Reproductive Health in the African Region. What Has Been Done to Improve the Situation?

Africa accounts for about one tenth of the world's population and 20 per cent of global births; yet, nearly half of the mothers who die during pregnancy and childbirth are from this region. The World Health Organization (WHO) estimates that poor reproductive health accounts for up to 18 per cent of the global burden of disease, and 32 per cent of the total burden of disease for women of reproductive age. One of the underlying causes of this situation is the lack of access to key intervention for improving reproductive health, such as family planning. Despite well-known benefits of family planning, there are unmet needs: contraceptive use among married women in sub-Saharan Africa is very low, estimated at 13 per cent, and the total fertility rate is 5.5 children per woman. Consequently, the adult lifetime risk of maternal death is highest in Africa (1 in 26), while developed countries had the smallest lifetime risk (1 in 7,300).


Maternal mortality estimates for 2005 indicate that the decline between 1990 and 2005 in sub-Saharan Africa was on average less than 1 per cent a year and that to achieve Millennium Development Goal (MDG) 5 -- improve maternal health -- a decrease of at least 5.5 per cent per year is needed. More than half of the estimated 536,000 maternal deaths worldwide occurred in sub-Saharan Africa, and 13 out of 14 countries with maternal mortality rates of at least 1,000 are in the region1. The main causes of death are severe bleeding (haemorrhage), infection (sepsis), eclampsia, obstructed labour and unsafe abortion (see Figure 1). However, an increasing number of mothers in the region die from indirect causes, such as HIV/AIDS, tuberculosis, malaria and anaemia.
Another important component of sexual and reproductive health that needs urgent action is the prevention and control of reproductive tract infections, particularly cervical cancer, which is the most common cancer among women, with a prevalence estimated at 20 per cent, and one of the leading causes of death among women. Although 80 per cent of these deaths can be prevented if diagnosed in time, 50 per cent of the cases are diagnosed too late.
Children in sub-Saharan Africa face the gravest challenges for survival. Africa accounts for 44 per cent of global under-five mortality. The main causes are neonatal complications, respiratory infections, malaria, diarrhoea and HIV/AIDS (see Figure 2). Malnutrition is associated with at least 50 per cent of child deaths. It has been estimated that out of the 60 countries worldwide, which contribute 94 per cent of child mortality, 37 are in the African region. While progress was made in improving the health of children aged one month to five years in the 1970s and 1980s, the health of neonates -- newborns less than four weeks old -- remains a neglected area of public health. Recent data show that neonates represent about 27 per cent of children who die before their fifth birthday and that 29 per cent of global neonatal deaths occur in Africa. Coverage of effective health and nutrition interventions and practices remains low, due to system-wide supply and demand obstacles. Although some progress has been made in child mortality reduction, it has slowed in recent years -- the current rate is estimated at 170 per 1,000 live births. To achieve MDG 4 -- reduce child mortality -- an 8.2 per cent average annual reduction rate of under-five mortality is needed in the African region.
Adolescents continue to be victims of sexually transmitted infection, HIV/AIDS, unwanted pregnancy and abortions as a result of unprotected sex. A large number of adolescents in the region are exposed to health-damaging habits, such as substance abuse and smoking, which continue on into adult life. In addition, the increasing trend of cardiovascular diseases and diabetes in adults is strongly associated with lack of proper nutrition and sedentary lifestyles during adolescence. Lack of adolescent-friendly health services and inadequate policy orientation to meet health needs are some of the priority problems that countries of the region are trying to address.
Reaching MDGs 4 and 5 in the African region. Maternal, newborn and child health is a basic human right. To achieve MDGs 4, 5 and 6, it is necessary to more than double efforts to scale up priority interventions in order to improve the care for women and newborn, as well as promote universal access to reproductive health services, including a continuum of care that spans the life cycle and ensures linkages between the community and health facilities for effective referral systems. Commitment to improve the situation in Africa is concretized by the adoption of the Integrated Management of Childhood Illness (IMCI) Strategy, the road map to accelerate the attainment of the MDGs related to maternal and newborn health, and the Sexual and Reproductive Health Maputo Plan of Action of the African Union, adopted in September 2006.
It is generally agreed that unless serious efforts are made, the MDGs will be unattainable. Although all countries in the region have committed themselves to allocating at least 15 per cent of their national budgets to health, expenditure on health currently represents an average of only 8 per cent of national budgets. Furthermore, funding for maternal, newborn and child survival has been very limited, compared to other public health interventions. That said, there are some positive indications that things are changing, as UN Member States and their development partners demonstrate commitment to bringing maternal and child health issues to the forefront of the development agenda.
In Africa, the response to the high maternal mortality is guided by the strategic approaches described in the Road Map for Accelerating the Attainment of MDGs Related to Maternal and Newborn Health, developed by WHO and its partners in the African region and adopted in 2004 by Member States at the 54th session of the Regional Committee for Africa. It calls for the provision of skilled attendance and the strengthening of the capacity of individuals, families and communities to improve maternal and newborn health. To date, 37 countries have developed national road maps. Increasing availability of skilled attendants is key to the reduction of maternal and newborn mortality, and strengthening pre-service training is one of the most effective ways to ensure a critical mass of skilled attendants in a long-term and sustainable manner. Empowering individuals, families and communities to participate in the development of the community-based intervention for maternal mortality reduction will increase demand and utilization of available maternal and newborn health services.
Some key achievements in maternal health include the capacity building of national experts in translating the national Road Maps into district operational plans, training of health providers in Emergency Obstetric Care (EmOC) and Focused Antenatal Care (FANC), and capacity-building of programme managers and health personnel for the institutionalization of Maternal Death Reviews to improve quality of maternal and newborn services in countries.
As the HIV/AIDS pandemic is still on the increase, prevention of mother-to-child transmission (PMTCT) of the virus is critical to controlling the epidemic. Countries in the African region have strengthened their capacity to accelerate scaling up PMTCT and paediatric HIV care, support and treatment programmes. Joint PMTCT technical missions with partners were conducted in seven countries to assess the status of implementation of programmes, which resulted in a $20- million UNITAID initiative to accelerate PMTCT and paediatric AIDS interventions2.
To improve access to reproductive health services, in particular family planning, the work of the WHO Regional Office in Africa is focused in three main areas: technical support for countries to strengthen capacities for planning, implementation and evaluation of reproductive health services; promotion of the utilization of evidence-based practices for the implementation of reproductive health services; and promotion of research and use of information generated through research for the improvement of sexual and reproductive health programmes and service delivery. Family planning, as a critical element to the attainment of MDGs 4, 5 and 6, has been given a great emphasis in the work of WHO. The Strategic Partnership Programme (SPP) of the United Nations Population Fund (UNFPA) and WHO is a collaboration to improve the quality of sexual and reproductive health care through the utilization of consensus-driven, evidencebased practice guides developed by WHO and partners. SPP seeks to promote sexual and reproductive health at the national and subnational levels, through support to countries in the introduction, adaptation and adoption of selected practice guides in family planning, prevention and control of sexually transmitted and reproductive tract infections.
The IMCI strategy is being implemented in 44 countries in the region. More than 60,000 health workers have already been trained under IMCI and 16 health facility surveys have shown that the strategy has markedly improved the quality of care. The Child Survival Strategy for the African Region, a joint partnership of WHO, the United Nations Children's Fund (UNICEF) and the World Bank, builds on IMCI and advocates for implementation at scale of a key package of cost-effective interventions, including newborn care, infant and young child feeding, prevention of malaria using insecticide-treated nets, immunization, management of common childhood illnesses using IMCI strategy, and PMTCT of HIV, as well as care and treatment of HIV-exposed or infected children.
Some key achievements in child and adolescent health include the development of national child survival strategies using the regional strategy as a framework; capacity-building of health workers in the management of newborns; review of IMCI guidelines to include newborn care, pediatric HIV/AIDS, managing diarrhoea using low osmolarity ORS and Zinc, improving the quality of care at the referral level and establishing community management of childhood illnesses; support to countries in the development of adolescent-friendly health services; and empowering families and communities through the Alliance of Parents, Adolescents and Community approach.
Notes 1. World Health Organization, Maternal Mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA and the World Bank, 2007, p. 15. The ranking is as follows: Sierra Leone (2,100), Niger (1,800), Chad (1,500), Somalia (1,400), Angola (1,400), Rwanda (1,300), Liberia (1,200), Guinea Bissau (1,100), Burundi (1,100), the Democratic Republic of the Congo (1,100), Nigeria (1,100), Malawi (1,100) and Cameroon (1,000). The only non-African country is Afghanistan (1,800). See www.unfpa.org/upload/lib_pub_file/717_filename_mm2005.pdf.
2. Botswana, Burkina Faso, Cameroon, Lesotho, Nigeria, Swaziland and Zambia.