Promoting and Monitoring Safe Motherhood in Ghana

Globally, the health of women in the reproductive age group has engaged the attention of all governments especially in the developing countries where maternal mortality ratios range from 200 to 800 deaths per 100,000 live births. Though women in the reproductive age group form about 22% of the population in most developing countries, they carry the burden of pregnancy, childbirth and child care and therefore form a special vulnerable group.

The problems of women in the reproductive age group can be summarized by the level of Maternal Mortality Rate (MMR), which covers deaths during pregnancy, child birth and up to 42 days after delivery. In Ghana, the ratio is 540/100,000 live births and is very high. The ratio differs across the regions and by locality. Regions in the northern part of the country have high ratios and also women in rural areas have higher ratios. There is a high correlation between the features of the region or the locality and the rate. Women in the northern part of the country or in rural areas have poor access to health care in all description of access, that is, geographical, financial and cultural and women in these areas also are relatively poorly educated and have poor nutritional status.

Maternal mortality is a sad event because majority of the factors associated with the deaths are preventable. It has a follow-up cost to the society and the health of the baby should the baby survive.

Governments all over have put in measures to address the problem of maternal deaths through the enactment and implementation of policies, legislations and services. In 1987, the World Health Organization (WHO) and other United Nations' agencies like UNICEF launched the Safe Motherhood Initiative which was accepted in Ghana. Since then, several Safe Motherhood programmes have been and continue to be implemented in Ghana. In 1998, Government of Ghana introduced free antenatal care to all pregnant women and in September 2003, a policy of exempting all users from delivery fees in health facilities was introduced. Thus financial barriers to using antenatal and delivery care in public and private health facilities have been removed. This is to complement the role of dedicated and skilled health professionals to achieve a reduction in the maternal mortality rate.

One of the Millennium Development Goals is to reduce maternal mortality by three-quarters by 2015 and it is necessary to assess the progress towards the achievement of the goal. Thus, the work of the Initiative for Maternal Mortality Programme Assessment (IMMPACT), a global research initiative with its collaborative researchers in Ghana on the evaluation of aspects of the exemption policy in the country is highly commendable.

Abortion deaths form a silent majority of the maternal deaths in the country. The law on abortion has been liberalized over the past decade yet there are other issues of the law which need to be clarified or amended. In view of the low doctor to population ratio; restricting the provision of abortion service to only medical officers will increase the number of women who would use the services of untrained personnel. In South Africa, trained midwives offer safe abortion services in rural areas. Many women do not know their legal rights to safe abortion and therefore do not avail themselves of safe abortion services. Moreover, the law is silent on the victims of rape and defilement of women aged below 16 years who could be given legal abortion. The law by permitting abortion on the grounds of risk to the life of the pregnant woman or injury to her physical or mental health seems to be allowing termination of pregnancy on a much broader grounds.

The Ministry of Health has just recently provided a policy on abortion service which can address termination of pregnancy on medico-social grounds which though allowed in the law, were not covered by services in public health facilities.

The IMMPACT studies have shown that the implementation of fee exemption for delivery increased the proportion of deliveries in health facilities. The greatest increases in facility-based deliveries occurred among the poorest and least educated women. However, the studies also showed that the quality of service did not show any appreciable improvement, especially the attitudes of all the professionals involved in care of delivery was in question from the doctor to the nurse. This will thwart all the efforts of the Government and measures directed at improving access to health services and will slow down the march to achieve the Millennium Development Goal.

There is a need by all to join forces to achieve the Millennium Development Goal regarding maternal mortality rate for Ghana. Everybody has a role to play. Periodic upgrading of the skills of health professionals is vital. Appropriate legislations and policies must form the environment for safe pregnancy and delivery. The cost implication and the difficulty in estimating the Maternal Mortality Ratio has lead to confusion over the correct rate for the country. There is a need for increasing the coverage of civil registration and good cause of death attribution. The alternative method of using the direct or indirect sisterhood household survey methods provide imprecise estimates on a reference point some years in the past. It is strongly suggested that all efforts must be put together to obtain a good estimate for the use of policy makers and service providers.

In conclusion, the call to review the abortion law must be considered; mothers must know their legal rights to safe abortion, use health services for antenatal and delivery; and health professionals must put in their best including the right attitudes to offer quality care to mothers and the babies to guarantee safe motherhood in Ghana.

Professor R.B. Biritwum
Editor, Ghana Medical Journal
Department of Community Health
University of Ghana Medical School
Accra, Ghana.