Analytical summary - Maternal and newborn health
Women’s health has come to the fore in the nation’s health agenda most recently due to concerns over maternal health. The maternal mortality ratio is on the increase (almost doubling between 1992 and 2007) despite increased delivery at health facilities, indicating weaknesses in the quality of services.
The DHS of 2006/2007 shows that the perinatal mortality rate was 29 per 1,000 pregnancies. The overall rate of stillbirths is below 10 in 1,000 pregnancies, while early neonatal mortality lies at 20 deaths in 1,000 pregnancies. (MoHSS and Macro, August 2008) Infant mortality declined from 71 deaths per 1,000 live births in 1980 to 45 in 2006. The same trend is observed in the under-five mortality rate, which is 61 deaths per 1,000 live births. This is a marked improvement from the 1980 level of 108 deaths per 1,000 live births (Inter-Agency Child Mortality Estimation Group (IACMEG), 2009).
However, according to the DHS 2006/2007 data, there is a slight upwards trend in infant and under-five mortality as compared to 2000 (38 to 46 and 62 to 69 respectively) which poses a significant challenge. The reduction in the under-five mortality rate, which is expected to be 42 deaths in 1,000 live births, is not sufficient to meet the MDG target of 29 per 1,000 live births by 2015.
The maternal mortality rate has increased from 271 deaths in 100,000 live births during 2000 to 449 deaths in 100,000 live births in 2006/ 2007. The direct causes of maternal deaths are eclampsia, obstructed and prolonged labour, haemorrhage and complications of abortion. Indirect causes of maternal mortality are mainly related to the high HIV/AIDS prevalence in Namibia.
About 18% of pregnant women have been tested HIV positive. A further indirect cause of maternal deaths is related to malaria infections. Pregnant women are more prone to malaria infections than non-pregnant mothers. Therefore, mother’s protection against malaria is essential during pregnancy. The DHS 2006/2007 indicates that in the group of pregnant women aged 15–49 years, 10.6% slept under any net, 9% did so under an ever treated net, while 8.8% slept under an insecticide treated net (ITN) in the night prior to the survey (MoHSS and Macro, August 2008).
Under-five mortality is 1.3 fold higher in rural than in urban areas. Moreover, the under-five mortality rate is nearly double among children in the lowest wealth quintile as compared to children in the highest wealth quintile. (WHO, 2008) There are also strong variations in under-five mortality between regions. According to the DHS 2006/2007, the highest under-five mortality rate among the 13 regions surveyed in Namibia was reported in Ohangwena. In this region, 95 children per 1,000 live births died before they reached age five. This was followed by Caprivi with an under-five mortality rate of 93 per 1,000 live births. In contrast, Kunene shows a significantly lower mortality rate, with 49 deaths per 1,000 (MoHSS and Macro, August 2008).
In Namibia, during 2006/2007, 14% of babies were too light for their gestational age. This is a clear increase from 5.7% during 1992 and 8% during 2000 (MoHSS and Macro, August 2008; MoHSS, 2000; MoHSS, 1992). Interestingly, according to the DHS 2006/2007, almost 16% of women during 2006 were underweight and exhibited a body mass index of less than 18.5 (MoHSS and Macro, August 2008)
The nutritional condition of children in Namibia is poor. Almost 30% of children are stunted. This is a marked increase from 2000, where the number of stunted children was just higher than 20%. Of children born during 2006/ 2007, 14% had a low birth weight. This indicates that a significant number of women suffer of insufficient calorie intake, or have pregnancy related complications that condition foetus development. (WHO, 2011)
The Namibian society in general leans towards and desires large families. Considerations of choices concerning family planning are determined accordingly (MoHSS, 2001). During 2006/2007 the total fertility rate (TFR) in Namibia (the number of children a woman would have by the end of her childbearing years if she were to pass through those years bearing children at the currently observed age-specific rates) was 3.6, indicating a reduction since 2000. Given the relatively high fertility rate, at least in some regions, concerns exist regarding the spacing of births. The median length of period between births in Namibia is 42.3 months.
The number of teenagers who have begun childbearing is high. More than 15% of teenagers are pregnant with their first child or already had a child. In the Kavango, Otjozondjupa, Kunene, Caprivi and Omaheke regions, adolescents that are at least pregnant with their first child exceed 25%.
Trends in coverage of health interventions for newborns and children under-five suggest that it has been on the increase since 1992, except for initiation of breastfeeding within one hour after birth; and the treatment with anti-malarial drugs amongst under-five year olds. For both interventions, coverage has gone down since 2000 (MoHSS and Macro, August 2008; MoHSS, 1992; MoHSS, 2000).6
Coverage of interventions is consistently higher for the upper wealth quintile. Only for initiated breastfeeding within the first hour after birth that the lowest quintile has marginally higher percentage coverage. In terms of anti-malaria treatment, lowest and highest wealth quintiles have similar coverage. (MoHSS and Macro, August 2008)
Most pregnant women receive antenatal care during at least four visits. This is in accordance with WHO standards. However, on average pregnant women attend to their first visit rather late. Most visit a health facility during the fourth and fifth month (38.3%), while 20.8% go for a visit during month six and seven. The median length of the pregnancy at first visit is 4.7 months. (MoHSS and Macro, August 2008)
Factors can be related to distance to health service facility and expensive or non-availability of transportation. More than 70% of women reported at least one serious problem to accessing health care when sick. During 2006 more than 70% of pregnant women received at least four ANC checkups. This signifies an increase of 14 percentage points since 1992. In terms of quality of antenatal care, while more than 90% of women were weighed and had blood pressure measured and blood and urine sample taken, only 58% were informed of signs of pregnancy complications. (MoHSS and Macro, August 2008)
Women and maternal and child health care givers are aware of the importance of nutrition to the health of pregnant women. This can be seen in terms of the high percentage of women taking iron supplements. However, the percentage of women taking antiparasite medicines is rather low. (MoHSS and Macro, August 2008; WHO, 2008).
Contraception can be a very useful tool to allow the body of the woman to recover before a next child is born. The use of modern contraceptive methods amongst women during 2006/ 2007 was at 46%, as opposed to only 26% in 1992. At regional level, according to the DHS of 2006/2007, the use of contraceptives varied from a low of 28% in Ohangwena to a high of 59% in the Erongo region. According to the DHS 2006/2007 most women who demanded means to limit or space births had their demand satisfied, which translates into more than 90% of demand for family planning being met. (MoHSS and Macro, August 2008)
In Namibia, according to the DHS of 2006/2007, nearly 60% of all births occurred in rural areas. Statistics also show that about 81% of all births took place in a health facility. This is an improvement over the previous years with 67% and 75% of births taking place in health facilities in 1992 and 2000 respectively. (MoHSS and Macro, August 2008) Despite the high numbers of women delivering in health facilities, the quality of care is a concern.
Every day more than 10,000 newborn die mostly because pregnant women do not have access to skilled emergency care. A 2005/06 survey of all hospitals found that only four out of 34 hospitals provided comprehensive EmOC. (MoHSS and Macro, August 2008)
In 2006-07, more than 70% of births were assisted by Skilled Birth Attendants (SBAs), and more than 10% of babies were delivered by caesarean section. (MoHSS and Macro, August 2008) Of the births in urban areas, more than 20% were delivered by caesarean section, in rural areas this number is only 7%, mainly due to a lack of EmOC facilities and staff such as anasthetists. (MoHSS and Macro, August 2008; MoHSS, 2008)
Comprehensive emergency obstetric care (CEmoC) facilities are unevenly distributed in Namibia. The four health facilities providing all the eight signal functions are in the central regions - two in Windhoek, one in Otjiwarongo and one in Oshakati. The highly populated northern areas do not have CEmoC facilities (MoHSS, 2006).
The DHS of 2006/2007 indicates that 65% of Namibian mothers received a postnatal check-up within two days for her last live birth. Of these, most women had their check-up within four hours after birth. (MoHSS and Macro, August 2008)
According to the 2006-07 NDHS, coverage of ARV prophylaxis was less than 10%. Considering that 18.8% of pregnant women are HIV positive, the ARV coverage is rather low. Prophylaxis administered to the baby is at about the same level. Again, considering the high percentage of under-five deaths due to HIV/AIDS, this level is also rather low. (MoHSS and Macro, August 2008)
The main policies governing maternal and newborn health in Namibia are the National Policy on Infant and Young Child Feeding, 2007 and National Policy for Reproductive Health, 2001. Efforts are being made to build capacity and skills of health workers to provide quality essential services to mothers during pregnancy and after delivery. The 2011-2015 Strategic Plan for Nutrition includes strategic priorities to improve maternal nutrition and contribute to improved maternal health, as well as reductions in neo-natal and infant mortality rates.
A Road Map for Accelerating the Reduction of Maternal and Neonatal Morbidity and Mortality (2010) was developed to guide Government and partners in achieving universal access to comprehensive quality maternal and neonatal health care, and accelerate progress towards achieving the health MDGs.
Namibia is experiencing a general crisis in human resources for health in the public sector. In terms of capacity for EmOC in particular, human and other resources are not sufficient and unevenly distributed. (MoHSS, 2008; MoHSS, August 2008)
Nearly 90 percent of total health spending (THE) on reproductive health (RH) was funded by the central government in 2008/09, down slightly from 93 percent in 2007/08. The total RH expenditure (THERH) was estimated to be N$583 million (US$65 million) in 2007/08, declining to N$508 million (US$57 million) in 2008/09, and bringing RH to only 10 percent of the THE in 2008/09. The decline in RH spending has occurred as maternal and child mortality rates are increasing, especially among poor, remote, and uneducated populations.
Namibia has developed a Reproductive Health Roadmap to strengthen availability, access, and provision of quality maternal and child health services, surveillance, referral mechanisms, and monitoring and evaluation. The roadmap is estimated to cost N$6.4 billion (US$717.2 million) over five years (2009–2014) and calls for steep increases in RH spending, from N$633 million (US$70.5 million) in 2010 to N$908 million (US$101.1 million) in 2014. If Namibia is to implement its roadmap, it will need to place a much stronger emphasis on RH using a combination of several sustainable methods such as HIV/AIDS and RH integration, public-private sector collaboration, and integration of RH services into existing and future medical aid schemes. (MoHSS, December 2010)
In response to the maternal and child mortality rates, Namibia has undertaken additional resource tracking activities to provide more detailed information in these priority areas. The newly integrated national health accounts therefore include subaccounts for HIV/AIDS and reproductive health. (MoHSS, December 2010). A wide range of maternal and newborn health indicators are also surveyed in regular NDHSs.
In April 2010, Guidelines for Completing the Maternal & Peri/Neonatal Death Review Form was produced in order to facilitate the investigation of maternal, peri-natal and neonatal deaths within health facilities (MoHSS, April 2010). In 2005 a needs assessment was conducted for EmOC (MoHSS, 2006).