Population Growth and its Impact on Maternal Health
The fifth Millennium Development Goal (MDG) calls for improvements in maternal
health, by reducing maternal mortality by three quarters. The current essay will argue that
unless substantial efforts are taken towards lowering fertility rates that will then impact
population growth, attempts to achieve this goal are compromised. I will provide
evidence pertaining to the effect of population growth on maternal health by focusing
specifically in sub-Saharan Africa, where most of the maternal deaths occur, and where
the danger of failure to achieve this goal is the greatest. I will provide examples from
available research in the field, and will include my own personal experience as a
practicing public health physician in Angola.
Despite the efforts to bring maternal health to the forefront of public health concerns, the
desired improvements have not been achieved. In sub-Saharan Africa, most countries
experienced on average no changes in the percentage of deliveries assisted by a skilled
attendant1 [figure 1], and show no signs of achieving the scheduled reduction in maternal
mortality2. Several reasons for the lack of success so far can be named, but two stand out
and are directly related to population growth: current focus on delivery practices and
failure to meet the demand for family planning.
Most of the current focus on decreasing maternal mortality is on increasing skilled
attendants at birth, which involves multifaceted problems. The presence of skilled
attendants at birth is conditional on the number of skilled providers and or health care
facilities available, and on many socio-cultural factors associated with the delivery
process. With a rapid growing population as in the case of sub-Saharan Africa,
concurrent substantial improvements on education would have to take place, as well as
expansion of the health care infrastructure. Both education and health care are highly
linked to economic growth. No country, with the exception of a small number of oil-rich
states, has achieved significant economic development while still maintaining high
fertility. This means that neither the educational systems nor the health services can be
constructed until birth rates decline. The reason for this is the dependency factor:
governments of countries in which each cohort of children is followed by a larger cohort,
year after year, find it impossible to catch up with the need for education and health
services.
According to the WHO, Africa’s burden of disease represents 25% of the world’s burden,
but its health care workforce constitutes only 1.5%3. Most of the countries in sub-Saharan
Africa have lower health care worker density than what is considered reasonable,
2.5/1,000 population. The WHO estimates that it will take on average 20 years for most
1
Abouzar and Wardlaw, 2001. Maternal mortality at the end of a decade: signs of progress?. Bull World
Health Organ 79(6):561-8.
2
Koblinsky, 2003. Reducing maternal mortality: learning from Bolivia, China, Egypt, Honduras,
Indonesia, Jamaica, and Zimbabwe. HNP Series, World bank.; MDG Report 2005.
3
WHO, 2004 – Addressing Africa’s health Workforce Crisis: An avenue for action. Paper prepared for the
high level forum on MDGs, Abuja, Dec. 2004.
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African countries to achieve significant increases in the needed health care work force,
and this is if substantial investments on a large scale are made now. The insufficient
number of health care professionals in sub-Saharan Africa is further exacerbated by the
fact that the existent work force would like to leave the continent, as measured by
intention to migrate4 [figure 2]. African governments have also to deal with health
professional’s retention difficulties in rural areas. Even those originally from rural areas,
would prefer to leave and work in urban areas after finishing school. Young women for
example, after attending high school and some sort of health care training, do return to
their villages. However, when they are married and have children, with educational
opportunities they need not available in rural areas, they tend to move and settle in urban
areas.
The socio-cultural factors are more difficult to address. Delivery is perceived as a natural
process in life and not a medical condition. Women have been delivering at home with
traditional birth attendants in Africa for as long as we have existed. For example, my
mother delivered me at home with the assistance of a birth attendant. When trying to
understand why women even in urban areas deliver at home, my mother’s response
echoes those of many women whose births I assisted during almost 10 years of clinical
practice in Angola. Western delivery service models are too strict and do not
accommodate the presence of family members during delivery, and therefore the
possibility of performing rituals and ceremonies. In addition, women tend to perceive
maternal mortality in health care facilities to be high, and rightly so5.
The practical solution for the moment in maternal health, while countries are struggling
to improve health care systems, is to train existing traditional birth attendants to provide
better care, by providing them with the necessary knowledge, low cost and easy to use
available technology (and specifically misoprostol tablets for postpartum hemorrhage, the
leading cause of maternal mortality), and set up a good referral system, so that only the
complicated cases are referred. This might sound as a harsh, dismissive, and hopeless
conclusion for maternal health in poor settings. I do consider settling for the lowest
possible care an injustice to safe motherhood. However, my conclusion comes from
personal experience, when as a young physician in Angola I was sent to complete my
two-year community service to a 200,000 population. My public health priorities were
maternal and child health, but as the only doctor I soon realized that after seven years in
medical school I could not by myself make an impact on the health of the population I
was serving. The only strategy was to focus on a very few achievable interventions that
could be delivered on a large scale, and to trust and count on the community’s own
existing non-professional sector in health care6. I used traditional birth attendants to
improve safe delivery practices; community volunteers to recruit, distribute and teach the
use of contraceptives, immunization, and the early signs of the most prevalent infectious
diseases; and traditional healers to refer to the health center all suspected cases of
4
WHO Migration study, 2003.
Facilities tend to receive the most difficult cases; some of them arrive too late, when a life cannot be
saved.
6
In this case for maternal health and child health I worked with traditional birth attendants, community
volunteers and traditional healers.
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infectious diseases. The same community I served in 1989-1990, with now more than
double the population7, has still only one health center, and for the last 5years it has had
no doctor. The non-professional health sector is entirely responsible for the health of the
community.
Most countries where maternal mortality is the highest are not implementing effective
interventions on a large scale, such as the provision of family planning and safe abortion.
The beneficial public health impact of these interventions is well known, and so is their
impact on reducing population growth and improving maternal health.
There is an enormous and well documented unmet need for family planning in the
developing world [figure 3]. About 150 million married women in developing countries
want to delay or avoid pregnancy but are not using contraceptives. Each pregnancy
multiplies a woman’s chance of dying from complications of pregnancy or childbirth. In
settings such as sub-Saharan Africa where most of the women do not have access to basic
obstetric care, access to contraception may be a matter of life and death, particularly
when presented with risks of an unwanted or unplanned pregnancy.
According to the UNFPA, meeting the existing demand for family planning services
would reduce pregnancies in developing countries by 20 per cent, and maternal deaths
and injuries by a similar degree or more. We also know that as family planning use rises,
women’s desired family size declines. When family planning is made easily available,
along with the correct information required to make the various methods useful, the
population factor is indeed amenable to change.
About 13 to 25 per cent of all maternal deaths are attributed to unsafe abortions, coupled
with lack of skilled follow-up. The high level of unmet need for quality contraceptive
services, along with the corresponding number of unwanted pregnancies, is a key reason
why so many women who want to control their fertility seek out abortions. More than one
quarter of pregnancies worldwide, about 52 million annually, end in abortion. There is a
small difference in abortion rates per 1000 women aged 15-44 between developed and
developing countries ( 39/1000 and 34/1000 respectively)8. The large differences lay in
the fact that developing country abortions, particularly in sub-Saharan Africa, are unsafe
abortions and many of these results in the death of the woman.
In 2005 the UNAIDS estimated that 17.5 million women were living with HIV (one
million more than in 2003). Twenty-five percent of them have unmet need for
contraception, representing roughly 4.4 million HIV+ women in need of contraception.
Family planning is one the most cost-effective ways of preventing mother-to-child
transmission9.
7
8
Mostly due to migration
Alan Guttmacher Institute, Sharing Responsibilities: Women, Society and Abortion Worldwide. 1999.
9
Reynolds HW, Janowitz B, Homan R, Johnson L. Cost-Effectiveness of Two Interventions to Avert HIV-.
Positive Births. Family Health International (FHI).
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Clearly, a woman’s ability to plan how many children she wants and when she wants
them is central to the quality of her life. The ability to control fertility can be given
through family planning programs that have an effect on both population size and
maternal and child health.
Finally, most countries in sub-Saharan Africa have scarce resources for maternal health
services, and they lack the necessary capacity to mobilize resources and commitment for
these programs. Given the level of poverty prevalent in sub-Saharan Africa, most women
cannot afford family planning services [Table 1]. However, given the necessary
resources, most developing countries can decrease fertility by increasing contraceptive
prevalence, while at the same time reducing maternal mortality.
In my view, the greatest hope of decreasing maternal mortality in Africa and in poor
countries in other regions of the world lies on two fronts: decreasing fertility, and
tackling the main cause of maternal mortality, postpartum hemorrhage. Both of these are
related to population growth. For a country to have smaller families pays a demographic
dividend, opening the door for the government to expand its health infrastructure, and
resulting in better parenting and more stable and richer societies, in addition to having
significant effects on maternal mortality.
Figure 1: Trends in Skilled Attendance at Birth. Source: Millennium Development Goals
Repost 2005
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Figure 2: Intention to Migrate among health care workers in Africa.
Source: WHO Migration Report, 2005.
100
% with unmet need
90
% using a method modern contraceptives
80
74
70
62
60
54
52
50
40
28
30
30
25
20
10
9
0
Sub-Saharan Africa
Middle East
Latin America
Asia
Figure 3: Unmet need and use of modern family planning services among married
women.
Source: Data computed by the author using Statcompiler from Demographic and health
Surveys (DHS), measuredhs.com.
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Table 1: Percent Who Cannot Afford Family Planning.
full cost 3/4 cost half cost
only
commodities
Sub-Saharan Africa
98
96
93
77
Arab States/E.Europe
65
51
33
10
Latin America
54
44
30
9
Asia
89
82
71
30
all aid-dependent nations
84
76
66
34
Source: Green, R. 2002. Empty pockects: Estimating ability to pay for family planning. Bay
Area International Group, University of California, Berkeley.
http://big.berkeley.edu/research.workingpapers.atp.pdf
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