It is 2015, the deadline for the WHO Millennium Development Goal 5 (MDG5) to reduce 1990s’ maternal mortality by 75%. On May 23, the world will observe United Nations International Day to end obstetric fistula (a breakdown of the birth canal caused by obstructed labour, leaving women incontinent, infection-prone and ostracized). 2015 is also the deadline for WHO MDG4 to reduce 1990s’ under-five child mortality by two-thirds.
A London-educated obstetrician gynaecologist and fetal medicine specialist, I’ve just returned to South Africa after 14 years. I’m delighted to be joining the WITS Maternal and Fetal Medicine Centre at Morningside Mediclinic in Sandton in Johannesburg and with the extra day I’ll spend every week as an Honorary Consultant at Chris Baragwanath Hospital in Soweto.
As a Ugandan-Rwandan, I also return as a sub-Saharan African, fully aware that sub-Saharan Africa made the slowest progress (under 20%) in reducing maternal mortality, that its share of the world’s maternal deaths actually grew from 42% in 1990 to 62% in 2013, and that the projection is it will fail to meet the MDG5 target. I’m also aware that nearly three million women and girls, mostly sub-Saharan African, live with obstetric fistula. Sub-Saharan Africa also has the highest under-five child mortality – 16 times that of developed countries, with more of the 6.6 million child deaths (44% in 2012 compared to 37% in 1990) occurring in the newborn period, clearly linked to a deficit in safe maternity care.
Coming from a UK system, my conscience is heavy. I have worked within clinical governance frameworks where maternity health workers manage obstetric emergencies in multidisciplinary teams, have unrestricted access to updated evidence-based protocols, emergency drugs, blood products and broad spectrum antibiotics and are regularly appraised and supported through enforced emergency drills and continuous professional development. In sub-Saharan Africa, there will be an isolated traditional birth attendant dealing with a post-partum haemorrhage on her own, an unknown expectant mother walking in labor to get help, and I can remember the midwife I met traveling through rural Uganda in 2013 who, when I asked about clinical audit in her unit, responded saying “we are too demoralized by what we face everyday to be dealing with audits”.
However, against the bleak backdrop of sub-Saharan Africa’s high maternal and under-five child mortalities, I’m hopeful. The speed of mobile phone penetration in sub-Saharan Africa over the last decade, faster than anywhere else in the world, points to Africa’s potential. In 2007, mobile subscriptions were already three times faster than in Europe, and in 2009, there were 10 times as many mobile phones as fixed-lines, Kenya being a shining example.
Aside from clear evidence that GDP increases with mobile phone penetration in developing countries, the possibilities are countless.
Relevant to me are the growing number of mHealth projects. Programs and applications that provide real-time intelligence, monitoring and response to disease outbreaks (Nigeria’s ‘EOCs’), provide remote diagnoses (Botswana’s ‘Kgonafalo’), prompt patients to take their medication (South Africa’s ‘Cell-Life’), and prevent drug counterfeiting (Ghana’s ‘mPedigree’). I’m excited by the mHealth projects in maternal health – Nigeria’s ‘mCBS’, South Africa’s ‘MAMA’ and Uganda’s mobile electronic fetal heart monitor ‘Winsenga’.
I owe something to the 800 women and 25,000 children under five who die every year, from preventable causes.
The United Nations has called for accelerated interventions and prioritization in maternal and child health and we await political will, sound strategies and adequate resources. I’ve decided I must take advantage of the great strides Africa is taking in mobile infrastructure and have taken to mHealth, developing a mobile App targeted at safer childbirth as most maternal deaths are due to complications occurring around pregnancy.
Mismanaged labour is also a direct cause of obstetric fistula and newborn deaths. The App will prompt community birth attendants on timely assessments during labour and detect deviation from normality for both mother and fetus. These remote assessments will be electronically visible through a real-time location-based platform for skilled obstetricians and midwives.
Pre-existing medical conditions are another cause of maternal death. The App will therefore in the first instance, perform a risk-assessment to guide on the safest venue for delivery. Patient data and outcomes will be captured into an electronic system to facilitate audit and accuracy of maternal mortality estimates for central monitoring.
I can’t be a bystander as Africa goes through this historic boom in technology while women are evicted from our world simply because they are deprived the safe experience of childbirth. I have to do this because my heart is heavy knowing that with every hour, 33 women die in childbirth from preventable causes. Investing in maternal health will not only improve a mother’s health and her family’s, but will increase women’s numbers in the workforce and promote the economic wellbeing of their countries. I have to do this because women hold up half the sky.