What's holding back Ghana's progress in reducing maternal mortality

© Flashon Studio – 123RF.com

Between 1980 and 2008, Ghana successfully cut maternal deaths from 731 to 409 per 100,000 pregnancies. The current rate of 380 is below the sub-Saharan Africa average of 510 in 2013, making Ghana the country with the lowest number of deaths in the West African region.

The long-term figures show great progress but year-on-year change has been slow. Efforts to reduce the number further is being hampered by female illiteracy, poor transport infrastructure, skills shortages and complications created by some local pastors.

Successful interventions

Over the past two decades the Ghanaian government has recognised the need to tackle the problem of maternal mortality and has worked internally and with international agencies and governments to save mothers.

Several programmes have been put in place. One is the Safe Motherhood programme under the Ghana health service. The programme went hand-in-hand with a comprehensive review of all maternity service provisions. These include skilled manpower shortages, a lack of equipment and an inadequate supply of essential medicines.

There is also the Making It Happen programme - a collaboration between a British university, hospital and government donor agency. Ghana is one of 11 countries in Africa and South Asia that are part the programme. It involves 300 UK-based volunteers giving local healthcare teams and trainers a three-day training course in essential obstetrics knowledge and skills.

The programme has trained more 12,000 healthcare workers with an ultimate target of 17,000. It has resulted in a mean reduction in maternal deaths of 50% and a 15% reduction in stillbirths.

The programme won the prestigious British Medical Journal Women's Health Team award this year. The programme judges remarked:

"Over the last six years, this inspiring project has saved the lives of countless women and babies in 11 developing countries across several continents. In 2014 alone its UK-based volunteers have held over 100 essential obstetrics knowledge and skills training courses for local health care teams and trainers. The project has been continuously expanding its geographical reach to tackle maternal morbidity."

But challenges remain

Ghana's progress in further reducing maternal mortality is stunted by several challenges. These include a combination of female illiteracy, poor road infrastructure, skill shortages and unnecessary interventions by pastors. In some instances, there are initiatives to mitigate these challenges - but they have not achieved major breakthroughs.

Many women in rural areas refuse access to skilled care during the delivery of their babies. This is often because of a lack of understanding of the public health messages. Female illiteracy has a role to play. Although the Ghanaian government offers free education for all children up to junior secondary school, families in rural communities are more likely to get a girl to work in the farm than encourage further education. Between 2008 and 2012, only 43% of girls attended secondary school.

Another contributing factor is that women often adhere to the norms and traditions of their mothers and grandmothers who had their babies without skilled birth attendants.

Getting to a clinic is a major challenge for many women. Road infrastructure in rural Ghana is poor and roads are sometimes impassable in the rainy season. In Ghana's central region, communities have paired up with the Ghana health service, transport unions, the European Commission, the United Nations and Ghana's government to address the problem. This, it is believed, will help reduce maternal deaths.

Aside from a cash injection, the initiative includes dedicated taxi drivers who leave their telephone numbers with nurses at the health facilities in cases of emergency or to transport pregnant women in labour.

Skill shortages are also a problem, mainly in rural areas. Newly qualified staff are reluctant to get postings in rural areas - and those with skills in maternity care who are posted are rotated in other departments such as respiratory and orthopedics, depriving mothers of skilled birth attendants.

Lastly, the intervention of pastors, particularly when there are complications for the women in labour, can prevent emergency procedures being performed on mothers. This too is having an impact on maternal mortality rates.

This issue was raised at an international conference in 2014. A call was made for research into the influence of prayer camps and preachers on obstetric and reproductive decision-making in Ghana.

Intervening pastors are widespread in southern Ghana where there is a predominantly christian population. It is also predominantly a rural problem, although some urban areas are also affected.

On recent visits to programme sites, trainees have recounted harrowing stories to volunteers about local pastors who prevent highly trained health service staff from doing their jobs, resulting in the unnecessary deaths.

The most common occurrence is when an emergency caesarean is required. Before doctors and midwives can operate, the woman calls her pastor who delays the operation until his arrival, saying he could possibly "save" her from having an operation. Inevitably, she and her baby die in the wait.

Another scenario is that a male pastor decides that the woman is better off delivering her baby on the church premises instead of the hospital.

Mutual respect could save the day

Although all maternal deaths in Ghana cannot be blamed on a few pastors, the matter does require the services of an organised body of religious leaders to tackle the issue.

Pastors provide good pastoral care to their parishioners and are to be commended. Mothers are dying for many reasons, some of which are being addressed through the various training programmes and enhanced health service provisions. In the broader scheme, though, the function of the obstetrics health care workers needs to be understood. Their goal is to provide the best service for pregnant women. They take no delight in simply undertaking interventions on pregnant women for no medical benefit. They do, however, need the respect they deserve as precious lives are at stake.