Maternal Mortality in Somalia
II. Global Public Health Issue Somalia is a country that has suffered from many issues since the collapse of any sort of centralized government. The Somali people have suffered from countless diseases, poverty, conflict, environmental disasters, and constant displacement.
For almost an entire generation the country has been without an effective central government, which in turn had major effects on the country’s health system. The Somali health system consists primarily of fragmented and privatized services that are insufficient and unequally distributed. The country’s public health system has very little central governance or management.
Due to these factors most of the population do not have access to the most basic health services and definitely do not have access to higher level of services if needs arises. The lack of an overall adequate health system that is controlled by a centralized government has crippled the progress of reproductive health. Giving birth in Somalia is extremely dangerous and very unpredictable. Somali woman are among the highest risk women in the world with a Maternal Mortality (MMR) of 1,044-1,400 per 100,000 live births compared to a 12 per 100,000 in the United States. Even after a mother survives all these risks and delivers her baby, both mother and child continue to face constant risks. The under-five infant mortality rate is 225 per 1,000 live births2 compared to 8 per 1,000 live births in the US3, putting infants in Somalia in the highest risk category worldwide. A woman’s health and behavior during pregnancy affects the health of her unborn baby. A poor diet, certain environmental exposures, illnesses, medication, and other factors affect the baby’s development. Prenatal and antenatal care is extremely important in order to ensure the health of the baby and the mother.
In Somalia only one out of every four pregnant woman gets antenatal care and for those lucky few that do, the service isn’t even good enough and they do not receive vital interventions. 4This missed opportunity to catch any complications that would arise contributes to the high MMR and IMR in Somalia. The lack of adequate antenatal care also increases the chances of pregnant women developing eclampsia during their pregnancy, a complication that is one of the major causes of maternal mortality in the country and could be easily prevented with a simple blood or urine test.
Interestingly the amount of women that receive antenatal care differs across the region. Somaliland, a northwestern region of Somalia that has declared itself a sovereign state and enjoys a higher level of stability and governance, has the highest antenatal care coverage percentage according to the last survey done by MICS in 2006. Somaliland had 32% of its population receiving at least four antenatal visits, followed by Puntland that has 26% of antenatal care coverage. The lowest coverage in the country was recorded in the central south region, a pattern that is the same for most other health disparities in the country. Aside from the lack of proper antenatal care during pregnancy, traditional beliefs that are held by the Somali population affects the maternal mortality rate in the country. Most Somali mothers do not believe in prenatal health precautions, such as taking vitamins and attending checkups. They take on the motto of, “if one isn’t experiencing pain or bleeding there is no need to see a doctor until birth. The rest should be left to god”. This type of behavior greatly contributes to the high MMR. Infections due to unattended and unhygienic deliveries also contribute to the high maternal mortality rate in the country.
For all the births that take place in Somalia only a mere 2% of births take place in a health care facility that is attended by skilled staff6. Most rural women do not have the resources or access to deliver in facilities with staff that are trained in child delivery. By the time they go into labor most are alone or with untrained family members and neighbors. They resort to unsafe traditional methods of delivery, using equipment that is unsanitary or harmful to the mother and child. These methods mostly result in postpartum hemorrhaging; a major cause of maternal mortality in Somalia.
Also with the high number of deliveries outside of maternal facilities, the attentions that mothers would have received if complications arise are not available. Prolonged and obstructed labor leads to the death of the mother or infant, and in some cases the death of both. Aside from those mothers who do not deliver in health facilities, the few that do are not that much better off. Due to the high personal risk in Somalia aggravated by the violence, most hospital staff do not come to work in fear for their own personal safety. The health care system in the country uffers from poor healthcare workers retention, lack of medical supplies, lack of neonatal facilities, and extreme lack of trained personnel on duty. For those mothers that do give birth at a facility most do not have access to an emergency obstetric referral care. A pregnancy complication called postpartum hemorrhaging is treated in emergency obstetric referral care. Most mothers that are suffering from this excessive bleeding only have a one to two hour window to be treated or else they die due to blood loss. Unfortunately many mothers lose their life in this timeframe in Somalia.
Some other factors that also contribute to maternal mortality is a custom practiced by many Somali woman in the country. Female genital mutilation (FGM) is the process of partial or total removal of the external female genitalia for whatever purpose that is not a medically prescribed surgery. It is a painful process that many young girls go through and most experience infections and in some worse cases death. During pregnancy women that went through FGM experience complications and have to go through a de-infibulation process in order for her to even deliver vaginally.
If this process of infibulation is not done properly and the woman attempts to do it without specific precaution, the death of the baby and the mother can easily results. Many young mothers, especially those that live in rural and nomadic areas, do not have access to health care facilities that can do this procedure and they are forced to do this procedure with unsanitary equipment and methods. Moving beyond the pregnancy and birth, mothers and children that survive this risky situation, have to deal with a lot more.
According to the Multiple Indicator Cluster Survey (MICS) that was taken in 2006 the infant mortality rate (IMR) is at 86 per 1,000 live births. A survey collected by UNICEF in 2008 calculated the under five child mortality rate (U-5MR) to be at 135 per 1,000 live births. The lack of proper supplies and vaccination contributes to infants passing away due to polio or malaria. Subsequently since most mothers do not give birth in facilities and opt to delivering at home, infants do not receive postnatal care at all, exposing them to a deadly world with no defense mechanisms.
Diarrhoea, disease-related dehydration, and respiratory infections are also the highest reason for more than half of infant death. The major reason for the contraction of Diarrhoea being the lack of safe water and poor food hygiene a child experiences during pregnancy or after birth. The countries harsh weather conditions and natural disasters in Somalia also affect maternal mortality rates and infant mortality rates in the country. Harsh famines that occur leave pregnant mothers and infants extremely malnourished with no access to food, clean water, or medication.
Pregnant woman sometimes have to deal with no food or water for many days while they walked in the harsh weather to the nearest shelter. This results in miscarriages and stillbirths. Infants that are born into these situations mostly die of malnutrition and disease since they have no access to food, water, or medicine. Subsequently environmental health in Somalia is extremely lacking and services are concentrated in small towns and wherever security conditions allow. After the collapse of a centralized government, public health and environmental health services became almost non-existent.
Due to the lack of regulation and monitoring by a strong government, the environmental and public health situation has declined tremendously. Somaliland and Puntland seem to have at least some adequate levels of public health and environmental services, but they too are only focused on small densely populated areas. As you travel out into the rural parts of these regions, any sort of health services becomes minimal. South and Central Somalia seems to be suffering the most, with large populations going without much health care and environmental services.
One of the biggest environmental risks in Somalia is access to safe drinkable water. Only 29% of the population has access to safe drinking water7. In the urban areas people depend on wells that are located on private property and are dependent on the purchase of water. In the villages people and animals use the same water source, sometimes causing the water to become contaminated. The situation has been worsened with the constant and massive movement of the population from rural areas to more stable cities, cities that do not have the capacity to provide safe water for their steady population rise.
To aggravate the situation even more, due to the lack of national environmental services, most Somali households live in a situation where they do not have proper means to dispose of waste and excreta. This is felt more in places where people live close to one another and have their waste near where they dwell. Due to the poor hygiene and sanitary precautions, outbreaks such as cholera between woman and children become extremely common. Lack of a garbage collection system also affects environmental health and contributes to water pollution.
Since there is not regulation to where garbage is dumped or any garbage collection system, it is normal to see trash everywhere. Whether it is the streets, inside buildings, or even in bodies of water, it is not uncommon to see garbage lying around. The smell that neglected garbage emits and the health risk it brings, not to mention the unsafe animals it attracts, is something that the population is left to deal with. III. Public Health Impact and Policy Reducing maternal mortality rates in Somalia has had a global affect on the public health world. Many campaigns were launched in order to reduce this staggering high MMR in the country.
Whether big or small, each campaign primarily focuses on ways to support the pregnant women during pregnancy and transition her and her newborn into the world. One of the larger and more global campaigns Somalia is a part of is the launch of the Millennium Development Goals (MDGs). At a sit down that occurred at the end of he 20th century, governments from across the world came up with a set of goals for all developing countries known as the MDGs. These goals, which would be completed by the year 2015, would help cut world poverty in half, improve health standards across the world, and save millions of lives.
The MDGs are time sensitive and have a set and pre-determined outcome. With connection to the MDGs pertaining to Somalia’s maternal issues, MDG1, 2,3,and 7 are closely related to reproductive health. While some progress has been made with some of the goals, most of the goals pertaining to maternal and infant health have seen little to no progress thus far. Somalia has shown a commitment to achieve all the MDGs, and has submitted the first report this year on the status of the MDGs since the campaign was launched.
Although it is recognized that the progress reached is not as high as expected, with a country like Somalia that is extremely suffering in all categories, any progress is welcomed. In order to fully reach all the goals set by the MDGs, a commitment by the government to create a strong national health system with strong policies that will lead stakeholders in providing quality services is needed. Globally the MDGs pertaining to maternal health are showing a positive result. According to a report produced by the United Nations, the number of woman dying during pregnancy or childbirth has halved in the twenty years this program was launched.
The report they submitted, called Trends in Maternal Mortality: 1990 to 2010, show that between 1990 and 2010 the number of maternal deaths decline 47% annually. Even though progress has been made, many countries that are mostly in sub-Saharan Africa will not make the MDG goal of minimizing maternal death by 75% at the end of 2015. Thirty-six of the forty countries that have the highest maternal death rate are in sub-Saharan Africa. Ten countries have already reached the MDG goal of 75% reduction in maternal mortality. Those countries are Belarus, Bhutan, Equatorial Guinea, Estonia, Iran, Lithuania, Maldives, Nepal, Romania, and Viet Nam. Recently in 2010 at a UN Leaders Summit for the Millennium Development Goals, a Global Strategy for Women’s and Children’s Health was launched with a total of US 40 billion for funding. The MDGs that are at target are MDGs 4 & 5; those that are aimed to reduce child mortality and improve maternal health. In Somalia the National Reproductive Health Strategy is aimed to reach the highest possible reproductive health for Somalis and reduce the amount of women and children that die from easily preventable diseases and complications. With just three years left till 2015, initiatives have to intensify in order to reach satisfactory progress.
Malaysia and Sri Lanka are an example of successful implementation of the policies set by the MDGs. Both countries have succeeded in reducing maternal mortality to levels that are comparable to industrial countries. In Sri Lanka female literacy was expanded and with Malaysia’s strong economic performance, both succeeded in a steady decline of their MMR. All it took from them was a steady and modest investment in poverty reduction, providing maternal health services that were accessible, and improving access to quality emergency obstetric care. Both countries took step to remove inancial obstacles that pregnant woman face in order to receive maternal care. Both countries success was also aided with their increased skilled birth attendants that were vigorously trained in the art of child delivery. The more accessible skilled birth attendants and emergency obstetric care that a country has, the more chances for pregnant woman to have successful deliveries. Culture can either take on a role of aiding or impeding the implementation of public health practices. In the case of Somalia, the widespread practice of FGM in the past has caused great harms to public health practices.
The repercussion FGM has caused to woman health is immeasurable. Even though FGM is so deeply woven into the Somali culture and has been practiced almost since the establishment of the Somali people, Somali woman have been working hard to eradicate it as early as 1977. The Somali Women’s Democratic Organization (SWDO) was formed in 1977, to become the implementation agency for the eradication of FGM. In 1988 a campaign was launched to eliminate the practice of FGM under the premise that it was unhealthy and completely unreligious.
Shortly after a research center was opened solely to focus on the harmful affects of FGM and ways to eradicate this practice. Unfortunately, the fall of Siad Barre’s regime and the countries collapse in 1991 halted all progress made. Since 1996 UNICEF in Somalia funded series of awareness seminars attended by women organizations, religious leaders, government officials, and health professionals. In 1997, Somaliland’s government with the help of UNICEF organized a national seminar on FGM and established committee to develop policies in order to eliminate this practice.
UNICEF also sponsored workshops in Mogadishu, Galgaddud, and Mudug regions in 1999-2000. Religious leaders have also been doing their own work informing the public that FGM is not a religious practice and is in fact prohibited by Islam. On November 1999, the Parliament of the Puntland administration approved legislation making the practice of FGM completely illegal. Since then there is no real evidence that this law is being enforced 9. Through many campaigns and initiative people across Somalia are actively talking about the discontinuation of FGM. More and more women are joining he fight against this practice, a feat that in of itself is huge. Talking about this topic publicly was a taboo for such a long time, and it is a huge progress for people to just be talking about it. Changes are gradually being seen in the Somali community. Recently, with the collaboration of an NGO called TOSTAN, UNICEF, and Somali community leaders, an awareness programme was launched in Somalia. This programme is aimed to create community awareness around many issues including FGM. So far a total of eighty-four communities already have been engaged and of those eighty-four, twenty-eight have declared abandonment of FGM10.
IV. Costs: Economic and Societal “There is no tool for development more effective than the empowerment of women. ” This quote was said by the former General Secretary of the United Nations, Kofi Annan. In this simple sentence Kofi Annan explained the importance of women in our society. Women play a key role in improving the health, education, and economic productivities of their families and communities. Yet strangely, even though the health of woman is so essential to the wellbeing our society, they are the poorest and most vulnerable people in the world. out of every 10 women dies in childbirth. All public health professionals and frankly everyone around the world should be very concerned about maternal mortality. When a mother dies she most likely leaves behind children. Those children become neglected because it is the mother who really takes care of the kids, ensures they are fed, well educated, and medically well. If those children lose their mother they either pass away themselves, or become unfit members of their community. A child that could have become a positive asset to his or her community is now part of the chain of poverty.
Keeping mothers alive is essential part of helping end the chain of poverty. Most mothers that die during pregnancy or childbirth die due to an easily preventable disease or complication. In the case of Somalia where maternal mortality rate is at an all time high, most complications could have been easily preventable. Mothers face economic hardship, no access to healthcare services, and face harsh environmental risks. Also due to the lack of stability and a strong central government that has equally strong public health policies and procedures, their chances of survival while pregnant or giving birth is very slim.
Major stakeholders on this public health issue in Somalia are: private sectors, NGOs, United Nations, Ministry of Health of Somalia, and Regional Ministry of Health in Puntland and Somaliland. Unfortunately, the Ministry of Health of Somalia has no real power due to lack of financing and resources. Its regional counterparts (Somaliland & Puntland) may fare a little better by they too have no major resources. That leaves this issue to heavily depend on private sector and Non Governmental Organizations. Groups such as UNICEF and WHO have launched many great campaigns, but the greatest challenge they face is in security.
Due to the threat posed by Al-Shabaab and its terroristic activities, aid worker’s lives are at a constant risk when performing within the country. This forces these organizations to either work outside the country or wait until conditions become more favorable. Working outside the country entails using local leaders an workers to implement projects, and due to the chaos in governance, corruption is inevitable. V. Proposed Resolutions In order to reduce MMR in Somalia there has to be many steps taken.
Somalia must first develop and maintain a strong healthcare system that supports maternal health. There must be universal access to antenatal and prenatal care by every pregnant woman, with consistent checkups. These facilities should also be created in rural and urban areas where there is little to none in order to ensure the health of pregnant woman in those areas. Abundant supply of Trained Birthing Attendants need to be established that are skilled and have gone through training in safe and sanity birthing, and are equipped with all the supplies they need to carry out this procedure.
Emergency Obstetric Referral Care must be developed and made accessible. Programme in family planning, use of contraceptives, and reproductive health should be developed for woman and families to go through. Policies should be implemented for families that cannot afford maternal care, through free services or vouchers. Vaccinations and other preventatives measure must be taken during and after pregnancy to ensure the health of both mother and child. Campaign to eliminate cultural practices that bring harm to mothers must be created and advanced.
Sexual health education programme should be provided to young girls in order to prevent young pregnancies. Somalia is a war torn country with little no to none stable governmental structure, and lacking in a strong health care system. All proposed solutions require a functioning government to implement and monitor these solutions. Until Somalia can develop this, it will be extremely hard to lower the maternal mortality rate. 1 http://www. unicef. org/somalia/health_53. html 2 http://www. unicef. org/infobycountry/somalia_865. html 3 http://www. unicef. rg/infobycountry/usa_statistics. html 4 http://www. unicef. org/somalia/SOM_ReproductiveHealthReport-WEB. pdf 5 http://www. childinfo. org/mics/mics3/archives/somalia/survey0/outputInformation/reports. html 6 http://ethnomed. org/clinical/mother-and-infant-care/perinatal-profile-for-patients-from-somalia 7 http://intersos. org/en/countries/africa/somalia/somalia? page=1 8 http://www. un. org/apps/news/story. asp? NewsID=42013&Cr=maternal&Cr1= 9 http://www. asylumlaw. org/docs/somalia/usdos01_fgm_Somalia. pdf 10 http://www. unicef. org/somalia/reallives_7723. html