Feature Article of Saturday, 23 April 2011
Columnist: Mensah, Robert
LOSING LIVES IN THE PROCESS OF GIVING LIVES: How is Ghana Dealing with Maternal Mortality?
By: ROBERT T. MENSAH
Africa is the continent in the world mostly plagued with poverty and diseases. With only four years remaining to 2015, there are signs of progress in achieving the health-related Millennium Development Goals (MDGs) in some countries; while in other countries, progress has been limited because of conflicts, poor governance, economic or humanitarian crises, lack of resources and some entrenched cultural and traditional practices.
According to estimates made for the year 2005, half a million women – most of them in developing countries – die each year of complications during pregnancy or childbirth. The risk of death was highest in the WHO African Region, where there were 900 maternal deaths per 100 000 live births; compared with only 27 per 100 000 live births in the WHO European Region. In fact, half of all maternal deaths occurred in the WHO African Region and another third in the WHO South-East Asia Region. Further analysis of the estimates indicated that between 1990 and 2005, no WHO region achieved the 5.5% annual decline in maternal mortality necessary to attain the relevant MDG target.
Ghana seems to have made some progress in the reduction of maternal mortality. An estimation taken in 2001 showed that maternal deaths in the year 2000 stood at 740 per 100 000 live births. According to the 2010 World Health Organization Report, maternal mortality has reduced to 560 per 100 000 live births in the country. What this study sought to do was to find out the causes of maternal mortality in Ghana; the progress that has been made in reducing, if not to eradicate it and find out about new ways of dealing with it.
Causes of Maternal Mortality in Ghana The causes of maternal mortality in Ghana are not that different from that of other African countries. To better understand these causes, we will need to employ the medical anthropologists’ tools. Medical anthropology studies how people in different cultures and social groups explain the causes of ill health, the type of treatment they believe in and to whom they turn if they do get ill. It also studies how the beliefs and practices relate to biological, psychological and social changes in the human organism.
Lack of Health Centres: One of the causes of maternal deaths in Ghana is lack of sufficient medical care. As said by Helman, the availability of medical care is one of the factors that determine the treatment that a patient seeks . Many towns and villages in Ghana, until recently, did not have health centres. Chereponi, Janga, Karaga, Kpandai and Tatale of the Northern Region of Ghana just got health centres built for them in 2010. Many areas still lack hospitals and where there are even clinics, according to Mr. Godfred Tango, the Member of Parliament for Wa East, they are ill-equipped with facilities. This, lack of health centres, forces many of the women to turn to traditional birth attendants, some of whom are not skillful enough, and result in maternal mortality. The distance that those who decide to go to health centres have to travel and the bad road conditions also lead to many deaths in times of emergency.
Poverty: Poverty is also another cause of maternal mortality in Ghana. Although many of the women in Ghana now seek prenatal care during pregnancy, poverty makes it difficult for them to purchase the food they need and live in conditions better for their health and nurturing of the foetuses. Poverty, again, prevent most of the women from getting education that will let them understand their medications, nutrition and proper care of themselves during pregnancy. Until the User Fee Exemption Policy was implemented for pregnant women, the cash-and-carry system operated by the Ghana health sector also prevented many of the women from accessing professional perinatal care and services during labour.
Shortage of Health Workers: The alarming rates of maternal mortality in Ghana can also be attributed to the shortage of health workers in the country’s health centres; and this, I believe, is mainly due to the migration of Ghanaian health staff. Within the country, most of the health workers refuse to be posted to the rural areas. All the health professionals prefer staying in the urban areas. Even those from the rural areas refuse to go back after their training. This makes health delivery in the rural areas very poor. Another, and the most disturbing, is the migration of health workers to the Western countries. The 2010 health report taken in the Sissala District indicated inadequate skilled personnel and equipment in the area. The high doctor-patient ratio of 1: 54 000, forces one doctor to work in six health centres. The following table shows Ghanaian- trained nurses registered in the United Kingdom between 1998 and 2003, obtained from Dr. Bach’s project report.
Ghanaian-trained nurses registered per annum in the UK 1998-2003
Year 1998-99 1999-00 2000-01 2001-02 2002-03
Number of Nurses 40 74 140 195 255
Dovlo estimated that in 1998 vacancy levels in public health in Ghana was 72.9%. This increases the workload on the few health staff. I could not obtain statistics of the total number of all health workers trained in Ghana per year in my research, but the figures above are indicative that the shortage of medical staff in Ghana is partly due to the brain drain of its health workers. Religious Beliefs, Traditional and Cultural Practices: Religious beliefs and cultural practices, in a way, affect the health and well-being of women. For instance, in Ghana, like many other African countries, HIV/AIDS has been identified as one of the indirect causes of maternal mortality. The spread of HIV/AIDS in Africa are partly due to the polygyny practiced by many African societies. When a man married to many wives gets the disease he is likely to pass it on to all of his wives. It is also assumed that due to the many wives one man may have, he may not be able to satisfy all of them sexually and this forces them to seek sexual satisfaction elsewhere, which make the women susceptible to attracting the HIV/AIDS disease.
Religious beliefs also make some of the women go to priests for prayers or/and rituals when they are sick and during pregnancy. They only seek medical assistance when these prayers fail. Many Africans when sick or not getting pregnant attribute it to witchcraft. The belief in this, witchcraft, makes them consult fetish priests, pastors (Christianity) or Baraka (Islam) for prayers rather than going to a professional medical doctor for checks and cure. During pregnancy, as said above, they prefer going to priests and Baraka to pray for protection from witchcraft than going to clinics, or sometimes do both. In the rural areas of Ghana, some traditional practices make some parents not see the need to send their daughters to school. Men are seen in many societies in Ghana as the heads of their families. Women’s jobs are in the kitchen and taking care of children. Although education and campaigns by both governments and non-governmental organisations have improved this, they are still practiced by some few in the rural areas; and this lead to illiteracy which affects how the women take care of themselves later in life during pregnancies. One other thing in African societies is the stigma attached to childlessness. Many women are forced to have children by the society. It is considered a shame for a woman not to have children in many African societies. In the villages, it is considered that the more children a woman has the more fertile she is; but this has adverse effect on the women as it increases their chances of dying through giving birth.
Teenage Pregnancy: In comparison to the record in Kenya, where up to 31.9% of children born are born to women between the ages of fifteen and twenty-four, it was recorded in February 2011 in the Central Region of Ghana that a total of 169 children between the ages of ten (10) – fourteen (14) years reported pregnant. As said by Lewis Wall, early marriage (at younger ages) and pregnancy before the pelvic growth is complete can result in maternal mortality. While some are blaming this, teenage pregnancies, on the influence of Western cultures, others argue that some of it are caused by the early marriages of young girls among the Northern people of Ghana.
As in many African societies, Ghanaian women were expected to be virgins until they were married. On the day of marriage, friends and family members would stand outside and wait while the couple had their first sexual intercourse. When they finished, the bed sheet that they lay on would have to be inspected by the witnesses to see if there was blood on it to indicate that the woman had not had sex before the marriage. The parents of a woman found not to be a virgin at marriage were considered bad parents and the man (groom) had the right to collect the bride price. This is not done any more in African societies. Although this was a very good way of making sure women abstained from sex until they were married, I believe that it would not always correctly prove whether a woman had had sex before marriage since the hymen can sometimes break without sexual intercourse, and the woman and her parents would be wrongly accused of premarital sex.
Training of Health Workers: Lack of proper training of health professionals also causes maternal mortality in Ghana. At a seminar held in the country recently, it was revealed that the inappropriate use of uterotonics during and immediately after labour contribute to maternal mortality. An uterotonic is an agent used to induce contraction or greater tonicity of the uterus. Abortion and Other Causes: Thirty per cent of maternal deaths recorded in Accra in 2001 were said to be caused by abortion. Abortion is legal in Ghana, but many of the women go for backstreet abortions due to poverty. An interview conducted to find out why some of the women terminated their pregnancies indicated that most of them did it because they either wanted to continue their education or careers, and others cited problems with their partners as the motivational factor behind their actions. However, data collected by the close of last year indicated that hypertension had taken over as the number one cause of maternal mortality in the country. Other maternal deaths recorded were caused by postpartum haemorrhage, eclampsia, puerperal sepsis, prenatal infections, HIV/AIDS, malaria, placental abruption, cardiac failure, sickle cell disease, anesthetic deaths, ectopic pregnancy, pulmonary embolism, obstructed labour and hypoglycaemia.
How is the Problem Being Addressed? As I said earlier, one of the main causes of maternal mortality in Ghana is poverty. As argued by Helman, economic factors and social inequality are some of the most important causes of ill health, since poverty may result in poor nutrition, overcrowded living conditions, inadequate clothing, low levels of education, housing (or work) sited in areas with greater environmental dangers as well as exposure to physical and psychological violence, psychological stress, drug and alcohol abuse. According to the Graphic Newspaper, the most prominent and reliable national newspaper in Ghana, Ghana is on track to achieving the Millennium Development Goals (MDGs) 1 and 2, which deal with the reduction of poverty and hunger by 2015. This will in turn reduce maternal mortality in the country. As in other African countries, most mothers in Ghana are aware of what healthy diets are. Nutrition remains inadequate not because mothers lack information, but because they lack resources. With maternal mortality, Millennium Development Goal 5 (MDG 5), the government has said that it may be difficult to meet the target, but all efforts are being made to reduce it to 0%. To do this, Ghana has stepped up the training of midwives with at least 500 being trained every year. The vice-president of Ghana, John Dramani Mahama, has also appealed to newly trained health professionals, especially nurses and midwives to accept postings to the deprived areas to cater for the health needs of the people while the government make effort to improve conditions of service and incentive packages for them. The Ghana Health Service said it intends to set up clinics in all the rural areas so that the people could access health care delivery. Health delivery in the country is now free to everyone under the National Health Insurance Scheme introduced in 2004. This has encouraged pregnant women to seek prenatal and postnatal care, and helped to reduce maternal mortality in the country. Family planning centres have also been set up in all the health centres to counsel people on birth-control and prevention of Sexually Transmitted Infections (STIs).
Basic education is also free and compulsory to everyone under the Free Compulsory Universal Basic Education (FCUBE) scheme, and parents are being encouraged to send, especially, their girl children to school. The Ghana Health Service also conducts an annual review of their operations to help them know their performances and where they need new or improved strategies for better health delivery.
In the area of migration of Ghana’s health staff nothing is being really done to stop that in particular, and most of the government officials have remained silent about it; however, there have been a lot of appeals to the youth on brain-drain in general. And I believe the efforts being made, as said by the vice president, to improve conditions of service and incentive packages for the health workers will go a long way to address migration problem. One result of the growth of international labour market is the large number of doctors and nurses moving from poorer countries to work in richer ones. These poorer countries pay a lot of money for the training of those health professionals, which means they are indirectly subsidizing health delivery in the richer countries. I believe changing the immigration policies of these richer countries will stop the brain-drain of poorer nation’s health workers which will in turn help to reduce maternal mortality in the developing countries.
Maternal mortality rates have reduced in Ghana quite dramatically. As to whether Ghana will be able to meet the Millennium Development Goal 5 (MDG 5), is something I am not sure of. Some government officials are optimistic of meeting it; while others say Ghana may not be able to meet it. However, all measures are being taken to make sure that quality health services are offered not only to reduce MDG 5, but all the other health related Millennium Development Goals, as they affect one another.
The government and Professor Afua Hesse, the new President of the Medical Women's International Association (MWIA), also better described as the world Association of Women Doctors, have pledged to completely stamp out maternal mortality in the country.
World Health Statistics 2010, World Health Organization Helman, C. G. (2007). Culture, Health and Illness (5th ed.) London: Hodder Arnold. Main course book ISBN: 0-340-91450-5
Dr. Stephen Bach, International migration of health workers: Labour and social issues, 2003, Accessed: 2011-02-25, (To access this article, google: “scholarly articles for International migration of health workers: Labour and social issues, Dr Stephen Bach”)
Barbara Stilwell et al, Developing evidence-based ethical policies on the migration of health workers: conceptual and practical challenges, http://www.human-resources-health.com/content/1/1/8, 2003, Accessed: 2011-02-25
Weisner, TS, Bradley, C. Kilbridge, PL (eds). (1997) African Families and the Crisis of Social Change. Bergin & Garvey, Westport, Conneticut. London. (366 p). ISBN 0-89789-519-3
L. Lewis Wall, Dead Mothers and Injured Wives: The Social Context of Maternal Morbidity and Mortality among the Hausa of Northern Nigeria, 1998
Huss-Ashmore, R & Katz, SH. (1990) African Food System in Crisis. London etc. Gordon and Breach. (289 p). ISBN 2-88124-306-1
First Lady in Move to Stem High Maternal Mortality Rate, “Ghanaweb”, www.ghanaweb.com, 2001-05-15
Northern Region gets more polyclinics, “Ghanaweb”, www.ghanaweb.com, 2011-02-24
Abortion is Leading Cause of Death in Accra, “Ghanaweb”, www.ghanaweb.com, 2001-09-04
Eastern Regional Hospital records 41 maternal deaths in 2010, “Ghanaweb”, www.ghanaweb.com, 2011-02-24
Sissala East District reviews health delivery, “Ghanaweb”, www.ghanaweb.com, 2011-03-02
Pregnant children, high maternal mortality ..., “Ghanaweb”, www.ghanaweb.com, 2011-02-08
Health workers urged to learn proper use of Uterotonics, “Ghanaweb”, www.ghanaweb.com, 2011-02-21
Lucy Adoma Yeboah, Ghana on Track To Achieve Millennium Goals, “Daily Graphic”, www.graphic.com.gh, 2010-09-15
Kwame Asare Boadu, Hypertension Now Leading Cause Of Maternal Death, “Daily Graphic”, www.graphic.com.gh, 2010-11-23
Timothy Gobah & Samuel Duodu, 'Accept Postings To Deprived Areas', “Daily Graphic”, www.graphic.com.gh, 2010-11-29 Maternal death drops in Brong Ahafo Region, “Ghanaweb”, www.ghanaweb.com, 2011-02-04