Why 70 percent of the world’s maternal deaths are in sub-Saharan Africa

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In 2018, a hospital in Kenya admitted Ashley Muteti, who was 25 at the time, for a month. Muteti, who was over six months pregnant with what was to be her first child, was diagnosed with the hypertension disorder pre-eclampsia. During her hospital stay, Muteti met 10 other expectant or new mothers, seven of whom also had similar hypertension during pregnancy — though, like Muteti, they had no idea what the life-threatening condition was prior to being diagnosed with it.

While these women did receive care, the lack of awareness and health care delay poses a serious problem. Pre-eclampsia causes high blood pressure and can result in internal bleeding, seizures, stroke, premature birth, and more. The condition is one of the leading causes of maternal deaths globally, resulting in the death of 500,000 infants and 76,000 mothers every year.

Muteti survived her pregnancy, but her daughter, Zuri, who was born prematurely, died 49 days after her birth. In her daughter’s memory, Muteti started the Nairobi-based organization Zuri Nzilani Foundation, which seeks to strengthen maternal health care in Kenya by financially and emotionally supporting pregnant people, increasing training opportunities for health care professionals, and running digital education campaigns on the importance of prenatal care.

Muteti’s vision is that just as each country has a task force that addresses issues of conflict or natural disaster, every region will establish a team that focuses on maternal health. “How can we work together to ensure that no mother will die as a result of bringing life into this world?” she asks.

While global maternal death rates have dropped 30 percent in the last two decades, the world is still far from reaching Muteti’s goal.

A recently released WHO report found that the drop in maternal death rates stagnated after 2015. In 2010, there were 95,000 fewer maternal deaths globally than the decade before, but in 2020 there were only 65,000 fewer deaths than there were in 2010. Over 250,000 women died because of pregnancy-related causes in 2020. According to UNICEF, 2.3 million infants died within a month of birth in 2021.

In the Americas, Europe, and the Western Pacific, maternal mortality rates actually increased. The situation in the US is particularly shameful — newly released data from the Centers for Disease Control and Prevention (CDC) shows that the maternal mortality rate increased by about 40 percent in 2021 compared to the year before. The rate increased for all racial groups but was disproportionately worse for people of color, with Black mothers dying at rates more than twice as high as white mothers. All told, maternal deaths in the US hit their highest number since 1965.

But mothers in sub-Saharan Africa have it far, far worse. While rates still declined in the region between 2010 and 2020, the drop was slower than in the previous decade, and sub-Saharan Africa still has the highest rate of maternal deaths in the world. Of the 13 countries with the highest maternal mortality rates, 12 are located in sub-Saharan Africa (the only country on the list not in the region is Afghanistan), and in 2020 alone more than 200,000 women in the region died due to pregnancy.

Maternal deaths are primarily considered preventable, but if current trends persist, millions in sub-Saharan Africa will die from pregnancy-related causes in the next decade. The tools to prevent maternal deaths exist — birth control, safe abortions, cesarean sections, regular prenatal care, and more — but the distribution of these resources and the training to implement them is unequal.

WHO’s report found that four key factors contribute to high maternal death rates: health system failures such as a shortage of trained personnel or up-to-date supplies; economic and social circumstances including lack of education and wealth; harmful gender norms and stigma; and external pressures, like climate and humanitarian crises. To overcome them, women’s health care will need to be prioritized in a way it has never been before in sub-Saharan Africa.

“Women are not dying of diseases we cannot treat,” said Angela Gorman, the founder and outgoing CEO of Life for African Mothers, a nonprofit that provides medication and training to midwives in countries like Cameroon, Liberia, and Sierra Leone. “They’re dying because society has decided that they’re not worth treating.”

Maternal deaths are both those that occur from conditions that arise due to pregnancy, such as hemorrhaging or pre-eclampsia, as well as those that are aggravated by pregnancy, such as complications with heart disease or HIV.

WHO recommends that women have at least eight prenatal visits to monitor their health and detect any abnormalities, such as infection or high blood pressure in the mother, or birth defects in the fetus. In sub-Saharan Africa, many women do not receive this recommended level of care due to economic circumstances, lack of available care, and social pressures. Only 37 percent of women in Niger and 31 percent of women in Chad saw a health care provider at least four times during their pregnancy between 2015 and 2021 (the WHO updated its recommended number of visits from four to eight in 2016). In the US, the standard recommendation is approximately 15 prenatal visits.

Without these appointments, certain life-threatening conditions, like hypertension disorders and diabetes, can go undetected. Pre-eclampsia, for instance, causes swelling, headaches, and nausea: all symptoms that expecting mothers will also experience during routine pregnancies. This is why many women don’t realize they’re experiencing something life-threatening and do not receive care in a timely manner, said Muteti.

Whether caused by a direct or indirect pregnancy-related condition, maternal deaths are the definition of preventable. The reason they still occur is almost always a lack of adequate care. “The scientific and medical knowledge exists to ensure positive outcomes,” said Jenny Cresswell, one of the authors of the WHO report and a sexual and reproductive health scientist. “We know what we need to do to avert these deaths clinically, but getting the right people and equipment in the right place at the right time is where there needs to be progress.”

Between 2000 and 2015, the world was getting better at doing just this, lowering maternal deaths by getting the right people and equipment in the right places. Partially as a result, the global rate of maternal deaths per 100,000 live births dropped from 339 deaths to 227. But, following this period of success, in 2016, maternal death rates took a turn for the worse, especially in low- and middle-income countries, where 95 percent of maternal deaths occur.

Sub-Saharan Africa — 21 low-income, 19 lower-middle-income, 6 upper-middle-income countries, and one high-income country (Seychelles) — experiences the greatest number of maternal deaths, 545 deaths, per 100,000 live births. “This is over 100 times higher than in Australia and New Zealand,” said Cresswell. “In 2020, sub-Saharan Africa remains the only region globally with a very high maternal mortality ratio.”

In 2020, a 15-year-old girl — the bottom limit for reproductive age as defined in the WHO report — in sub-Saharan Africa had a one in 40 chance of dying due to pregnancy in her lifetime. But the odds can be even worse in some countries within the region. For example, in the central African country of Chad, one of the 20 poorest countries in the world, a 15-year-old girl has a one in 15 chance of dying due to pregnancy (this is the highest risk of any country).

Pregnancy and childbirth are global leading causes of death for adolescents, which is one of the reasons maternal mortality rates are so high in sub-Saharan Africa. In Chad, as of 2019, 44 percent of women ages 20 to 24 had their first child before they were 18 years old.

The cost of care in sub-Saharan Africa prevents pregnant people from receiving lifesaving treatments. The leading cause of maternal deaths globally is hemorrhaging, or internal bleeding, and yet there is a simple and effective treatment for the condition: a pill. Misoprostol tablets were originally created to treat stomach ulcers, but they can also stop internal bleeding from childbirth, said Gorman.

These pills are not always adequately available to mothers in Africa, and despite their low cost, they can still be too expensive to afford. In Senegal, three tablets cost $1.75, which is a heavy burden when about a third of the population is living below the global poverty line of $1.90 a day.

Another expensive treatment, albeit one that is often medically necessary in risky pregnancies, is a cesarean section. In Kenya, a C-section can be very expensive, said Muteti, costing between $700 to $2,000 US. This is more than the monthly earnings of an average Kenyan family. Additionally, women should rest for at least a few weeks after the procedure, putting them out of work for an extended period of time.

In Zimbabwe, where the maternal mortality rate is 357 deaths per 100,000 live births, maternity care is supposed to be free, yet women often end up paying for ultrasounds, diagnostic tests, and medicines out of pocket, said Edinah Masiyiwa, a midwife and the executive director of the Women’s Action Group, an organization that advocates for women’s rights in Zimbabwe.

Even if a woman can afford maternal care, finding care at all, let alone competent care, is another challenge in a region with a severe lack of adequately trained medical staff and health care workers.

“The West, rich countries, have gone into Africa and taken so much of their resources,” Gorman said. “And the people who are left have stepped into the role, oftentimes without the skills they need, and they’ve made do.” In recent years, midwives and nurses have left the country of Zimbabwe to work in other regions, leaving the nation with fewer skilled birth attendants than needed, said Masiyiwa.

There are only 500 OB-GYNs in Kenya, a country of 53 million people, Muteti said, and because of this many nurses and midwives are tasked with taking on roles they were not trained for. Of the 3.6 million health workers in Africa, only 9 percent are doctors, according to a 2022 WHO study.

The worst health-care-to-people ratio on the continent is in Niger, where there are only 1,065 physicians for a population of more than 25 million. (Relatedly, the maternal mortality rate in Niger is 441 deaths per 100,000 births, one of the 20 highest rates in the world.)

Given the state of the health care systems in many sub-Saharan countries and the time and resources that will be needed to improve them, one of the least expensive and most effective ways to reduce maternal mortality in the region is by increasing access to family planning, specifically birth control.

“There’s a lot of cultural religious taboos around family planning,” said Klau Chmielowska, the executive director and co-founder of Lafiya Nigeria, an organization increasing access to birth control for women in Nigeria, which has a large Islamic population. Explaining the intervention in the context of religion is one way to overcome this perception, said Chmielowska.

“In the past five to seven years, there has been a lot of effort from the government, from NGOs, alongside them, to engage religious leaders, to engage imams to discuss family planning and the benefits,” said Chmielowska. “Interestingly, one of the explanations is that within the religion, the man in the family has to be able to provide for their wife and for their kids. So family planning is actually essential to be able to fulfill this duty.”

In Nigeria, as of 2018, only 14 percent of the 45 million women of reproductive age use contraception, and that’s primarily male condoms, meaning the women themselves have little control over their use, according to the Guttmacher Institute. Over 90 percent of those in the lowest income bracket lack access to any type of modern contraceptive (pills, implants, injectables, patches, rings, and male and female condoms). Similarly, in Chad, over 19 percent of women desire contraception but do not have access to it.

Women that experience unplanned and unwanted pregnancies in sub-Saharan Africa have few legal options. In most countries in the region, abortion is illegal unless it is for health-related reasons or, under the most extreme laws, for the sake of saving the mother’s life. While some sub-Saharan countries have relaxed their abortion laws over the last decade, 43 countries still have highly or moderately restrictive regulations. As of 2014, it was reported that 77 percent of abortions in the region were unsafe, and as of 2019, the region was the riskiest place in the world to receive an abortion.

One study found that 56 percent of unintended pregnancies in Nigeria (where abortion is only legal when performed to save the mother’s life) end in abortions, made riskier by the fact that most are performed “clandestinely, by unskilled providers or both.” As of 2018, it was estimated 14 women died every day in Nigeria from unsafe abortions. In South Sudan, the country with the highest maternal mortality rate (1,223 maternal deaths per 100,000 live births), 26 percent of pregnancies are unplanned, and nearly half of those end in abortion.

In Zimbabwe, abortion is legal if the pregnant person’s life is in danger, in cases of rape or incest, or if there is severe “fetal impairment.” However, many women in the country are not aware of their rights. “It doesn’t seem to save the ordinary Zimbabwean, it’s a law for the elite,” said Masiyiwa of the abortion regulations.

In one instance, Zimbabwean Mildred Mapingure was raped in 2006 and went to the police so she could receive post-exposure care for possible HIV exposure. Mapingure later found out she was pregnant, but was told that she could not receive an abortion until the rape trial concluded, at which point her pregnancy was too advanced to be terminated, said Masiyiwa.

“This is why we have researched the gaps and documented the gaps in the current law,” said Masiyiwa. “This is also feeding into our advocacy work because we are saying let’s speed up these cases where you are allowed to terminate under the current law. Let’s reduce the processes.”

There is also a cultural stigma around losing a pregnancy, Muteti said.

“People think because you’re going through a particular condition in pregnancy, you have been bewitched or someone has looked at you with an evil eye,” Muteti said. “Women in our support groups actually lose their husbands and lose their marriages because they’ve gone through multiple pregnancy losses. People will brand you that you’ve done an abortion before and that’s why you’re going through these particular medical complications where you cannot hold a baby to term.”

Ultimately, overcoming these harmful stigmas around pregnancy conditions and loss is necessary to save lives. “We have a lot of unlearning to do,” said Muteti. “I’m happy our organization is really trying to talk to the community about that because the community can also help in identifying these risks and symptoms and knowing when to take a woman to the hospital.”

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