September 20, 2011 marks the one-year anniversary of Every Woman Every Child, a global effort to achieve country-led commitments to bring life-saving health care to millions of women and children in the developing world by 2015. This series looks at maternal health in several countries with the highest number of maternal deaths every year. UNFPA, UNICEF, WHO, the World Bank and UNAIDS – known as the Health 4+ -- are supporting these countries to achieve their Global Strategy commitments.
BOGA, Democratic Republic of Congo — “My last two children were born on banana leaves, with help from my husband and women in my village,” recalls Antoinette Androsi, 32, who has been displaced by war for over six years in the north-eastern region of the Democratic Republic of the Congo. “We used a machete to cut their umbilical cords, and one of them died a few days after she was born in the bush.”
During her latest pregnancy, however, Antoinette was able to give birth in a maternity ward for the first time. Health facilities in the region lack even basic supplies and usually require expecting mothers to purchase materials like soap, gloves, a razor blade and a sheet, which are needed to ensure a clean delivery. Because many women can’t afford to buy these supplies, they often have no end up giving birth at home or outdoors without a trained health worker. However, this time Antoinette had access to a clean delivery kit, one of more the two thousand handed out to women in Ituri and South Kivu provinces through a joint effort by international non-governmental organisation MEDAIR and UNFPA.
Women need to provide midwives with sterile supplies
“I didn’t have to be embarrassed this time, as I was able to give to the midwife everything she needed. Many of my friends had to leave the hospital and give birth in the bush because they didn’t have money,” explains Antoinette.
The health centre in Boga, where Antoinette recently delivered, provides health care for over 30,000 internally displaced people who have fled armed conflict. More than a decade of fighting between rebels and government forces in eastern DRC has intensified long-standing instability in the region and displaced over two million people. Women, whose needs and health concerns are often overlooked in crisis, have been disproportionately affected. The United Nations High Commissioner for Refugees (UNHCR) estimates that women and children generally account for around 80 per cent of internally displaced persons and refugees worldwide.
Women who deliver in a clean health facility with skilled personnel are much less likely to die, lose their babies or suffer a serious childbirth injury, like obstetric fistula. A health worker with midwifery skills can facilitate normal delivery, identify complications early and refer a woman to emergency obstetric care, assuming such care is accessible.
Devastated infrastructure impedes progress
Displacement alone may impede a woman’s access to a health facility. But in the case of the DRC, conflict has destroyed much of the national infrastructure – not just health facilities, but also roads and transport and networks. UNFPA and partners recently supported national surveys of midwifery service coverage in countries including the DRC, and findings were published the first-ever State of the World’s Midwifery Report 2011 in June. There was not enough data available for the DRC.
A woman’s lifetime risk of maternal death is 1 in 24 in the DRC, and the maternal mortality ratio is 670 deaths per 100,000 live births. Estimates put the total number of women who die of maternal causes each year at 19,000 – making it one of six countries that together account for half of all maternal deaths.
With funding from the Government of Finland, UNFPA has been working with partners to provide basic emergency reproductive health care in the region. In coordination with MEDAIR, over ten tons of medication and equipment were distributed to three general hospitals and 28 maternity wards in the five health zones of the region. These supplies were designed to provide care for at least 900 cases of obstetrical complications, 1,000 rape cases and 2,250 cases of sexually transmitted diseases. Moreover, 2,500 pregnant women received individual clean delivery kits in the region.
Clean delivery kits can help save the day
“At first, we feared that the clean delivery kits would encourage women to give birth at home,” says Agnes, one of the midwives in the health centre in Boga. “But as it was the case with Antoinette, I was able to wash my hands with soap, wear gloves and cut the newborn’s cord in a clean environment. Even last week, I was able to successfully practice an episiotomy [a surgical incision to prevent vaginal tearing during delivery] on a teenage girl thanks to the razor included in the kit.” The kits are assisting the work of midwives and nurses, and also help prevent tetanus among newborns, an ailment which is widespread in the region.
Improvements in maternal and child health in eastern DRC reflect a national trend. But while maternal mortality dropped by close to a third between 1990 and 2008, the annual decrease has averaged just 1.7 per cent, well below the 5.5 per cent per year that would keep the country ‘on track’ to achieve Millennium Development Goal 5. Child mortality in DRC continues to rank among the highest in the world, claiming nearly one in five children before they reach the age of five. And the average life expectancy in the country is 46 years.
The ongoing process of recovery and periodic flare-ups of conflict continues to hamper development in the DRC. The country ranks at the very bottom of the Human Development Index, at 168 out of 169 countries. And while security is improving, the United Nations Security Council recently extended the mandate of the international peacekeeping mission in the east.
Sexual brutality adds another layer of suffering
Add sexual violence to the litany of suffering born by both women and men in the DRC. The figures are difficult to document, but most available data estimates that several hundred thousand men and women have been raped in the country in the last decade, and many of the assaults are unspeakably brural. Rapes that result in unwanted pregnancy, HIV infection or fistula exacerbate the risks to women's health. Survivors are rarely compensated through the weak judicial system and may lack the financial resources to manage their medical complications.
UNFPA is supporting comprehensive efforts to move from immediate post-conflict recovery to rebuilding. The project that supplies clean delivery kits also supported the Ministry of Health and other humanitarian partners to train sexual health coordinators Oriental province. At the end of the training, the regional government for the first time included a reproductive health action plan as part of its priorities for 2011 – 2015.
The national government has also made a commitment to the Global Strategy for Women’s and Children’s Health to begin strengthening the health system, to increase the proportion of deliveries assisted by skilled personnel to 80 per cent, and to increase emergency obstetric care and the use of contraception. It is also addressing causes of maternal and child death, such as malaria and HIV/AIDS by providing insecticide-treated bed nets and antiretroviral therapy. UNFPA support also provides medical assistance for survivors of rape and equip health facilities with the medication and materials to treat fistula.
— Assane Ba, UNFPA/DRC