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Maternal Health in Angola

Introduction

The World Health Organization lists the leading causes of maternal death as severe bleeding, infections, high blood pressure during pregnancy, obstructed labor, and unsafe abortions. These problems contribute about 80 percent of all maternal mortalities worldwide with the vast majority occurring in developing countries. The other remaining factors that contribute to maternal death are malaria, anemia, and HIV/AIDS during pregnancy. The World Health Organization also states that the reasons why so many women die during childbirth usually are poverty, distance to care, lack of information, inadequate service, and cultural practices. All of these causes of maternal death and the corresponding reasons are very wellknown among women in Angola.

Angola is a relatively large African country that is located on the southwest of Africa on the Atlantic Coast. Angola shares boarders with The Democratic Republic of the Congo, Zambia, and Nambia. In the Sub-Saharan region of Africa where Angola is located, poor maternal health has been an ongoing problem in the early 21st century along with other health problems. In Angola, maternal health is a very complicated issue.

Maternal Health Statistics

Angola represents one of the highest maternal death rates in the world Results vary, but the estimated maternal mortality ratio (MMR) toward the end of the Angolan Civil War was between 1281-1500 maternal deaths to 100,000 live births. This estimate was taken during the late 1990s and, again, in 2002 and represents the MMR situation in the country at the end of the War. In 2008, the estimate decreased to around 610 deaths per 100,000 live births. In comparison, Sweden is estimated to have an MMR of five deaths to 100,000 live births.

Angola has very few physicians to attend to the medical needs of its population. It is estimated that there are only about 0.08 physicians per 1,000 people in Angola. Due to the length of the Angolan Civil War, nearly an entire generation of Angolans were not given the opportunity to receive any education. This has led to a dramatic decrease of health workers and added to the poor maternal health problem. In response to the shortage of health workers, Cuban physicians are currently working in the country to improve health overall, as well as to improve maternal health.

The maternal mortality rate of the country appears to be decreasing since the end of the Angolan Civil War in 2002. However, it is still one of the highest in the world. On average, women give birth 7.2 times. The infant mortality ratio is 154 deaths per 1,000 live births. The mortality rate of children under 5 years of age is 254 per 1,000 live births. These figures represent improvement since the end of the war, although they still are very high and show the need for improvement in maternal health.

Factors Contributing to Maternal Health

In any given country, the health of the people is affected by many different factors. Health factors can be as simple as daily life activities, as well as national and cultural customs. Specifically, maternal health is closely related to social economic class, education, economics, topography, and infectious diseases.

Diseases

Due to Angola’s location, the climate is ideal for many tropical diseases that directly affect maternal health. Angola has a narrow coastal plain that rises into a high plateau in the country's interior. Rain forests are prevalent in the north, and in the south, the land is dry.Malaria and [shistosomiasis] are prevalent in the country. These diseases and others, such as tuberculosis and especially HIV/Aids, further increase the complications and dangers faced by women during pregnancy.

Location also plays a role negatively affecting maternal health, especially with the entrance of HIV/AIDS into the country. Throughout the 1970s and 1980s, the civil war created an environment with elevated levels of internal migration. These migrants were more likely to behave in ways that increased HIV risks. However, due to the violence and political instability over the decades, the number of people entering Angola from other countries decreased, causing fewer cases of HIV/AIDS to enter the country. This is evident in the HIV/AIDS rate in Angola in 2008at only 2 percent, compared favorably to neighboring Zambia, which has an HIV/AIDS rate of 13 percent.

The location of Angola also makes the population susceptible to tropical diseases. Malaria alone is a huge factor affecting maternal health. In Angola, malaria is very prevalent in the northern part of the country due to the climate and appears more seasonally in the south. Unfortunately, the majority of the population lives in the northern areas in cities, such as Lunada. Malaria is a huge concern for maternal health, contributing about 25% of the total maternal mortality alone. In 2009, UNICEF, NMCP, WHO, and other organizations have partnered together in an effort to reduce the malaria burden.

Angolan Civil War

Of all the factors that negatively affect maternal health in Angola, the Angolan Civil War may have been the most severe. During the War, as many as 1 million people were killed, 4.5 million people became internally displaced, and 450,000 fled the country as refugees.

The 27-year-long Angolan Civil War had devastating effects across the country. The Civil War was fought between the two political parties, "The Popular Movement for the Liberation of Angola" and "The National Union for the Total Liberation of Angola." The War began in 1975 and finally ended with the death of the leader of the National Union for the Total Independence of Angola party, Jonas Savimbi, in 2002.

The consequences of the war have been devastating throughout the country and had a particularly negative affect on women seeking prenatal care. The war damaged the country’s health infrastructure. Records in war-torn areas were not kept during episodes of violence and many were lost due to the war. Vital statistics, including death and birth certificates, were not kept current, and access to reliable healthcare was limited for citizens. For this reason, data from this time period regarding maternal health is difficult to find. This harsh reality during the War was partially responsible for a cultural shift.

The war has affected the attitudes of women in Angola regarding healthcare and child birth. Understandably, the war has made women more cautious and distrustful of government programs, including healthcare programs. The War has caused behavioral changes in women seeking health care. It is common for women today to not seek medical attention when in childbirth but to give birth to their children at home.

Health Care System

The Angolan Government has not had much success in developing an effective healthcare system. Due to lack of infrastructure and rapid urbanization, the government has been unable to promote programs that effectively address some of the basic needs of the people. Healthcare, specifically, is not available for much of the country.

Unsafe Abortion

Unsafe abortions are one of the leading causes of maternal death in the developing world. In many African countries, abortions are considered taboo. Women who get abortions often are associated with negative stereotypes due to cultural beliefs. Many of these cultural issues force women to seek abortions in unsafe ways. These "back-alley" abortions are the cause of thousands of deaths every year. .

More political attention has been given to the issue of abortions in Angola due to the unsafe procedures and the health effects on young women. Justice Minister Guilhermina Prata recently presented legislation that may help decrease the number of illegal abortions. In the region of Sub-Sahara Africa, it is believed that 40 percent of women who have an illegal and unsafe abortion die due to complications of the surgery. Information on unsafe abortions is difficult to obtain, but due to the nature of the healthcare system and the prevalence of unofficial fees, the number of illegal abortions is potentially much higher than reported. The debate regarding unsafe abortions in Angola is not new and is highly affected by the cultural and religious atmosphere in the country.

Cultural Aspects of Maternal Health

Maternal health in Angola is greatly influenced by culture. However, it is a culmination of a society that has faced decades of war, urbanization, political uncertainty, and a number of other issues.

On the individual level, women named four factors that highly influenced their decisions regarding child birth and prenatal care: 1) the individual's perception of the quality of care, 2) the process of labor, 3) the significance of informal fees, and 4) the woman’s perception of being empowered to make her own decisions regarding child birth.

Perceptions of the quality of care vary greatly across the country. For many women, care at a formal facility is so bad that they prefer to stay at home and have a home delivery. The process of labor is affected by strong traditions. Great influence is given by grandparents with more traditional methods who normally suggest home births. However, due to more access to technology and the mixing of women in larger cities, a shift is taking place moving toward more advanced means of childbirth in formal hospitals. Despite this shift of thinking from traditional to more modern child births, other factors such as high informal fees and an individual woman’s perception of being “courageous,” seem to bar women from seeking care in health facilities.

Poverty

One of the major problems with maternal health in Angola is the existence of widespread poverty throughout the country. The poverty in the country is a result of the long period of violence. The infrastructure was so badly damaged during the war that electricity is not reliable or accessible to many areas, especially areas of dense poverty. Poverty is associated with an elevated risk of all kinds of health problems, especially with maternal health.

As of 2010, in Angola, 68 percent of the population lives below the poverty line, living on only $1.70 per day. Of these, 28 percent live in extreme poverty, living on only $0.70 per day. Poverty discourages women from seeking healthcare during childbirth. It is common for women to give birth at home for free instead of going to the hospital and being forced to pay “hidden fees” or ad-hoc fees in order to receive care.

In Angola, ad-hoc demands at clinics are commonplace. It is not uncommon for patients to arrive at a hospital or a clinic in need of care and be forced to wait until payment is made. The economic state in the country has created a culture with prevelant bribery. In many cases, women chose to have their children at home instead of go to a hospital. This reality, along with the negative level of confidence many women have of the clinicians, results in higher numbers of MMR and IMR.

Policies to Reduce Maternal Health

International programs that improve maternal health are currently being developed and implemented in Angola. The government has implemented programs that train midwife providers in order to increase the number of births attended to by a credentialed clinician. . The government is also investing money into education and healthcare. The money that is generated due to the large oil reserves in the country is being used to improve maternal and child health across the country. Free clinics are availible to pregnant women and women with small children.

Malaria Operational Plan

In 2008, President Obama announced the Global Health Initiative, allocating funds to be used to decrease the number of women afflicted with malaria and increase maternal health. Angola was one of the first countries to receive aid and to have programs implemented to reduce the risk of malaria, as well as increase the number of healthy pregnancies.