Midwife Certification & The Key to Reduced Maternal Mortality in the Democratic Republic of the Congo

BY ANNA SOPHIA YOUNG

Belvie is lying on a mat in a hut in a rural village in the south of the Democratic Republic of the Congo (DRC). As her two children, Claude and Ruth, play outside, she is trying to give birth to her third child. Belvie has not had any antenatal care, and though she has given birth alone before, she just realized that this time there is an unusual amount of blood. This is not a particularly unusual situation in the DRC, where each year 540 out of every 100,000 women who give birth will die in childbirth.1 Belvie will likely be among them. While in the United States such a fate is highly unusual, maternal disorders are the top cause of death for Congolese women between the ages of 15 and 24.2 Main factors that contribute to these tragic deaths are the deficit of skilled attendants present during birth, as well as the fact that few women receive the four-visit antenatal care recommended for pregnant women.

Women in the DRC have a one-in-24 risk of death related to maternal disorders.3 Worldwide, the three most prevalent maternal disorders are hemorrhage, preeclampsia (high blood pressure) and obstructed labor, all of which can be prevented by a properly trained and equipped healthcare attendant. In fact, while hemorrhaging causes 27 percent of maternal deaths worldwide,2 it can be treated with just one injection – an intervention that, sadly, the DRC’s government policies forbid midwives from administering. Furthermore, while the number of midwife-training schools in the DRC has increased in the last 5 years due to government initiatives to increase enrollment, there are still just 0.6 midwives, doctors or nurses for every 1000 citizens.3

Certain groups of Congolese women are particularly vulnerable to complications in childbirth. Adolescent mothers account for 12.7 percent of the women giving birth in the nation, and are more susceptible to complications because their bodies are not developed enough to support a child. Accordingly, mothers under 15 are five times more likely to die in childbirth than mothers in their 20s.4 Poorer and less educated women are also more likely to succumb to maternal disorders because they lack information or resources to prevent these complications. Exacerbating this problem is a low level of female education: only 25 percent of school-aged girls are enrolled in school, and 44 percent of women in the nation are completely illiterate.3

Many complex factors influence why certain women are more susceptible to maternal mortality than others. Socioeconomic status, distance from health care, lack of information and inadequate services, as well as hygiene and sanitation problems all contribute to the high maternal mortality rate in the DRC. Although midwives are authorized to administer “life-saving interventions,” poorer women often have less access to healthcare, particularly emergency care, and do not receive a midwife’s services. In addition, rural women are less likely to receive adequate care before, during, and after giving birth, causing, on average, 854 birth complications per day.3 Finally, even a lack of information about basic self-care methods during pregnancy has major effects. The United Nations Population Fund estimates that with appropriate medical information services, 74 percent of mothers’ lives internationally could be saved.4

The consequences of maternal mortality encompass much more than the tragedy of preventable deaths. By reducing the size of the labor force, maternal death shrinks a nation’s production capacity. In addition to serving as educators and protectors, women comprise 70 percent of the African labor force and produce 80 percent of the continent’s food.5 Clearly, high maternal mortality rates are deleterious to the economy. Women’s unpaid house and farm work amounts for about one third of many African nations’ Gross Domestic Product, and the annual economic loss worldwide due to maternal mortality is estimated at US$15 billion per year.6

As a result of mothers’ poor health, fathers must often sacrifice working hours to care for children. Moreover, poor maternal health forces families to spend a large portion of their money on healthcare, necessitating loans and reductions elsewhere, such as in the meals provided to other family members. This has a negative impact on child nutrition, which impacts future GDP by harming the human capital development of the nation’s youngest generation. As a result of the aforementioned factors, approximately US$313.20 per family is lost as a result of maternal mortality in the Democratic Republic of Congo.7

If the DRC truly wants to address maternal disorders, its top policy priorities should be to properly train and certify more midwives and to create a government agency that works to make births safer by regulating midwife licensing and practicum. Despite significant efforts to encourage more women to become officially trained, only 82 percent of spaces available at midwifery schools are filled, according to 2009 statistics.3 Secondly, a vital step in the nation’s broader solution to maternal mortality is through a government initiative to legalize more life-saving actions for midwives so women receive proper care before, during and after birth.

The Ministry of Health should create a program devoted to the training, licensing and regulation of midwives. Such a program would equip midwives to provide higher-quality care during more births. Through regulation, the state should also monitor for unlicensed midwives, therefore enhancing mothers’ safety. Unfortunately, the Ministry of Health will need a substantial funding increase to undertake such ambitious midwifery reform.

In urban areas, formal schools are the best way to certify midwives. To address instruction challenges in rural areas, the DRC should create a contingent of travelling midwives who serve as teachers in rural areas. There, they would teach local midwives basic methods to improve the sanitation and effectiveness of their work, therefore improving the quality of care for mothers across the nation. However, government subsidies or a partnership with an NGO will be necessary to incentivize trained midwives to volunteer in rural areas.

A system that awards two different tiers of midwifery licenses would be the best model to address the DRC’s specific challenges. The upper-tier license would allow for more freedoms in practicum for fully trained midwives, while the lower one would be for midwives who have received basic training, but lack full technical knowledge. The higher-level midwives would, for example, be authorized to provide life-saving medicines that no midwives are currently authorized to provide, such as the one that stops preeclampsia. Lower-level midwives could be taught how to administer the most basic drugs. Increasing access to these drugs would positively impact mothers. Further, these second tier midwives could gain certification to administer more advanced and complex drugs as they pass through additional stages of formal training. As the nation develops and urbanizes, greater access to city centers would swell the ranks of midwives with higher-level certification.

With this kind of authorization, a midwife who knows how to treat hemorrhaging would be present to help Belvie. Her children would be healthier because she would get proper care throughout her pregnancy —and most importantly—she would likely survive labor. In the end, increased training and authorization of midwives would benefit not only individual mothers like Belvie, but also the DRC as a whole. All Congolese women would eventually receive better care, leaving both them and their children healthier and ultimately fuelling the nation’s development.

Anna Sophia Young is a junior in Calhoun College majoring in Global Affairs. She can be contacted at annasophia.young@yale.edu.
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References

1. Democratic Republic of the Congo Maternal Mortality Rate. (2010). Index MUNDI. Retrieved from http://www.indexmundi.com/democratic_republic_of_the_congo/maternal_mortality_rate.html.
2. Global Burden of Disease 2010 Heat Map. (2010). Institute for Health Metrics and Evaluation. Retrieved from http://vizhub.healthdata.org/irank/heat.php.
3. The Democratic Republic of Congo. (2011). The State of the World’s Midwifery. Retrieved from http://www.unfpa.org/sowmy/resources/docs/country_info/profile/en_DRC_SoWMy_Profile.pdf.
4. Maternal and Child Health. (2010). The Population Institute. Retrieved from http://www.populationinstitute.org/external/files/Fact_Sheets/maternal_and_child_health.pdf.
5. The Impact of Maternal Mortality and Morbidity on Economic Development. (2010). The Wilson Center. Retrieved from http://www.wilsoncenter.org/event/the-impact-maternal-mortality-and-morbidity-economic-development.
6. Maternal Mortality. (2009). International Women’s Health Program. Retrieved from http://iwhp.sogc.org/index.php?page=maternal-mortality&hl=en_US.
7. Kiringia, Joses M., et al. (2006). Effects of maternal mortality on gross domestic product (GDP) in the WHO African region. African Journal of Health and Sciences.