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A mother in the West African nation of Togo was seven months pregnant when a community health worker went to her home to connect her with prenatal care for the first time. She had given birth five times before. Only two of her children had survived.
“She was really worried [about whether] the baby she was pregnant with was going to live or not,” said Emile Bobozi, the program director of Integrate Health—a non-profit organization that trains community health workers at local clinics throughout Togo. Community health workers connect people with the local health care system and provide basic health services. They are typically members of the communities they serve.
While access to maternity care in sub-Saharan Africa has improved, women are still confronting malnutrition and a lack of access to prenatal and emergency care.
When the mother was taken to a clinic, the ultrasound showed she was pregnant with twins, making the pregnancy high-risk. Providers at the clinic ensured she was able to give birth at a local hospital where she had a Caesarean and safely delivered two healthy babies. Without prenatal care, Bobozi warns, “the outcome may have been really different.”
In Togo, 45% of women do not receive adequate prenatal care—defined by UNICEF as four or more visits with a provider during pregnancy—echoing similarly low rates across the continent. According to UNICEF, less than half of women in sub-Saharan Africa are seen four or more times by a provider during their pregnancy—one of the lowest rates in the world.
For women, this lack of care can have dire consequences. “In these communities where you don’t have access to prenatal care, that leads to a really high rate of mortality,” said Bobozi.
Women in sub-Saharan Africa are fifty times more likely to die from childbirth than women in high-income countries, according to a 2019 UNICEF report, and their babies are ten times more likely to die in their first month of life. The region has the highest maternal mortality rate in the world.
“I actually think prenatal care is the most important part of making sure that the women deliver safely,” said Myron Glick, an OB-GYN and founder of the Adama Martha Memorial Community Health Center in Sierra Leone and the Wellness Clinic in the Democratic Republic of Congo.
A key component of prenatal care is ultrasounds. These scans reveal critical information about a pregnancy, like whether the baby is growing at a normal rate, how the baby is positioned in the womb, and whether the mother is having twins. If the baby is not headfirst by the third trimester, for example, that means the baby may need to be turned before or during delivery. Without this information, women—particularly those who plan to stay home and birth—may not have access to the medical care they need.
Prenatal visits are also a chance to screen women for diseases, like gestational diabetes or preeclampsia—both major contributors to maternal deaths worldwide. Providers can administer medication, if needed, and give women vaccines or antibiotics to prevent them from contracting other illnesses.
“We treat every woman for malaria to ensure they don’t have malaria during pregnancy,” said Glick, in addition to giving them a TDAP shot to protect against tetanus, diphtheria and respiratory infections. “We do all of these things to help the women to be as healthy as possible for the delivery.” Without these interventions, childbirth can be a much riskier undertaking.
The reason? “Women just don’t have access to care that’s quality or even care at all, so if things don’t go well during the labor or during pregnancy, they’re in trouble,” said Glick.
For many women who live in rural villages, medical care is just too far away. In Togo, for example, Bobozi says natural obstacles, like flooded rivers and dense forests, prevent many women from accessing timely maternal health care: “You have really dense forests and you don’t necessarily have roads that cross them and that makes it really difficult to go to the health centers.”
While this can prevent women from getting prenatal care, it also complicates their delivery. Bobozi says more women birth at home during the rainy season, when the rivers are difficult to cross, making it extremely challenging to get emergency care in time.
In Sierra Leone, Glick says some mothers choose to forgo medical care because of a lack of transportation–or a lack of comfortable options: “If you’re in labor you don’t really want to ride on the back of a truck or the back of a motorcycle, so women labor in the village.” To avoid this trek, some women live around the clinic for a month or two before their due date. While this can be disruptive to their lives and family, “they are there, ready when they go into labor.”
But distance isn’t the only obstacle to a healthy pregnancy. In sub-Saharan Africa, malnutrition is a chronic health issue, making it difficult for expectant mothers to get all of the nutrients their body needs during pregnancy. If a woman is anemic because she’s not getting enough iron in her diet, for example, she is at higher risk of hemorrhaging during her delivery, the cause of nearly one-third of global maternal deaths, according to UNICEF.
In addition, malnourished women are more likely to be deficient in folic acid—an essential B vitamin that helps create genetic material and prevent birth defects. One study found folic acid supplementation among African mothers reduced the incidence of neural tube defects—a malformation in the developing spine of a fetus—by 60%. This particular defect accounts for 400,000 infant deaths worldwide each year and is the most common birth defect in Africa. “[Nutrition] is very important…as a building block for a healthy pregnancy and a healthy birth,” said Glick.
While pregnancy is something Glick’s patients celebrate—raising a family is important to them—“it’s not easy,” he says. Without resources, and disconnected from medical care, women face a host of obstacles that put both their health and the health of their baby in jeopardy. “They’re focused on just getting through it,” he says. “When you’re pregnant in a rural place like Sierra Leone, it’s a risk to your life…It takes on a different meaning.”
Since 2008, Direct Relief has supported medical efforts, including maternal and child healthcare, in Togo, Sierra Leone and the Democratic Republic of Congo with more than $120 million worth of medical support. This includes prenatal vitamins, midwife kits, surgical supplies for fistula repair and other birth injuries, and essential medical support for women and babies.