Policy Brief
Maternal Health in Yemen
From: Lindsay Lennon, Secretary of Health, Yemen
To: Minister of Finance, Yemen
Introduction:
Yemeni women face a 1 in 39 lifetime risk of maternal death. UNICEF estimates that 470 women per 100,000 live births die from obstetric complications.[i] An estimated 82% of these deaths occur during delivery.[ii] Yemen’s high maternal mortality rate is primarily due to a lack of skilled health care personnel for antenatal, delivery and postnatal care. In order to reduce the rate of maternal mortality and improve the overall health status of women, we should focus on recruiting and training midwives, especially in rural and underserved areas.
Nature and Magnitude of the Problem :
In Yemen, pregnancy and childbirth are “life-threatening events”. Maternal deaths account for 42% of all female deaths among women of reproductive age (15-49 years).[iii] It is the leading cause of death among women in that age group.[iv] Most maternal deaths occur between the third trimester and the first week after the end of pregnancy.[v] Approximately 80% of maternal deaths are from direct causes, such as hemorrhaging (39%), obstructed labor (23%), infection (19%), and eclampsia (19%).[vi] Indirect causes account for the other 20%. Indirect causes are diseases that complicate, or are complicated by pregnancy, such as malaria, anemia, HIV/AIDS and cardiovascular disease.[vii] In addition, for every woman who dies due to childbirth complications, 20 more will suffer injuries, infections and disabilities.[viii]
Affected Populations:
The majority of maternal deaths are poor women who live in rural areas. Presently, approximately 40% of the population has no access to health services.[ix] Many of the poorest women live in areas where there is no access to health services. The geographic distribution of health services is concentrated in economically advantaged areas where there is access to clean water, sanitation and electricity.[x]
Moreover, female genital mutilation/cutting, which is widespread in rural areas, also affects the reproductive health of women. In addition, pregnant adolescents account for a large number of maternal mortalities. The average age of marriage for Yemeni women is 16.2 years and almost half of the women have had their first birth before the age of 20.[xi] Women who give birth during adolescence have a higher risk of having a low birth weight baby.[xii]
Risk Factors:
The greatest risk factors for maternal mortality in Yemen are the mother’s economic status and the overall low social station of women in Yemeni society. The poorest mothers are 75% to 86% less likely to receive prenatal and delivery care than the wealthiest mothers.[xiii] Therefore, location is a risk factor for maternal death.[xiv] This is because the poorest areas lack access to health care facilities and skilled health personnel. Another risk factor for maternal death in Yemen is education. Approximately 84% of Yemeni women are illiterate.[xv] Poorly educated women, especially in the rural areas in the north face higher rates of maternal mortality than well-educated women in urban locations. Child marriages and adolescents giving birth are also associated with maternal death.[xvi] In Yemen, the average birth interval is 18 months, and between 10.5 to 20.3 months in remote, rural regions.[xvii] Such short intervals between births are a large risk factor for maternal death. Having more than 5 children is another risk factor. Presently, the average fertility fate is 6.7, and there is a general lack of awareness of family planning methods.[xviii]
UNICEF estimates that 30% of Maternal-Child Health services is of poor quality, and women receive insufficient care during pregnancy and postpartum.[xix] Nationally, an estimated 84% of women deliver at home. Only 22% of women receive skilled assistance during delivery. Often, home deliveries are unclean, unsafe and unsupervised by a skilled healthcare professional. Manpower and resource constraints are the primary contributor to the low standards of obstetric care and referral.[xx] Women are often afraid of being examined by a male healthcare worker, and traditional values restrict many women from working in the public sector.[xxi]
Social and Economic Consequences:
The intense childbearing practices that are common in Yemen have serious health consequences for both the mother and the child. These health problems include malnutrition, stunting, anemia, and high-risk pregnancies.[xxii] A woman’s nutritional status is “especially important to the outcome that she will have in pregnancy, both for herself and her newborn.”[xxiii] Moreover, when a woman dies during childbirth the impact is great. As the woman is often the primary caregiver, her death often leads to the child’s death shortly thereafter.[xxiv] Also, adolescent motherhood increases the likelihood of low birth weight babies. Low birth weight babies have mortality rates substantially higher than average weight babies. Children who are malnourished have lower IQs, are less attentive in class and are likely to learn less in school. They are therefore more likely to drop out of school, which prevents them from obtaining higher paying jobs and improving their socioeconomic status.[xxv] The cycle of poor health perpetuates over generations.
Priority Action Steps:
In order to reduce the rate of maternal mortality, the quality of obstetric care must be improved. Currently, travel-related costs delay women from reaching health services until it is too late, “at which point they attempt to access more costly and distant tertiary services, which lack appropriate care for obstetric emergencies, including drugs, equipment, or safe blood transfusion capability.”[xxvi] Creating a community-based midwifery-training program would avert some of these difficulties. Such a program would train women to give antenatal and postpartum advice, as well as to recognize signs of obstetric complications that require additional care. This would help direct women to places of appropriate care before it is too late. These midwives would also assist in deliveries. With knowledge of basic obstetric care and sanitary birthing conditions, many of the maternal deaths that occur during delivery can be averted. It is estimated that 75% of maternal deaths are preventable.[xxvii] By implementing a comprehensive community-based midwifery program progress can be made in reducing the number of maternal deaths.
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[i] UNICEF, “At a Glance: Yemen,” cef.org/infobycountry/yemen_statistics.html
[ii] Abdul Wahed Al Serouri, Arwa Al Rabee, Mohammed Bin Afif and Abdullah Al Rukeimi, “Reducing Maternal Mortality in Yemen: Challenges and Lessons Learned from Baseline Assessment,” International Journal of Gynecology and Obstetrics, 105 (2009), 86-91.
[iii] Qaiser Khan and Susan Chase, “Yemen and the Millennium Development Goals,” The World Bank, Middle East and North Africa Working Paper Series, March 2003. ldbank.org/INTMENA/Resources/WP31SEPTEMBER2006.pdf
[iv] “Reducing Maternal Mortality in Yemen”
[v] Carine Ronsmans, Wendy J Graham, “Maternal Survival 1,” The Lancet, (2006); 368: 1189-1200.
[vi] “Yemen and the Millennium Development Goals”
[vii] Richard Skolnik, “Women’s Health,” Essentials of Global Health, (Sudbury: Jones and Bartlett Publishers, 2008), 152-153.
[viii] UNICEF, “Maternal and Newborn Health,” cef.org/health/index_maternalhealth.html
[ix] “Yemen: What is Blocking Progress on MMR,” Forward, 20 January 2009, warduk.org.uk/news/news/468
[x] “Meeting Women’s Health Needs in Yemen”
[xi] Debra S. Penney, “Meeting Women’s Health Needs in Yemen: A Midwifery Perspective,” Journal of Midwifery & Women’s Health, (2000); 45: 72-78.
[xii] Save the Children, “State of the World’s Mothers 2008,” ethechildren.org/publications/mothers/2008/SOWM-2008-full-report.pdf
IRIN, “Yemen: Eight Women Die Giving Birth Every Day,” 8 March 2007, rtnet.org/thenews/newsdesk/IRIN/ee8a3da900e31da429e6e88860f65157.htm
[xiii] Skolnik, “Women’s Health,” 153.
[xiv] “Meeting Women’s Health Needs in Yemen”
[xv] Skolnik, “Women’s Health,” 153.
[xvi] “Meeting Women’s Health Needs in Yemen”
[xvii] “Meeting Women’s Health Needs in Yemen”
[xviii] Skolnik, “Women’s Health,” 155.
[xix] “Yemen and the Millennium Development Goals”
[xx] “Yemen and the Millennium Development Goals”
[xxi] Debra S. Penney, “Meeting Women’s Health Needs in Yemen: A Midwifery Perspective,” Journal of Midwifery & Women’s Health, (2000); 45: 72-78.
[xxii] Richard Skolnik. “Nutrition and Global Health.” Essentials of Global Health (Sudbury: Jones and Bartlett Publishers, 2008), p. 133.
[xxiii] “Nutrition and Global Health,” 138.
[xxiv] “Yemen and the Millennium Development Goals”
[xxv] IRIN, “Yemen: Eight Women Die Giving Birth Every Day”