Emily Russel
Maternal Health in Chad
From: Secretary of Health, Chad
To: Minister of Finance, Chad
Introduction
With the fourth highest maternal mortality ratio in the world, improving maternal health
in Chad presents a daunting challenge; however, in accordance with the fifth Millennium
Development Goal, this should be a top national priority. The magnitude of poor maternal health
is huge: 1,200 women will die for every 100,000 live births.i The nature of this problem varies,
with maternal deaths ranging from infection, to post-partum bleeding, to hypertensive disorders.
In addition, women are also at risk for developing conditions such as obstetric fistula.ii Poor,
rural, and uneducated women have the greatest risk of poor maternal health, and the risk factors
include access to care, fertility rates, female genital cutting, early marriage, and the underlying
health of the mother. Additionally, high maternal morbidity and mortality poses serious
economic and social repercussions for the wider society, further entrenching affected families in
poverty and decreasing the nation’s overall economic growth. In order to address the problems of
maternal ill health, the Chadian government should focus its efforts on increasing the
accessibility to maternal health services and on promoting family planning.
Nature and Magnitude of the Problem
The level of poor maternal health in Chad is staggering. A ratio of 1,200 women will die
annually per every 100,000 live births,iii giving Chad the fourth highest maternal mortality ratio
in the world.iv With roughly 508,000 births a year,v Chad can expect well over 6,000 maternal
deaths annually.vi Furthermore, the lifetime risk of dying due to complications of pregnancy or
during childbirth is one in fourteen. The nature of maternal death is varied: it is estimated that
34% of maternal mortality is due to hemorrhaging, 19% comes from pregnancy related
hypertensive disorders, 9% is caused by a septic infection, and another 9% results from
complications with abortion.vii Finally, the 241 cases of obstetric fistula reported each year –
arguably a low estimate of the reality –viii is an indication that poor maternal health in Chad also
leads to serious morbidity, in addition to high rates of mortality.
Affected Populations
While maternal health is a problem for the greater part of women in Chad, poor maternal
health falls disproportionately on rural and impoverished women. Because the majority of
Chad’s population lives in rural areas, they have limited access to proper health care facilities.
Each year, 81% of births take place in rural areas, while 19% are in urban districts.ix Of the rural
births, only 7.3% of women had a skilled birth attendant, compared to the 54.8% of urban
women.x Additionally, 62% of Chadians live below the poverty line,xi further limiting health care
access for these individuals. The percentage of women who utilize health services varies
dramatically by wealth quintile: 55.4% of women in the wealthiest quintile utilize health
services, which is in stark contrast to the 12.5% and 3.6% in the lowest two quintiles.xii Finally,
poorly educated women have a greater chance of suffering from maternal health problems.
Today, only 12.8% of adult women in Chad are literate, indicating the great extent to which
these women are affected.xiii
Risk Factors
There are many risk factors contributing to poor maternal health, including access to care,
fertility rates, female genital cutting, early marriage, and the underlying health of the mother.
Biologically speaking, the primary risk factor for poor maternal health is pregnancy. Thus, the
high fertility rate in Chad of 6.1 indicates that a woman’s risk for poor maternal health increases
with every child.xiv Both limited access to family planning and a cultural desire for many
children contribute to the high rate of fertility. Overall, only 1.6% of the Chadian population uses
modern contraceptives.xv
Limited access to proper health care also presents women with a huge risk. Only 18% of
women in Chad have the four recommended antenatal care (ANC) visits, a full 86% deliver at
home instead of in health facilities, 83.9% of women do not have a skilled birth attendant
present,xvi and only 0.4% of women receive emergency obstetric care through cesarean
delivery.xvii These numbers indicate that women with limited access will likely experience lifethreatening delays in identifying complications and getting to a medical facility in time.
Additionally, once at a facility, women may also experience a delay in receiving emergency
obstetric care due to inefficacy, limited equipment, or objections from male relatives.xviii
Together these three delays put both the mother and her child at serious risk.
Female genital cutting (FGC) and adolescent pregnancy are also associated with an
increased risk of obstructed birth, which can lead to fistula or death. According to some reports,
the incidence of FGC in Chad is around 44%, with a greater frequency among women in urban
areas.xix The percentage of women who gave birth before the age of 18 years old is 48%xx and
52% of women marry by the age of 16.xxi Finally, the underlying health of women is also a major
risk factor for maternal health problems, with factors like anemia and HIV increasing the
incidence of maternal death. In Chad, one of every three women are anemic,xxii the HIV
prevalence among young women is 2.5%,xxiii and 8% of women were counseled for HIV during
an ANC visit.xxiv
Economic and Social Consequences
High maternal mortality and related health conditions have lasting effects on Chadian
women and on society as a whole. Maternal death has a negative effect on the remaining children
who are more likely to suffer from neglect, malnutrition, and even death without the care of their
mothers. Additionally, older children must assume the responsibility of their younger siblings,
limiting their own opportunity to attend school. In the long run, the results of limited education
and poor nutrition hinder a child’s ability to grow into a productive member of society, thus
creating a substantial impact on society as a whole.xxv Furthermore, for women who do not die
from maternal complications, many sustain serious illness such as fistula and must live a
compromised and limited life. The stigma of fistula alone creates serious social consequences;xxvi
however this and other conditions limit a woman’s ability to economically contribute to the
needs of her family and household.
Priority Action Steps
In order to make a significant reduction in maternal health problems, Chad should focus
on a few specific, cost-effective approaches that will reach the most women. To begin, the
country should focus on improving the accessibility and availability of reproductive health
services and address the problems presented by the “three delays.” Because complications of
pregnancy are not predictable, the first and most important step is to ensure that all women
receive care from skilled health professionals whose guidance can mean the difference between
life and death. In addition to funding more rural clinics throughout the country, the government
should train local women as community health partners to detect signs of pregnancy
complications and to advise women when they should seek additional support. Next, the
government should partner with local NGOs in order to provide formal and informal ambulance
services that will take women who need emergency care to the appropriate facilities. Finally,
government should ensure the health clinics themselves provide efficient and appropriate
emergency obstetric care.
In order to incentivize the health care system for women, community partners should
promote conditional cash transfers for maternal health care that include services such as ANC
visits, HIV and nutrition counseling, delivery with a skilled attendant, and emergency obstetric
care. The transfers both incentivize the health care system and ensure greater accountability for
the services. Finally, the government should promote a comprehensive family planning program
that promotes the use of modern contraceptives, offers safe abortion services in accordance with
Chadian law,xxvii and emphasizes adolescent reproductive dialogue. xxviii Overall, family planning
in conjunction with improved services is the most cost-effective method of reducing maternal
mortality, morbidity, and disability.xxix
Bibliography
i
UNICEF. Statistics on Chad. http://www.unicef.org/infobycountry/chad_statistics.html#80. Last Updated 2 March
2010
ii
UNFPA. Obstetric Fistula Needs Assessment Report: Findings from Nine African Countries. 2003.
http://www.unfpa.org/fistula/docs/fistula-needs-assessment.pdf
iii
UNICEF. Statistics on Chad.
iv
The Guardian UK. Maternal Mortality: How many women die in childbirth in your country?
http://www.guardian.co.uk/news/datablog/2010/apr/12/maternal-mortality-rates-millennium-development-goals.
Last Updated 13 April 2011
v
UNICEF. Statistics on Chad.
vi
Countdown 2015: Maternal, Newborn, and Child Survival.
http://www.countdown2015mnch.org/documents/2010report/Profile-Chad.pdf
vii
Countdown 2015: Maternal, Newborn, and Child Survival.
viii
UNFPA. Obstetric Fistula Needs Assessment Report: Findings from Nine African Countries.
ix
WHO. Making Pregnancy Safer: Chad Country Profile.
http://www.who.int/making_pregnancy_safer/countries/cha.pdf
x
WHO. Making Pregnancy Safer: Chad Country Profile.
xi
UNICEF. Statistics on Chad.
xii
WHO. Making Pregnancy Safer: Chad Country Profile.
xiii
https://www.cia.gov/library/publications/the-world-factbook/geos/cd.html
xiv
WHO. Making Pregnancy Safer: Chad Country Profile.
xv
WHO. Making Pregnancy Safer: Chad Country Profile.
xvi
WHO. Making Pregnancy Safer: Chad Country Profile.
xvii
WHO. Making Pregnancy Safer: Chad Country Profile.
xviii
UNFPA: Country Programme Document for Chad. 2005. http://chad.unfpa.org/drive/dpfpa_cpd_tcd-5.pdf
xix
Population Reference Bureau. Female Genital Mutilation/Cutting: Date and Trends. 2008.
http://www.prb.org/pdf08/fgm-wallchart.pdf
xx
UNICEF. Statistics on Chad.
xxi
UNFPA: Country Programme Document for Chad. 2005.
xxii
FAO. Republic of Chad: Summary. 2010. http://www.fao.org/ag/AGN/nutrition/TCD_en.stm
xxiii
UNICEF. Statistics on Chad.
xxiv
WHO. Making Pregnancy Safer: Chad Country Profile.
xxv
UNICEF. Statistics on Chad.
xxvi
UNFPA. Obstetric Fistula Needs Assessment Report: Findings from Nine African Countries.
UN Population Publications. Abortion: Chad. www.un.org/esa/population/publications/abortion/doc/chadsr1.doc
xxviii
Ibid.
xxix
WHO. Maternal Mortality. http://www.who.int/making_pregnancy_safer/topics/maternal_mortality/en/
xxvii