Maternal and child health in Africa for sustainable development goals beyond 2015

The papers contained in this special issue of the Global Public Health examine the current realities of Africa with reference to ‘Maternal and Child Health’ as the world transitions into an era of Sustainable Development Goals (SDGs) beyond 2015. The special issue contains a set of papers that were originally presented at a three-day symposium on ‘Health in Africa and the Post-2015 Millennium Development Goals (MDGs)’ that was co-organised by Ezekiel Kalipeni, Juliet Iwelunmor and Diana Grigsby-Toussaint at the University of Illinois at Urbana-Champaign on 20–22 May 2015. As the Millennium Development Goals came to an end in 2015 with the introduction of SDGs for 2016–2030, there remains the unfinished business of maternal and child health in sub-Saharan Africa.

The statistics with reference to sub-Saharan Africa are startling. Recent statistics from the United Nations Inter-Agency Estimates indicate that from 1990 to 2015, the global maternal mortality ratio declined by 44% – from 385 deaths to 216 deaths per 100,000 live births (UNICEF, 2016). Although this is commendable, it is less than half the 5.5% annual rate needed to achieve the three-quarters reduction in maternal mortality that was targeted for 2015 in Millennium Development Goal 5 (UNICEF, 2016). While every region in the world experienced declines in levels of maternal mortality between 1990 and 2015, levels in sub-Saharan Africa remain unacceptably high. According to the World Health Organization in 2013, there were an estimated 289,000 maternal deaths globally, of which 62% occurred in sub-Saharan Africa (WHO et al., 2014). The region also has the highest maternal mortality ratio of 510 deaths per 100,000 births (WHO et al., 2014). It has been noted that:

a 15-year-old girl living in sub-Saharan Africa faces about a 1 in 40 risk of dying during pregnancy and childbirth during her lifetime. A girl of the same age living in Europe has a lifetime risk of 1 in 3,300 – underscoring how uneven progress has been around the world in trying to achieve Millennium Development Goal 5. (Global Development, 2014; Lozano et al., 2011)

The same also holds for child mortality. There has been substantial global progress in tackling infant deaths since 1990. The number of under-five deaths worldwide has declined from 12.7 million in 1990 to 5.9 million in 2015–16,000 every day compared with 35,000 in 1990 (UNICEF et al., 2015). In spite of this progress, sub-Saharan Africa continues to be the region with the highest under-five mortality rates. Approximately 1 in 11 children born in sub-Saharan Africa die before age 5, nearly 15 times the average in high-income countries (UNICEF et al., 2015). Thus, progress for sub-Saharan Africa remains insufficient to reach Millennium Development Goal 4 in a timely fashion. In spite of the fact that Africa remains the region with the highest global burden of under-five deaths, there are hopeful signs that child mortality can be successfully reduced as countries such as Rwanda, Niger, South Sudan, Uganda, Malawi, Tanzania and Ethiopia have demonstrated (GE, 2016). For example, Rwanda experienced a 64% drop in the under-five mortality rate from 1990 to 2012 (GE, 2016).

The majority of these deaths are from preventable causes and treatable diseases (Alvarez, Gil, Hernández, & Gil, 2009) all of which highlight the need for maternal and child health to remain important priorities for SDGs beyond 2015. For sub-Saharan Africa, there is a great need to accelerate the pace of progress in order to achieve the SDG target on child survival. To achieve the SDG target of an under-five mortality rate of 25 or fewer deaths per 1000 live births by 2030, a total of 47 countries need to increase their pace of progress by at least doubling or even tripling their current rate of reduction (UNICEF et al., 2015). It is in this regard that this particular set of articles comes at a critical point in time. The issue is predicated upon what happens once the much talked about Millennium Development Goals came to an end in 2015. What will the landscape of the Sustainable Development Agenda for maternal and child health in Africa look like? The scale of the challenge posed demands an extraordinary response, hence the need to bring together articles from an interdisciplinary group of researchers to interrogate these issues with reference to maternal and child health in sub-Saharan Africa.

The set of articles contained in this special issue offers a broad range of case studies regarding maternal and child health in sub-Saharan Africa. Together, the papers focus on the major factors that affect maternal and child health. A particular focus is the interplay of how social, cultural, economic, political and environmental structures interact to influence maternal and child health outcomes in the region. The articles examine these issues in light of the just ended MDGs. The MDGs are now retrospective and analysis of how they did or did not improve health of targeted populations is useful to move the discourse forward. On the other hand, the SDGs are prospective and can be informed by how well the MDGs did or did not perform. As such, this special issue comes at a crucial juncture or an opportune moment, a kind of bridge to both the past and the future.

The articles in this issue fall into three main groups, each group with an overarching theme. The main themes are maternal health, utilisation of antenatal health-care resources, and infant and child health. What follows below is a synopsis of each article under these three overarching themes. The first group on maternal health contains four articles, that is, Okigbo, Adegoke, and Olorunsaiye (2017), Oyibo, Watt, and Weller (2017), Sofolahan-Oladeinde, Conserve, Iwelunmor, Airhihenbuwa, and Gbadegesin (2017) and Kaphagawani and Kalipeni (2017). These four articles examine issues concerning reproductive health indicators, community perceptions of maternal mortality, application of the PEN-3 cultural model to childbearing decision-making of women living with HIV and AIDS, and the problem of teenage pregnancy. The issues are discussed using specific case studies drawn from Nigeria and Malawi.

With the MDG 5 deadline past, the Okigbo et al. (2017) article highlights the progress Nigeria has made in improving access to maternal health services in the last two decades (i.e. 1990–2013). It examines the trends in three reproductive health indicators (contraceptive prevalence rate, skilled birth attendance and adolescent birth) from 1990 to 2013 using five available Nigeria Demographic and Health Surveys. The results in this paper show increasing trends in modern contraceptive prevalence rate from 3.8% in 1990 to 11.1% in 2013 and in skilled birth attendance from 30.8% in 1990 to 40% in 2013. The paper also found a decreasing trend in adolescent birth rate from 23.5% in 1990 to 17.1% in 2013. However, a closer examination of the results shows the presence of marked disparities in the indicators based on residence, wealth and educational attainment with rural residents, the very poor and the less educated bearing the greatest burden. Okigbo et al. (2017) conclude that Nigeria is not on track to achieve MDG 5 targets by 2015 which calls for concerted efforts to focus on vulnerable populations if maternal health is to be improved in Nigeria.

Oyibo et al. (2017) note that maternal mortality in Nigeria is one of the major challenges in the reproductive health arena. These authors espouse communication and education as vital to reducing maternal mortality and births that take place outside formal health-care environments. Oyibo et al. (2017) present a specific case study that compares expert and lay knowledge and interpretations about the important components of the maternal mortality problem as part of a wider mental models study aimed at improving risk communication. This study highlights the importance of teasing out emergent themes in attempts to identify important gaps in knowledge and misperceptions that have the potential for development of improved risk communication and education in Nigeria and beyond. While Oyibo et al. (2017) present an interesting study using a mental model, Sofolahan-Oladeinde et al. (2017) apply the PEN-3 cultural model to issues of childbearing decision-making by women living with HIV and AIDS (WLHA) in Nigeria. Utilising the PEN-3 cultural model, this paper attempts to understand the role of faith and spirituality in the lives of WLHA, why it matters for health-care utilisation, and how it influences childbearing decisions in Nigeria. These authors argue that understanding this link is important for increasing the number of WLHA who effectively utilise health-care services, and for eliminating new paediatric HIV infections post-2015.

The final article in this group moves from Nigeria to Malawi to examine the intractable problem of teenage pregnancy in Zomba district, a largely rural district of Malawi. Kaphagawani and Kalipeni (2017) note that teenage pregnancy is a major health and social problem in Malawi because of its physical, psychological and socio-economic consequences on the teenage mother, her family and the society as a whole. The case study explores risk factors associated with unplanned teenage pregnancy in the Zomba District. Among the prominent factors that stood out in the analysis for the high rate of teenage pregnancy were early sex and marriage, low contraceptive use, low educational levels, low socio-economic status, lack of knowledge of reproductive and sexual health, gender inequity and physical/sexual violence. The findings of this case study point to the need for a multi-sectoral approach to tackle the problem of teenage pregnancy in Malawi.

The second group of articles looks at the availability and use of antenatal care (ANC) and facility-based delivery. Recent work in sub-Saharan Africa has shown that the increasing trend in the utilisation of maternal care services is related to a steady decline in maternal mortality (Alam, Hajizadeh, Dumont, & Fournier, 2015). The two articles in this group show similar results concerning Nigeria, Malawi and sub-Saharan Africa in general. Kuuire et al. (2017) examine changes in the timing and utilisation of maternal health-care services in Nigeria and Malawi for successive years. Their findings show that women in Nigeria were 7% less likely in 2008 compared to 2003, and in Malawi, 32% more likely in 2013 compared to 2000, to utilise first ANC in the first trimester of pregnancy. The timing of first ANC visit was strongly influenced by wealth in Nigeria while this appeared not to be the case in Malawi. Kuuire et al.’s findings demonstrate clearly how various contextual issues such as poverty and wealth may be enabling or inhibiting utilisation of maternal health-care services. The second article in this group examines access to and utilisation of skilled birth attendants in Nigeria and Malawi (Atuoye et al., 2017). This paper confirms the sad truth that, despite World Health Organization’s guidelines that indicate women should deliver with skilled birth attendants, many women in low- and middle-income countries deliver at home without the assistance of a skilled birth attendant.

The third group of articles highlights the issue of infant and child health with two specific case studies from Nigeria and Malawi and two additional papers that look at the broader sub-Saharan African region. Blackstone, Nwaozuru, and Iwelunmor (2017) examine the case of under-five mortality in Nigeria and note that several maternal characteristics may be influential in childhood mortality. However, they argue that in order to reduce child mortality to meet the MDG goals, community and systems level factors need to be accounted for in any interventions, as maternal characteristics do not offer a full explanation for why children are dying so young in Nigeria.

Moise, Kalipeni, Jusrut, and Iwelunmor (2017) present an interesting case study of how Malawi, a resource- poor country, has been able to achieve the Millennium Development Goal 4 of reducing infant and child mortality over the past two decades. The commendable declines in infant mortality experienced by Malawi were due to factors that included wide-spread immunisation of infants as well as increasing levels of female education and availability of skilled birth attendants. What Malawi’s case demonstrates is that given a correct mix of strategies, even an under-developed country such as Malawi can meet some of the lofty targets set by the MDGs.

The last two articles in this grouping utilise data from several countries to examine the impact of environmental health hazards (Adjiwanou & Engdaw, 2017) and the impact of debt relief on childhood mortality (Oryema, Picone, & Gyimah-Brempong, 2017). Utilising Demographic and Health Survey data from 12 sub-Saharan African countries, Adjiwanou and Engdaw (2017) conclude that improvement in household environmental conditions can reduce the risk of mortality during late childhood. The policy implication here is obvious: there is a need to put in place policies and interventions which aim to improve environmental health for better success in reducing childhood mortality in the region. On the other hand, Oryema et al. (2017) investigate the impact of highly indebted poor countries initiative (HIPC) and Multilateral Debt Relief Initiative on under-five child mortality rate in sub-Saharan Africa. Their statistically robust study finds that HIPC reduces child mortality and the effects are important. They conclude that debt relief had a significant impact on the reduction of child mortality in sub-Saharan Africa and hence contributed towards the achievement of MDG 4.

The articles described above are important because they provide scientific evidence to inform health policy and programme development in sub-Saharan Africa where access to and quality of health services is low. This contribution cannot be overstated. As noted above, maternal and child mortality rates in Africa are among the highest in the world and evidence suggests that improving access to quality reproductive health services may contribute to improving maternal and child health. The collective agenda of the articles in this issue aim to assess the progress African countries have made over the past two decades in improving access to reproductive and health services such as family planning services, maternal health services, vaccinations and the like to improve the lives of mothers and children. Many of the articles utilise data from available Demographic and Health Surveys on the continent spanning 1990–2013 to test the trends in reproductive health indicators (contraceptive prevalence rate, skilled birth attendants and adolescent births) and to identify vulnerable populations that may be bearing the greatest burden of disease. Many of the papers find significant and interesting results in the examination of such trends throughout the continent, especially in light of the MDGs and the ongoing discussions for the post-2015 SDGs.

Together, the articles address the potential value of social science research in framing an intellectual vision for SDGs for maternal and child health and population well-being beyond 2015. They also highlight the need for capacity strengthening in social science and medical research for maternal and child health and population well-being in the region. As the studies presented encompass a select set of countries in sub-Saharan Africa, this special issue does not claim to present an overview of research on the whole continent. Rather it offers insights into the priorities ahead with the goal of stopping women and children from dying of preventable causes. Our hope is that the special issue will contribute to a more thorough examination of maternal and child health in sub-Saharan Africa while offering thoughtful theoretical perspectives towards the development of SDGs for women and children beyond 2015.

Acknowledgements

Any opinions, findings, and conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the National Science Foundation.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The three-day symposium on ‘Health in Africa and the Post-2015 Millennium Development Agenda’ held at the University of Illinois at Urbana-Champaign was supported by the National Science Foundation [grant number 1461724] as well as several Colleges and Departments at the University.