Improving Maternal Health Outcomes in Post-war Rwanda.
According to the World Health Organization (WHO), maternal mortality is the second leading cause of death for women of reproductive age globally. Maternal mortality claims the lives of over 300,000 women every year, which breaks down to roughly 830 deaths per day. Ninety-nine percent of these deaths occur in developing countries with over half of these deaths occurring in sub-Saharan Africa alone (WHO.int). Birn, Pillay, and Holtz describe maternal mortality as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy (i.e. ectopic or not), from any cause related to or aggravated by the pregnancy or its management but not from accidental causes” (Textbook of International Health, 244). The causes of maternal deaths include hemorrhage, infections, eclampsia, obstructed labor, unsafe abortion as well as other direct and indirect causes (Pfeiffer, Lesson 5 lecture). Women in developing countries face roadblocks to receiving adequate care that women in developed countries do not. For instance, women in developing countries face issues like higher rates of poverty, long distances to health care facilities, lack of information, inadequate services available in health centers, and cultural practices that inhibit women from seeking the care of a trained medical professional during pregnancy, childbirth, and after birth. Before the Safe Motherhood Initiative (SMI) in 1987, maternal care received very little global attention. After the World Health Organization reported their cumulative findings based on maternal mortality estimations provided by global government agencies, the various nations present agreed that something had to be done to improve maternal health, and subsequent conferences were held around the globe. SMI aimed to “improve women's status, educate communities, and strengthen and expand core elements of maternal health—antenatal care, delivery care, and postpartum care—at the community and referral levels” (Lancet, 2006). Unfortunately, the lack of a comprehensive plan to achieve these goals led to dismal results. In 2000, the United Nations introduced the Millennium Development Goals (MDG) which aimed to; eradicate extreme poverty and hunger, achieve universal primary education, promote gender equality and empower women, reduce child mortality, improve maternal health, combat HIV/AIDS and other diseases, ensure environmental sustainability, and create and maintain global partnerships for development (UN). All 189 countries present agreed to work to achieve these goals by 2015. Since then some achievements have been made in reducing maternal mortality. Between 1990 and 2013 we [the global community] achieved a 45% reduction in maternal mortality, with most of that reduction occurring after the year 2000 (WHO), but even with this improvement, there is still much effort needed to achieve the Sustainable Development Goal by 2030 to reduce the Maternal Mortality Ratio (MMR) to less than 70 per 100,000 births with no country having an MMR of more than twice the global average (WHO).
While many developing countries are struggling to meet the Millennium Development Goals (MDGs) to achieve a reduction in maternal mortality, some countries have made significant progress. One such country is Rwanda. Located in the heart of sub-Saharan Africa, Rwanda is one of the most densely populated countries and is currently home to roughly 12 million people (worldometers). After experiencing a catastrophic genocide in the mid-1990s that killed approximately 10 percent of its population and displaced another 2 million people, the Rwandan government decided to invest heavily in its public sector. Thanks to the help of international aid as well as hundreds of Nongovernmental Organizations (NGOs), the Rwandan government made significant investments in fixing its broken healthcare system. This wasn’t easy to accomplish after essential equipment was looted, buildings were destroyed leaving almost no usable structures, and 80 percent of its health workers were killed or fled the country (USAID, 1996). This left the government with the incredibly large task of building a new healthcare system from the ground up. With the Rwandan government’s insistence on taking the lead, aid money was used to rebuild and restock healthcare facilities, train and pay healthcare workers, and create a nationwide community health insurance scheme. Per capita, health spending increased from US$7 in 2002 to US$47 in 2008, which was an almost 500% increase and insurance scheme participation reached 90% by 2012 (Millions Saved, 117). Since the post-war population included a disproportionately higher number of women due to the higher rates of death for men during the genocide, new policies were created to support and empower women who were now the heads of households. As part of the Rwandan Governments Vision 2020 goals, their “National Reproductive Health Policy is based on six priority areas: safe motherhood and infant health; family planning; prevention and care of genital infections and sexually transmitted infections (STI) including HIV/AIDS; adolescent reproductive health; prevention and care of sexual violence; and social change for the empowerment of women” (WHO). Additionally the Rwandan government also invested heavily in education by creating their “universal education for all” plan to expand education from a 9-year program to a 12-year program. Expanding access to clean water as well as disposal systems has also aided the Rwandan government in improving health outcomes. As of 2010, 74.2% of Rwandans had access to clean water and the Rwandan government hopes to expand access to clean water and disposal systems to everyone by the year 2020. Due to these collaborative and cumulative efforts, Rwanda decreased its MMR by 77 percent between 2000 and 2013 (from 1071/100,000 births in 2000 to 320/100,000 births in 2013) and it has also reduced under-5 child mortality by 70 percent. This makes it one of the few developing countries on track to meet the Millennium Development Goals (BMJ). Rwandans were able to achieve these great outcomes by insisting on community-led efforts, investing in social programs like education and health care, implementing community insurance schemes to keep the cost of health care low for its people, and training and incentivizing health care workers which increased the number of workers and helped with worker retention as well. While these achievements in improving health outcomes are commendable, there are still holes in the system. Rural inhabitants still struggle to access health care at the same rates as their urban counterparts, whereby suffering disproportionately worse health outcomes. Rwanda also faces the challenge of sustaining its efforts and outcomes. This will require much work on the part of the Rwandan people, government, international aid community, NGOs, and other humanitarian organizations as the country continues to heal from the genocide and move toward continued economic growth.
From advocacy to collecting population statistics to researching the efficacy of health incentive programs and other public health initiatives, Anthropologists, Physicians, Statisticians, Epidemiologists, and more have played a vital role in capturing the success that has been achieved in Rwanda. Their dedicated work researching the intricate inner workings of vast public sector initiatives and maternal mortality at large has highlighted the strengths and weaknesses of the efforts made to improve life for the Rwandan people post-genocide and women around the globe. In a 1985 article in The Lancet, authors Rosenfield and Maine imparted the importance of addressing maternal health as essential to improving health outcomes in children. They stated, “In the discussion of MCH it is commonly assumed that whatever is good for the child is good for the mother. However, not only are the causes of maternal death quite different from those of child death but so are the potential remedies”. Rosenfield and Maine strongly urged the coming together of government agencies, international aid organizations, and NGOs to find comprehensive, long-term solutions that would reduce maternal mortality globally. In Millions Saved, case 12 “Motivating Health Workers, Motivating Better Health – Rwanda’s Pay for Performance Scheme for Health Services”, authors Glassman and Temin (2106) highlight how the implementation of paid incentives (in pilot programs in Rwanda) for health workers based on the provision of high quality of care and improved health outcomes has led to an increased number of hospital births, an increase in preventative visits for children under 5, and improved weight gain and reduced stunting in children. It has also led to a reduction in the rate of maternal mortality as well as infant and child deaths. They note that there were other initiatives made by the government during that time like free bed nets, community insurance schemes, and increased health spending by the government that may have also contributed to those positive changes in health outcomes (Millions Saved, 117).
The greatest strength of this research is that it has increased awareness of maternal mortality. It also highlights which programs work and which don’t so that other countries and agencies can use the information to improve health outcomes in other countries, particularly those with the highest maternal mortality rates and higher incidents of morbidity and mortality from several other causes. This research also sheds light on the important relationship between local governments and international aid and non-governmental organizations in reducing morbidity and mortality as well as the improvement of social conditions through investing in the public sector. In the case of Rwanda, outcomes may have been different had NGOs and other aid organizations been allowed to do as they pleased without the consent or guidance of the Rwandan government. The greatest weakness is the failure to differentiate statistical analysis between urban and rural populations to better illustrate where there is room for continued improvement. Additional research is also needed to more thoroughly understand what roadblocks keep the rural population from accessing biomedical care and how that has contributed to health outcomes for that population subset. Such research would allow government agencies and aid organizations to create new strategies for health initiatives that would benefit that particular subset of the Rwandan population.
At this point, there is plenty of research that acknowledges the steps the Rwandan government took to reduce maternal mortality and improve health outcomes for its population. The next step would be for Anthropologists and other researchers to collaborate with other sub-Saharan African countries to implement similar strategies with hopes that the same outcomes can be achieved on a larger global scale. Anthropologists must be involved in this process so that variations in cultural practices and beliefs are taken into consideration when tailoring initiatives to best meet the needs of the population they are interested in helping. It’s not a one size fits all approach, but with people-focused research and care, as well as an overall understanding of how programs have been effective in other countries, there is a greater chance of achieving outcomes in developing countries around the world to reduce maternal mortality as well as other causes of morbidity and mortality that reduce life expectancy, impede economic contribution and growth, and reduce the overall experience of security and well-being. The impact of work done in a small country like Rwanda could have an enormous global impact.
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