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA and the World Bank, 2007. WHO, Geneva. http://www.who.int/reproductivehealth/publications/maternal_mortality_2005/index.html (accessed on 29/10/08)
  2. Algeria, Botswana, Cape Verde, Comoros, Eritrea, Gabon, Madagascar, Mauritius, Mozambique, Namibia, South Africa, Swaziland and Togo
  3. Angola, Burundi, Cameroon, Chad, Democratic Republic of Congo, Guinea Bissau, Liberia, Malawi, Niger, Nigeria, Rwanda, and Sierra Leone
  4. Opportunities for Africa's newborns: Practical data, policy and programmatic support for newborn care in Africa. The Partnership for Maternal, Newborn and Child Health. WHO
  5. Towards universal access – scaling up priority HIV interventions in the health sector. Progress Report 2009. WHO, Geneva.
  6. World Health Organization, Department of Making Pregnancy Safer, Country Profiles, 2008. WHO, Geneva.
  7. World Health Organization, Department of Making Pregnancy Safer, Country Profiles, 2008. WHO, Geneva.
  8. Promoting optimal fetal development : report of a technical Consultation, 2003. WHO, Geneva. http://www.who.int/nutrition/publications/fetal_dev_report_EN.pdf (accessed on 16/08/10
  9. 10. Resolution AFR/RC51/R3: Adolescent heath: A strategy for the African Region, 2001. WHO Regional Office for Africa, Brazzaville.
  10. Promoting optimal fetal development : report of a technical Consultation, 2003. WHO, Geneva. http://www.who.int/nutrition/publications/fetal_dev_report_EN.pdf (accessed on 16/08/10)
  11. Cleland J, Bernstein S, Ezeh A, Faundes A, Glasier A, Innis J, 2006. Family planning: the unfinished agenda. Lancet 368 (9549):1810-27.
  12. World Health Organization. Antenatal Care Randomized Trial: Manual for the Implementation of the New Model, 2003. WHO, Geneva.
  13. Maternal mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA and the World Bank, 2007. WHO, Geneva. http://www.who.int/reproductivehealth/publications/maternal_mortality_2005/index.html (accessed on 29/10/08)
  14. World Health Statistics 2010. WHO, Geneva.
  15. World Health Organization, Department of Making Pregnancy Safer, Country Profiles, 2008. WHO, Geneva.
  16. World Health Organization, Department of Making Pregnancy Safer, Country Profiles, 2008. WHO, Geneva.
  17. Resolution AFR/RC54/R2: Repositioning family planning in reproductive health services: framework for accelerated action, 2005-2014. WHO Regional Office for Africa, Brazzaville, 2005