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Big Steps Forward: Cameroon’s Multi-Sector Approach to Reducing Pregnancy-Related Deaths

By Leocadia Bongben (Lead Writer)

Jean Firwa and his wife Martha were excited to be expecting a baby after 10 years of trying to conceive. However, neither realised that their joy would be short-lived. On the morning of May 15, 2015, tragedy struck for the couple. Experiencing sharp pains, Martha needed to be transported to a hospital. With the closest hospital being 35 miles away, it was a struggle to transport her from Zanyao to the hospital in Yagoua, Mayo Danay Division, in the far North of Cameroon. “She was bleeding and there was no other means of transportation so, we used a wheelbarrow to push her. She died before we got to the Yagoua district hospital, the doctor told me,” Jean Firwa said.

A woman being taken out of the motor ambulance. Photo source: Unicef Cameroon.

According to the World Health Organisation (WHO), globally, approximately 810 women died from preventable causes related to pregnancy and childbirth daily in 2017. Sub-Sahara Africa alone accounted for roughly two-thirds of these deaths. The Cameroon 2018 Demographic and Health Survey (DHS) revealed that in 2011 the country’s Pregnancy-Related Mortality Ratio (PRMR) was 782 for every 100,000 live births. Seven years later however, there was a significant decline as the PRMR was now 467 deaths for every 100,000 live births.

The increase in maternal mortality in 2011 was so great that it triggered a reaction from health officials across the country. According to Dr Martina Lukong Baye, Coordinator of the National Multi-sector Programme to Combat Maternal, Newborn and Child Mortality, “We got a shock; maternal mortality was increasing in Cameroon, 782 maternal deaths per 100,000 live births, so on the average about 6,000 women died every year in Cameroon,” she said.

Image credit: Nigeria Health Watch

A multi-sectoral programme to reduce maternal deaths

To effectively tackle maternal mortality, a multi-level approach was enacted across different sectors, at the local, national and international levels, focusing on planning, budgeting and monitoring and evaluation. A Prime Ministerial order enacted in November 2013 created the National Multi-sectoral Programme to Combat Maternal, Newborn and Child Mortality. Known by its French acronym PLMI, the order provided a framework for strengthening multi-sectoral commitment and coordination for better synergy in implementing interventions to improve reproductive, maternal, newborn and child health in Cameroon. PLMI started its activities in 2014 with a target to reduce maternal deaths by 29 percent — from 782 to 557 per 100,000 live births.

The programme aimed to ensure that pregnant women would be able to carry their pregnancy to term and deliver safely, with access to good post-natal care. It focused on interventions like sensitisation and reinforced family planning in rural and urban areas, as well as assisted births and emergency obstetric and neonatal care for mother and newborns.

The major interventions under the programme were carried out in the northern regions where poverty, poor access and bad roads prevented women from going to the hospital. Due to the unequal distribution of care available across Cameroon, maternal mortality in the north-east region remained disproportionately higher than other parts of the country. When the national mortality was 782, the northern and eastern regions recorded 1000 deaths per 100,000 live births, which justified the programme’s focus on these regions, Dr. Ernest Essomba Essomba, Head of Planning and M&E for the programme, explained.

The Motor Ambulance community project

Poor access roads and a lack of proper transportation to the hospital were contributing factors to Martha Firwa’s death, but with the motor ambulance, the situation Jean faced with his wife, where she died before she could get to a hospital, now occurs less often. The motor ambulance is a tricycle designed to navigate short cuts and roads in rural areas that are not easily accessible by cars or regular ambulances. This enables easy access in emergency situations. Through the ambulance community project, women in Firwa’s community could now be transported to health facilities or to referral hospitals.

As a community-driven initiative, the ambulances are run by the community who are also responsible for choosing and paying the drivers. Morenba Jeanne acts as the chairperson of the motor ambulance management committee. It is her job to manage the maintenance of the motor ambulances, then to report to the health center. The chairperson is selected by the community and trained alongside community mobilisers by the United Nations Population Fund (UNFPA). “We lost mothers in the past because they did not know how to get to the hospital, especially in emergencies. Now we encourage them to use health facilities because a means of transport is now available,” Morenba said.

The project uses health mobilisers and Delphine Adama, a former traditional birth attendant in Tignere, a district in the Adamawa Region, is one of 100 other traditional birth attendants in the northern region who now act as community mobilisers under the motor ambulance microproject. “I walk around the villages looking for pregnant women and sensitise and accompany them to the health units for antenatal care,” Adama said. After every hospital delivery, Adama and other mobilisers get about $ 5.50 (FCFA 3000).

Image credit Nigeria Health Watch

Thus far, there are 165 Motor Ambulances operating across 35 health districts in the northern and eastern regions of Cameroon. The UNFPA, has reported that 532 health personnel and 225 midwives have been trained and hospitals equipped under the Support Project for Maternal, Newborn and Child Health, known by its French acronym, PASMNI. In conjunction with UNFPA and UNICEF who act as technical partners, the Ministry of Health funds the project through the PASMNI project, financed by the Islamic Development Bank.

The Health Voucher

The Cheque Sante (Health Voucher) is another micro-project under the multisector program implemented with the technical support of UNICEF and UNFPA. The project is financed by the French Debt Relief — the C2D.

Typically, a woman would pay up to $119 (FCFA 65,000) in hospital bills to access antenatal and post-delivery care. Given the poverty level in the northern regions, this financial expenditure prevented women from going to the hospital. But with the Health Voucher which is a subsidised method of providing care to pregnant women, the women are only expected to buy a kit that contains delivery accessories at $11 (FCFA 6000) to benefit from services like antennal care, delivery, and post-natal care. If a woman needs a caesarean section, the caesarean kit can also be accessed for 40,000 FCFA in hospitals. The kit helps the staff act quickly when there are complications. Trained personnel are available to manage complicated situations and perform caesarean sections if necessary.

Image credit: Nigeria Health watch

Impact of the interventions on maternal health

According to Dr Baye, so far, the proportion of pregnant women who use hospital services has increased from 63 percent to 70 percent, a seven-point increase. Also, spending for pregnant women, especially in the northern regions, dropped from about $120 (65,000 FCFA) to about $11 (6000 FCFA). However, in the eight years of implementing the various programmes, the most distinct evidence of their collective impact has been the decline in maternal mortality in Cameroon, from 782 to 467 maternal deaths per 100,000 live births, as indicated in the 2018 Demographic and Health Survey.

Image credit: Nigeria Health 

Unfortunately, although the rural areas bear the greatest burden, these interventions are still largely implemented in urban areas. A lot still needs to be done in the rural and hard to reach communities. Delivery rooms in health facilities in some remote areas are still in a poor condition and there are not enough midwives to serve the needs of the local community. The government and its partners must focus on scaling up the programme, ensuring that there are midwives at every health center and that the health facilities are well equipped to provide quality care. Maternal mortality is so complicated that it requires a whole set of measures and interventions starting from the community to the health facility, Baye stressed.

The government of Cameroon, through the Ministry of Health has been working towards achieving universal health care, which Baye thinks would be beneficial for maternal health, especially as the government has been known to prioritise maternal and child health. The expectation is that this would eliminate major hindrances to accessing healthcare, as pregnant women who subscribe to the health insurance would be able to access quality and affordable healthcare when they need it.

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