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Katie Kauppi
Feb 13
Worldwide, 99% of maternal deaths occur in low- and middle- income countries. The right to safely deliver a child is practically a guarantee in higher income countries, but in a region like sub-Saharan Africa where maternal mortality rates are the highest in the world (some 2,000 per 100,000 births), mothers are often risking their lives by bringing a new life into the world. Many lives are lost due to the “brain drain” phenomenon that causes sub-Saharan Africa to lack the necessary healthcare professionals in many countries because the skilled doctors and nurses are emigrating to other countries. Even in regions with doctors, though, many women are still unable to receive care due to an inability to afford the costs of transportation to hospitals and care once they are there, especially if a cesarean section is required for safe delivery (Source 5, 3, 4).
Studies prior to this 2004 statistical study reported varying conclusions as to the significance of the effect the quantity of human resources has on maternal health and infant/childhood health. For this study, researchers found that there was a concrete link between the density of human healthcare resources and the health of mothers and children; in fact, the density of human healthcare resources impacts maternal mortality most of all. This study found that the prior studies used income measurements by the dollar amount rather than the purchasing power amount, which exaggerated the income gap between the richest and poorest countries. This supports Jahan’s idea that income is an imperfect measure of development because the dollar amounts can often mean different things in different concepts. It is reasonable that the maternal mortality rates are most directly impacted by the amount of healthcare workers because the leading causes of maternal death, “evere bleeding, unsafe abortion, eclampsia, obstructed labour, and indirect causes such as anaemia or infection,” all require a skilled medical professional to carry out successfully. On the other hand, the infant or child-under-five mortality rates are not as dependent on skilled professionals since it is easier to teach an unskilled worker how to administer vaccines and oral rehydration treatments, the most common techniques for avoiding infant or child death. The data on which this study was based comes from the WHO 2004 dataset. Though this was the best source of data at the time, it comes with three main limitations:
These limitations do not inhibit this particular study in a prominent way, though, so the dataset can still be regarded as accurate. When considering the results of the study, the density of doctors greatly impacted the mortality rates of mothers, infants, and children under five alike, while the presence of nurses really only had a strong impact on maternal mortality. The study ultimately confirms my assumption that human health resources are an essential feature of human development. In order to accomplish the Millenium Development Goals, we should first start by directing human health resources and similar aid to countries who need it most in order to allow their other goals to fall in place. Additionally, maternal health in this region as a whole will suffer greatly without the additional resources.
Prior to the 2014-2016 Ebola virus disease outbreak, Sierra Leone’s maternal mortality rate was 1100 deaths per 100,000 live births. As contrasted with a source on the region from 2006, the mortality rate in 2014 was almost half of what it was in 2006, demonstrating a trend towards better maternal health. Contributing greatly to the mortality rate still being high is that only 54.4% of births in Sierra Leone were in a hospital or health facility, which would have been able to prevent most of these deaths. When the Ebola epidemic hit, it had a great impact on maternity patients because pregnant women are more vulnerable to contract diseases like Ebola. The Ebola virus was typically fatal for both mothers and their children, and the symptoms generally mimicked pregnancy complications, often leading to misdiagnosis. Many women ended up in Ebola isolation facilities and required further testing when they didn’t even have Ebola and instead had a curable pregnancy complication. Not only did this endanger the mothers, it also wasted the healthcare personnel resources on persons who did not require Ebola assistance when these regions already have insufficient numbers of doctors. In another sense, the contact with bodily fluids had by healthcare professionals in a maternity ward put the doctors and nurses at a high risk for contracting the disease. This risk could contribute to a push factor that encourages doctors trained in sub-Saharan Africa to leave the region for somewhere less disease-prone, but it also greatly contributed to the lack of healthcare professionals as they became patients with Ebola. Thanks to the intervention of Partners in Health, the staffing at Sierra Leone’s Princess Christian Maternity Hospital nearly doubled (56 to 96), and the hospital was able to collaborate with 30 international health care providers. Another major issue Ebola caused mothers is that they were not allowed a cesarean section until confirmed negative for the Ebola virus disease “with a PCR test 72 hours after the onset of symptoms.” Operating on women with Ebola presented too high of a risk to health care professionals, so many mothers were denied that important procedure that greatly endangered them and their children. Similarly, the 72 hour wait time after the onset of symptoms was incredibly dangerous since cesarean sections are often a last resort for an emergency birth, and three days could be potentially fatal in dire situations. Partners in Health implemented more efficient screening tactics which may hopefully decrease this risk for mothers in need of cesarean sections.
At the time of this paper’s 2006 publication, Sierra Leone documented the highest rate of maternal deaths: 2,000 per 100,000 live births. The causes of these deaths are primarily due to an ineffective health system that is unable to manage complications during or after birth. Shortages of doctors who have expertise are commonly due to…
This is fascinating when viewing the issue through a data science lens because the immigration and emigration aspects of these shortages could be tracked through GPS data from mobile phone usage. The availability of mobile phone coverage in the area and the percent of the sub-Saharan African population that uses cell phones would need to be considered to see if this data collection method would be applicable in this situation. In another aspect, HIV can also spread to midwives due to the contact with blood and other bodily fluids during childbirth. Unfortunately, the ironic poor health of doctors is contributing greatly to a shortage of them. The idea of a “shortage” is interesting because of its subjective nature that can be clouded by the bias of a richer country. The United States’s nursing shortage was proclaimed due to only “773 nurses per 100,000 population,” but that is nowhere close to the Ugandan nursing shortage that has reported “6 nurses per 100,000 population.” Data from nursing schools about the percentage of graduates who continue to practice in the region versus those who emigrate to other regions could identify the areas that are not retaining healthcare professionals or simply not graduating enough in general in order to target where aid is needed. Additionally, in order for the highest quality of care to be delivered, one would need to track how many of these graduates go on to work for the private sector versus the public sector, since the private sector seems to generally offer higher qualities of care. In South Africa, “75% of South African specialists work in the private sector,” so the shortage of nurses for those who rely on the public sector for care may lead to worse conditions for mothers. The reasons for emigration generally come down to:
Because of a lack of healthcare professionals with the proper skills and training, the remaining doctors and nurses often find their skills spread too thin which can lead to less successful procedures like cesarean sections. Similarly, these facilities often find themselves inadequately prepared to deal with workload, infection control, and timely operations.
This 2004 article expands on the “brain drain” phenomenon, the idea that healthcare professionals who were trained in places like sub-Saharan Africa are emigrating to richer countries like the United States. Of the 771,491 licensed physicians in the United States in 2002, 23% received training in a country outside of the United States. Over 5,000 of them alone had emigrated from one of 22 sub-Saharan African countries to practice in the United States. Nigeria has had 2158 physicians leave for the United States, the most of any country in the region. And, this data only explores those who have emigrated to the United States. There are likely more sub-Saharan African healthcare professionals who have left for other rich countries. This is likely due to a variety of “push factors,” negative aspects of working in sub-Saharan Africa that would prompt doctors to move to a richer country. Some of these are “insufficient suitable employment, lower pay, unsatisfactory working conditions, poor infrastructure and technology, lower social status and recognition, and repressive governments,” while “pull factors” attracting physicians to richer countries represent the alternative for those conditions: “training opportunities, higher living standards, better practice conditions and more sophisticated research conditions.” This phenomenon invites the question about how a country can make itself more inviting for physicians and other healthcare professionals. Outside of sub-Saharan Africa, the United Kingdom has attempted to combat this problem by prohibiting the “National Health Service employers from recruiting healthcare professionals from a long list of developing countries.” The United States, on the other hand, has made strides in the opposite direction. They have policies in place to provide support for international medical graduates and allow them to practice in the US fairly easily. Within Africa, South Africa has taken action to encourage “the World Health Assembly to take measures to stop the flow of physicians from poor countries to rich ones” and has banned recruiting doctors from other African countries to work in South Africa. Ultimately, in order to keep doctors in their countries of origin, the end goal should be eliminating push factors rather than enacting legislation that forces them to stay.
The focus of this 2019 article is to identify how cesarean sections, surgeries that are necessary to save the lives of both mothers and their babies in many situations, may be inaccessible for many in sub-Saharan Africa. Primarily focusing on Rwanda, this study was supported by Partners in Health, a charity that works tirelessly to solve many maternal and neonatal health concerns. PIH’s impact on these types of health issues in the past two decades may be an interesting point of further research. This study reports that “99% of neonatal and maternal mortality occurs in low- and middle- income countries.” Cesarean sections are necessary to combat the most prominent causes of maternal death, “hemorrhage, obstructed or prolonged labor, and pre-eclampsia/eclampsia,” and it is estimated that “63-90%” of maternal deaths could be prevented by improving access to cesarean sections. At Butaro District Hospital in Rwanda, community-based health insurance covers 90% of costs for women who are part of that plan. However, the problem then lies with women who are uninsured. They are responsible for covering 100% of the “personnel, infrastructure, medicine, medical consumables and hospital indirect costs.” This case study presents the idea that perhaps the problem does not lie with the lack of healthcare professionals alone, but also presents cost as a major factor preventing women from getting the emergency maternal care they need, since “at least 95% of all deliveries occur at health facilities, and are assisted by skilled providers.” This also could likely be a result of the attention Rwandan facilities have received by organizations like Partners in Health, which would explain the fortunate increase in professionals who are dedicated to decreasing maternal and neonatal mortality rates in countries that need it the most. However, this is likely not the same situation in countries that have not received the same amount of aid. This study reported that the total cost of cesarean delivery ranged from US$320-$380, with the average being US$339. With the community-based insurance, women were responsible for US$34 for a safe delivery, “other expenditures such as transportation and food.” This cost could be “prohibitive or catastrophic” for many of the mothers who need this surgery, and the long hospital stay or expensive transportation costs will only make it worse. Attempting to bring down this cost by staying at the hospital for a shorter time or bypassing the surgery altogether will greatly increase the mother’s and/or child’s chance of complications or even death.