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Maternal mortality in Chad.


The maternal mortality ratio in developing regions is still 14 times higher than in the developed regions ("Goal 5," n.d.). This is unsettling due to the development and abundance of equipment and materials available worldwide. This alarming rate usually stems from lack of personnel to attend high risk deliveries and lack of education. These deaths can be avoided. Almost the entire maternal morbidity is preventable by proper care and supervision of the mother during pregnancy. Health services provided to mothers after delivery comprise an essential component of the package of maternal and child health (MCH) services in any population (Naseem, 2015). The millennial goal of improving maternal health is important to addressing the global burden of disease because these women are suffering from preventable scenarios for the most part and the children of these mothers also suffer greatly when these mothers die. In Bangladesh the mortality rate dropped by more than 40% in under 10 years when the government focused on providing core services for maternal and child health for the rural population through district hospitals, health complexes, union family welfare centers, and satellite clinics. The primary focus was to promote antenatal care, tetanus toxoid immunization, iron supplementation, clean delivery practices, and family planning (El Arifeen, 2014).

The U.S. enjoys many privileges the majority of the world does not; yet, those in the U.S. still have poor prenatal care. In fact, the U.S. ranks the worst among the developed countries (Creanga, 2014). With maternal health increased, the need for emergency procedures that are dangerous to the child in utero would be reduced. The health of children born would increase due to physical and psychological maternal support. There is a need for skilled personnel attending delivery suites and antenatal care. It is the ultimate goal to provide women with wealth status class, health insurance coverage, residence, and decreased history of previous birth complications (Amoakoh-Coleman, 2015).

Health Indicators

Infant and maternal mortality rates are among the best indicators used to compare the health status of countries as well as the global burden of diseases in and within different countries. In the country of Chad, one in 15 women dies due to such complications, which is the highest maternal mortality in the world (World Health Organization (WHO), 2014). Every couple of minutes a woman dies due to complications in childbirth. The fifth Millennium developmental goal envisioned a 75% reduction in this number by the year 2015. Developed countries have made progress, but poorer countries have not fared as well. In fact, some of the poorer undeveloped countries have actually done worse since 1990. Chad is one of these countries, in fact it has seen a 10% increase in maternal mortality from 1980 to 2010 (Lawson, 2013).

In Chad, one in 15 women dies, which is the highest maternal mortality in the world

Maternal mortality is defined as the death of a woman during pregnancy, childbirth, or during the 42 days after childbirth (Hogan, 2010). The health indicators that lead to such deaths are generally due to lack of access to medical care, products, and/or personnel. Specific health indicators that lead to these shortcomings or outcomes include: preterm birth, lack of prenatal care, early pregnancy, limited facilities, inadequate equipment, and most importantly lack of skilled individuals to facilitate necessary care. Education, lack of basic services, minimal contraception use, and low-pregnancy age (12-15) are also indicators associated with high maternal mortality rates, which are very significant risk factors associated with maternal mortality in Chad.

In Chad, the numbers of girls under 15 years of age give birth at a rate of 47.8 in 1,000 individuals (Neal, 2012). Islam and Catholicism comprise the top two religious branches and cover over 73% of the entire population (Central Intelligence Agency (CIA), n.d). This is relevant due to the structure of marriage and as we will see later some of the complications of early pregnancy. Catholicism discourages the use of contraceptives, which may also play a role in maternal mortality rates. As of 2011, contraception is only used by 5% of the populace. This is a major risk factor when coupled with the number of girls giving birth prior to 16 and the lack of education that is the national status quo (CIA, n.d.). As of 2006, there are 0.04 physicians per 1,000 individuals compared to 2.45 per 1,000 in the United States (CIA, n.d.). Bed spaces, while limited in Chad, are present for 0.4 per 1,000 people.

At most, half of the population has access to basic services. Running water is scarce in the country of Chad with 45% only in rural environments and 72% in urban environments (CIA, n.d.). Healthcare expenditures in Chad are only 4.3% of GDP in 2013 and education expenditure nationally was 2.3% of GDP as of 2011. As a reference point, the GDP noted in 2012 was about $200/per person (CIA, n.d.). With a population of 11.4 million individuals, the GDP is very low, which is why Chad is reliant upon foreign aid. The literacy rate for the country is 40% and only 32% for females as of 2015. As of 2011 female school age expectancy was merely six years of age (CIA, n.d.). Education is an arena that can drastically be improved upon both in general population and in healthcare systems/scenarios.

Maternal mortality rates throughout most of the world have dropped over the last 30 years due to better medical infrastructure, more trained personnel, and improved family planning both before and after pregnancy. This is not the case for all countries and in particular those that are impoverished and without adequate outlets to attain the necessary infrastructure like Chad.

These worldwide improvements over two decades have been attributed to a number of factors: 1) increased use of contraception and a reduction in fertility rates, except in Africa; 2) increased prosperity, especially in Latin America and Asia, which improves women's nutritional status and their access to health care and contraception; 3) improvements in the educational status of women; and 4) an increased number of midwives and health care facilities. (Lawson, 2013). This is not the case for Chad as the country has little contraceptive use, no increase in prosperity, little access to healthcare, and minimal educational forums for the women giving birth. Shortages of health professionals reduce the number of facilities equipped to offer emergency obstetric care 24 hours a day, and are significantly related to quality of care and maternal mortality rates (Gerein, 2006). Many women are having children earlier than may be safe. In Chad nearly 14% of women (girls) have become mothers by age 15 (Neal, 2012).

Teenage pregnancies are regarded as high risk. Timely prenatal care is not often available and is often an unknown luxury (Omole-Ohonsi, 2010). In a society that is majority Muslim and Catholic, having children out of wedlock can be a shaming and sometimes culturally an unacceptable act. This can lead to relocation, forgoing available resources and not being completely forthright about a medical history.

All of these things in turn can lead to complications during childbirth.

In Chad nearly 14% of girls have become mothers by age 15

Preterm birth complications have risen in number (339 per 1,000) and percentage (3.9%) in the top 25 reasons for years of life lost (YLL) in Chad (Kassebaum, 2014). The maternal mortality numbers (per 100,000) individuals is 1500 as of 2010 (WHO, 2010). On the world stage approximately 45-50% of preterm births are from unknown causes, 30% related to premature rupture of the membrane (PROM) and another 15-20% are due to elective or medically indicated reasons (Beck, 2010). The case for more adequate facilities, equipment, and personnel can be made in light of these numbers. Even in the best of situations with the most adequate personnel and facilities, maternal and infant mortality are unavoidable. That number drastically increases when considering the absence of these services in impoverished countries like Chad.

Contraception use in Chad is at a low 4.8% as of 2010 (CIA, n.d.). Whereas in the developed world it is 67% and even in undeveloped countries 1 in 5 women (20%) use some form of family planning (Clifton, 2014). The numbers in Chad are staggeringly lower than even those poor, underdeveloped countries. Education seems the key to changing this statistic.

The healthcare system in Chad is one of minimalism and scarcity. There are hospitals in the larger urbanized areas, but these facilities are outdated, poor, understaffed, and limited in equipment. There is also a network of health centers set up by the WHO across the country but these are highly understaffed (WHO, n.d.). The Ministry of Health runs all health related inquiries and institutions as well as decisions in the country (Ministry, 2013). The health system is overburdened and focused on communicable diseases such as HIV, malaria, and tuberculosis, which further diverts the resources that are available for maternal care (Kassebaum, 2013). There is a health information system in use but it is only used to record specific diseases and report back to the Ministry of Health. The available data from that health information system point to a low frequency and utilization of curative and preventive services (Wyss, 2003). There is also a disconnection between health planners and physicians which results in poor organization and can be attributed to poor conceptual understanding of culture as well as available resources. The health services do not take sufficient account of the patient's environment and thus the patients are treated improperly, if at all (Wyss, 2003). An added problem is the nomadic nature of a large portion of the populace is at odds with the non-nomadic nature of the residential populace (Wyss, 2003). This compounds the issue of tracking as well. Those individuals who can travel do not trust the system and those who are stationary have inadequate systems to address their needs.

With foreign aid and government allotment, the amount of health dollars that can be spent on an individual averages out to $4.20/person, the majority of which was spent upon necessary medications (Wyss, 2003). There is an enormous amount of infrastructure that needs to be built in Chad. Informational systems also need to be coordinated with physician desires/expectations. Health systems planners need to have more resources to bring physician ideas to fruition. More hospitals need to be built and those hospitals that are already built need to have adequate equipment. Tantamount to all of these infrastructure ideas is the simple need for more "boots on the ground." More clinical and non-clinical personnel (nurses, doctors, respiratory therapists, unit clerks, surgeons, etc.) need to be in the country. It is estimated that the number of nurses would have to grow nine times the number available in 2006 by 2015 in order to meet the MDG goal number five (Gerein, 2015). As of yet no growth has been noted (CIA, n.d.). An organizational layout of nomadic journey routes should be studied and satellite facilities should be established in the determined areas.


Education remains the single most significant factor associated with decreased maternal mortality rates in Chad. There is a need to for health education at the general and public health level as well as to create the needed health care professionals and power at the national level. Community involvement and stakeholders' contributions towards any planning is a must. The latter should include heads or chiefs of tribes and religious figures who need to partake in any decision making and community intervention relating to any policy making or awareness campaign. Leaders need to be proactive in designing and implementing campaigns for reducing maternal mortality rates in Chad. Building schools with water access in different communities would be beneficial in addressing the inequities at the national level and help achieve the required goals. Young mothers, those with multiple children and those who live in rural environments would be the target population for any intervention. A secondary population, often overlooked, is that of the children born to mothers who die in childbirth or shortly after. These orphans will more likely grow to have younger births and perpetuate the cycle. As the older population continues to live longer lives they will support the generation having more babies, if not having them themselves. And as pregnancies increase, so does risk to those individuals having multiple pregnancies. Of mention is also the lack of skilled personnel will be stretched even more thinly should this forecasted scenario play out.

The magnitude of these vulnerable populations are quite large. Most developed and developing countries have been able to curb the maternal mortality rates but not in Chad. Chad still experiences a 980 per 100,000 individual maternal mortality rate. This is down quite a bit from 1990 (41%) and the rate is dropping by about 4.2% per year (WHO, 2014). When considering poverty, lack of resources, and rapid population growth, driving the mortality rate down is not an easy task and the reality makes it very unlikely that women in sub-Saharan Africa will have access to skilled birth attendants or emergency obstetric care in the foreseeable future (Potts, 2012).

Discussion: Communicating Social Change

Chad has been labeled as one of the countries without sustained or rapid reduction in maternal mortality (Van Lerberghe, 2014). The policies outlined by the WHO are designed to drive global health to an optimum level However, this is not the case in Chad with little to no policy outlined regarding maternal care and mortality. Much of the country is non-attentive to the existent healthcare situations. The non-realization of the right to health raises serious concerns about the political commitment of state officials to public health (Azetsop, 2015). Other than sweeping organizational money that is donated in humanitarian and fiscal efforts, the only real efforts being made in Chad are performed by nongovernmental organizations (NGOs) providing gifts of goods and/or limited services. The only one of those performing maternal medical education and services is Islamic Relief (Miles, 2015).

Africa is the region with the largest remaining growth potential in the world and it is estimated that the market in telecom services will grow by 1.5 billion people (Rufai, 2014). Provided that cell towers and phones are easily accessible, it may be easier to transform healthcare information and social education to the populace and mothers-to-be by use of telemedicine and mobile health. Positive social change can be created by being proactive and by increasing the presence of NGO's. There are opportunities for childbirth educators to make a difference globally. Women of child bearing age should be targeted to be educated and empowered with the ultimate goal of reducing maternal mortality.


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by Hadi Danawi, PhD, Shon Deen, and Tala Hasbini, MSPH

Dr. Danawi is trained in Public Health with a PhD in Epidemiology from the University of Texas at Houston. He has an international exposure to various Public Health issues in the U.S., Middle East and Africa and is passionate about creating positive social change and advocate for maternal and child's health. Dr. Danawi currently serves as a full time faculty at Walden University, College of Health Sciences teaching and mentoring doctoral dissertations.

Mr. Deen is a medical Therapist and is affiliated with a number of relief groups. He hopes to be able to assist the underpriveledged in any forum. Mr. Deen is passionate about making changes to the way health is perceived and to affect the health of women and children incorporating new ways with a worldview.

Ms. Hasbini is Trained in nursing studies and practice with a Master's degree in Public Health from the American University of Beirut, Lebanon. Ms. Hasbini is passionate about bringing help and education to mothers and children alike as well as highlighting the awareness of Nursing and Public Health in the region.
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Author:Danawi, Hadi; Deen, Shon; Hasbini, Tala
Publication:International Journal of Childbirth Education
Article Type:Clinical report
Geographic Code:6CHAD
Date:Apr 1, 2016
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