From: Secretary of Health, Chad

Emily Russel

Maternal Health in Chad

From: Secretary of Health, Chad

To: Minister of Finance, Chad

Introduction

With the fourth highest maternal mortality ratio in the world, improving maternal health in Chad presents a daunting challenge; however, in accordance with the fifth Millennium Development Goal, this should be a top national priority. The magnitude of poor maternal health is huge: 1,200 women will die for every 100,000 live births.[i] The nature of this problem varies, with maternal deaths ranging from infection, to post-partum bleeding, to hypertensive disorders. In addition, women are also at risk for developing conditions such as obstetric fistula.[ii] Poor, rural, and uneducated women have the greatest risk of poor maternal health, and the risk factors include access to care, fertility rates, female genital cutting, early marriage, and the underlying health of the mother. Additionally, high maternal morbidity and mortality poses serious economic and social repercussions for the wider society, further entrenching affected families in poverty and decreasing the nation’s overall economic growth. In order to address the problems of maternal ill health, the Chadian government should focus its efforts on increasing the accessibility to maternal health services and on promoting family planning.

Nature and Magnitude of the Problem

The level of poor maternal health in Chad is staggering. A ratio of 1,200 women will die annually per every 100,000 live births,[iii] giving Chad the fourth highest maternal mortality ratio in the world.[iv] With roughly 508,000 births a year,[v] Chad can expect well over 6,000 maternal deaths annually.[vi] Furthermore, the lifetime risk of dying due to complications of pregnancy or during childbirth is one in fourteen. The nature of maternal death is varied: it is estimated that 34% of maternal mortality is due to hemorrhaging, 19% comes from pregnancy related hypertensive disorders, 9% is caused by a septic infection, and another 9% results from complications with abortion.[vii] Finally, the 241 cases of obstetric fistula reported each year – arguably a low estimate of the reality –[viii] is an indication that poor maternal health in Chad also leads to serious morbidity, in addition to high rates of mortality.

Affected Populations

While maternal health is a problem for the greater part of women in Chad, poor maternal health falls disproportionately on rural and impoverished women. Because the majority of Chad’s population lives in rural areas, they have limited access to proper health care facilities. Each year, 81% of births take place in rural areas, while 19% are in urban districts.[ix] Of the rural births, only 7.3% of women had a skilled birth attendant, compared to the 54.8% of urban women.[x] Additionally, 62% of Chadians live below the poverty line,[xi] further limiting health care access for these individuals. The percentage of women who utilize health services varies dramatically by wealth quintile: 55.4% of women in the wealthiest quintile utilize health services, which is in stark contrast to the 12.5% and 3.6% in the lowest two quintiles.[xii] Finally, poorly educated women have a greater chance of suffering from maternal health problems. Today, only 12.8% of adult women in Chad are literate, indicating the great extent to which these women are affected.[xiii]

Risk Factors

There are many risk factors contributing to poor maternal health, including access to care, fertility rates, female genital cutting, early marriage, and the underlying health of the mother. Biologically speaking, the primary risk factor for poor maternal health is pregnancy. Thus, the high fertility rate in Chad of 6.1 indicates that a woman’s risk for poor maternal health increases with every child.[xiv] Both limited access to family planning and a cultural desire for many children contribute to the high rate of fertility. Overall, only 1.6% of the Chadian population uses modern contraceptives.[xv]

Limited access to proper health care also presents women with a huge risk. Only 18% of women in Chad have the four recommended antenatal care (ANC) visits, a full 86% deliver at home instead of in health facilities, 83.9% of women do not have a skilled birth attendant present,[xvi] and only 0.4% of women receive emergency obstetric care through cesarean delivery.[xvii] These numbers indicate that women with limited access will likely experience life-threatening delays in identifying complications and getting to a medical facility in time. Additionally, once at a facility, women may also experience a delay in receiving emergency obstetric care due to inefficacy, limited equipment, or objections from male relatives.[xviii] Together these three delays put both the mother and her child at serious risk.

Female genital cutting (FGC) and adolescent pregnancy are also associated with an increased risk of obstructed birth, which can lead to fistula or death. According to some reports, the incidence of FGC in Chad is around 44%, with a greater frequency among women in urban areas.[xix] The percentage of women who gave birth before the age of 18 years old is 48%[xx] and 52% of women marry by the age of 16.[xxi] Finally, the underlying health of women is also a major risk factor for maternal health problems, with factors like anemia and HIV increasing the incidence of maternal death. In Chad, one of every three women are anemic,[xxii] the HIV prevalence among young women is 2.5%,[xxiii] and 8% of women were counseled for HIV during an ANC visit.[xxiv]

Economic and Social Consequences

High maternal mortality and related health conditions have lasting effects on Chadian women and on society as a whole. Maternal death has a negative effect on the remaining children who are more likely to suffer from neglect, malnutrition, and even death without the care of their mothers. Additionally, older children must assume the responsibility of their younger siblings, limiting their own opportunity to attend school. In the long run, the results of limited education and poor nutrition hinder a child’s ability to grow into a productive member of society, thus creating a substantial impact on society as a whole.[xxv]Furthermore, for women who do not die from maternal complications, many sustain serious illness such as fistula and must live a compromised and limited life. The stigma of fistula alone creates serious social consequences;[xxvi] however this and other conditions limit a woman’s ability to economically contribute to the needs of her family and household.

Priority Action Steps

In order to make a significant reduction in maternal health problems, Chad should focus on a few specific, cost-effective approaches that will reach the most women. To begin, the country should focus on improving the accessibility and availability of reproductive health services and address the problems presented by the “three delays.” Because complications of pregnancy are not predictable, the first and most important step is to ensure that all women receive care from skilled health professionals whose guidance can mean the difference between life and death. In addition to funding more rural clinics throughout the country, the government should train local women as community health partners to detect signs of pregnancy complications and to advise women when they should seek additional support. Next, the government should partner with local NGOs in order to provide formal and informal ambulance services that will take women who need emergency care to the appropriate facilities. Finally, government should ensure the health clinics themselves provide efficient and appropriate emergency obstetric care.

In order to incentivize the health care system for women, community partners should promoteconditional cash transfers for maternal health care that include services such as ANC visits, HIV and nutrition counseling, delivery with a skilled attendant, and emergency obstetric care. The transfers both incentivize the health care system and ensure greater accountability for the services. Finally, the government should promote a comprehensive family planning program that promotes the use of modern contraceptives, offers safe abortion services in accordance with Chadian law,[xxvii] and emphasizes adolescent reproductive dialogue.[xxviii] Overall, family planning in conjunction with improved services is the most cost-effective method of reducing maternal mortality, morbidity, and disability.[xxix]

Bibliography

[i]UNICEF.Statistics on Chad. Last Updated 2 March 2010

[ii]UNFPA. Obstetric Fistula Needs Assessment Report: Findings from Nine African Countries. 2003.

[iii]UNICEF.Statistics on Chad.

[iv]The Guardian UK. Maternal Mortality: How many women die in childbirth in your country? Last Updated 13 April 2011

[v]UNICEF.Statistics on Chad.

[vi] Countdown 2015: Maternal, Newborn, and Child Survival.

[vii] Countdown 2015: Maternal, Newborn, and Child Survival.

[viii]UNFPA. Obstetric Fistula Needs Assessment Report: Findings from Nine African Countries.

[ix]WHO.Making Pregnancy Safer: Chad Country Profile.

[x]WHO.Making Pregnancy Safer: Chad Country Profile.

[xi]UNICEF.Statistics on Chad.

[xii]WHO.Making Pregnancy Safer: Chad Country Profile.

[xiii]

[xiv]WHO.Making Pregnancy Safer: Chad Country Profile.

[xv]WHO.Making Pregnancy Safer: Chad Country Profile.

[xvi]WHO.Making Pregnancy Safer: Chad Country Profile.

[xvii]WHO.Making Pregnancy Safer: Chad Country Profile.

[xviii] UNFPA: Country Programme Document for Chad. 2005.

[xix]Population Reference Bureau. Female Genital Mutilation/Cutting: Date and Trends. 2008.

[xx]UNICEF.Statistics on Chad.

[xxi] UNFPA: Country Programme Document for Chad. 2005.

[xxii]FAO. Republic of Chad: Summary. 2010.

[xxiii]UNICEF.Statistics on Chad.

[xxiv]WHO.Making Pregnancy Safer: Chad Country Profile.

[xxv]UNICEF.Statistics on Chad.

[xxvi]UNFPA. Obstetric Fistula Needs Assessment Report: Findings from Nine African Countries.

[xxvii]UN Population Publications. Abortion: Chad.

[xxviii]Ibid.

[xxix]WHO.Maternal Mortality.