Maternal mortality is a global health that is crucial to our national health indicators. In this Women's Weekly edition, we provide a documented medical perspective on these important areas in our nation health systems.

Maternal, neo-natal and child mortality and morbidity
These are human rights issues and factors within the legal, social, economic and health systems, which deny women and children these rights, and should be addressed. Legislation and policies that work against safe motherhood should be given attention.

Definition of maternal mortality
Maternal mortality is the death of a woman while pregnant or within 42 days/6 weeks following the end of the pregnancy irrespective of the duration of pregnancy, the site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.

Neonatal, infant and under-5 mortality
Definitions:
-Neonatal Mortality: The probability of dying at birth and within the first 28 days of life.
-Infant Mortality: probability of dying between birth and the first birthday
-Under five mortality: probability of dying between age one and the fifth birthday.

Introduction
African governments are signatories to the relevant internationally agreed declarations such as:
-The CRC 1990
-CEDAW 1992
-ICPD POA 1994
-Beijing Platform for the Advancement of Women 1995
-The Millennium Declaration 2000 (MDGs)
-The Vision 2010 Initiative 2001 and OAFLA 2002
-The Protocol to the African Charter on Human and Peoples' Rights on the Rights of Women in Africa
-The African Union road map 2004.
One of the 3 inter-dependent quantitative goals and objectives recommended in the ICPD POA 1994 is: the provision of universal access to a full range of comprehensive reproductive health care service including family planning.

What is reproductive health?
-Reproductive health (RH) is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity in all matters related to the reproductive health, therefore, implies that people are able to have a satisfying and safe sex life and that they have the capability to produce, and the freedom to decide if, when and how often to do so.
-The concept of reproductive health is centred on human needs and development throughout the life cycle (from the womb until old age)

What is Reproductive Rights?
Men's reproductive rights and reproductive health needs including active and informed involvement in pregnancy, childbirth and child rearing are recognised as paramount
*The challenge is one of attitudinal change by men through the separation of culture from religion, as well as understanding the needs, risks and danger signs fo pregnancy, childbirth and postpartum periods to support women
.Reproductive rights are human rights for e.g the recognition that safe motherhood (i.e the right to go safely through pregnancy and childbirth) are human rights.  The Universal Declaration of Human Rights (1948) states that "Motherhood and Childhood are entitled to special care and assistance
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*Rights of women is also protected by the 1997 constitution of the 2nd Republic of The Gambia as stated in section 28 (1) that: "Women shall be accorded full and equal dignity of the person with men", and section 28(2): "Women shall have the right to equal treatment with men, including equal opportunities, in political, economic and social activities."

Reproductive Health Indicators
(statistics)
Global Level
-529,000 maternal deaths occur per annum = MMR 430/100,000 live brith (LB) {because, each minute day, in every, country, 1 woman dies}
Evidence has also shown that for every maternal dealth, 20-30 other women suffer permanent disabilities from the complications of child birth such as: Vesico Vaginal Fistual (VVF/RVF) or a hole between the vagina or rectum and bladder leading to continuous leakage of urine or faeces on the woman. {An average of 50,000 to 100,000 women per annum}
WHO: Globally, 4 million babies die each year, 96% of the 4 million newborn deaths occur in developing countries.  Two-thirds newborns die in first week of life and two-thirds of such deaths occur during the first 24 hours of life
Lifetime risk of a woman dying of pregnancy related complications is 1:4000

 Regional level (Africa)
251,000 (47%) out of the Global maternal deaths
-Maternal Mortality Ratio (MMR) =480 per 100,000 LB
-Neonatal Mortality 45 deaths/1,000 LB
-Contraceptive Prevalence Rate Very Low: 13% for married women
-Total Fertility Rate: 5.5 per women

Causes of newborn
deaths (African Region)
(Statistics)
*Birth asphyxia (inability to breathe spontaneously and normally after birth), often as a result of prolonged or obstructed labour - 40%
*Premature birth and low birth weight - 25%
*Infections such as: tetanus, sepsis, bacterial pneumonia and meningitis - 20%
*Multiple congenital defects - 10%
*Acute surgical conditions - 3%
*Other - 2%

*National Level (The Gambia)
-Maternal mortality ratio: 730/100,000 live births in 2001 from 1,050/100,000 live births (LB) in 1990
-Neonatal mortality rate: 31.2/1,000 LB, 2001 from 60/1,000 LB (1995 WHO)
-Infant mortality rate: 75/1,000 LB,2003 from 92/1,000 LB (1993 Census)
-U5 mortality rate: 99/1,000 LB, 2003 from 134/1,000 LB 2001
-Total fertility rate: 5.4 per woman (2003) from 6.04 (1993 census)
-Contraceptive prevalence reate: 17.5% (13.4% modern, 4.1% tradition (2001) doubled from 6.7% (1990)
-Obstetric fistula prevalence 0.5/1000 women R. Age

Why do women die?
(Causes of maternal mortality)
1.Direct medical cause of maternal deaths eighty (80) percent of all maternal deaths globally are as a direct result of complications arising during pregnancy,delivery,post partum. A quarter of these is due to:
 
*Haemorrhage (25 %) severe bleeding especially during the post partum period, sudden in onset and even dangerous when the woman is anaemic and absence of prompt and appropriate life saving care can lead to death.
Indirect medical causes of maternal death: (20%) as a result of pre-existing conditions worsened by pregnancy, typically anaemia which, as well as causing death through cardiovascular arrest is thought also to underlie a substantial proportion of direct deaths (particularly those due to haemorrhage and sepsis)

*Other important indirect causes include: malaria, hepatitis, heart diseases and increasing in some settings HIV/AIDS. Women need to be informed of these conditions (as relative, absolute contraindications to pregnancy) and be assisted to prevent further pregnancies while being treated.  The emergence of TB also poses a threat to mother and child.

Factors underlying the medical direct causes of maternal deaths
*Low social status of women limits their access to economic resources and education and consequently their ability to make informed decisions related to their health and nutrition.  Lack of decision making power and of alternative opportunities confine many women to a life of repeated childbearing.  Excessive physical work coupled with poor diet consequently leads to poor maternal outcome.

*Limited access to skilled attendants or attendance, during pregnancy, labour and post partum period.
*Poor nutrition contributes to poor maternal health, obstetric problem and underlie pregnancy outcome such as:
-Stunting: during childhood as a result of severe malnutrition.  Risk of obstructed labour by CPD
-Anaemia may be due to several causes, which may interact such as, inadequate intake and losses due to parasitic infestations and malaria, or iron, folic acid and vitamin A. Severe anaemia exposes women to obstetric haemorrhage and poor operation risks in caesarean section delivery.

Interventions
*Road Map on MNB Health
*EMCH Strategy
*Adolescent/Youth S&RH

Challenges
*Health human resource
*Finance
*Essential drugs and other Medical drugs
*Functioning health system
*Activate male participation
*Functioning laboratory and blood transfusion service
*Donor, private and Civil Society Partnership
*Domestication of the African Protocal and it Enforcement

The 3 delays that kill
 * Evidence have also shown that 3 major delays that contribute to maternal mortality and morbidity are:
-The delay in deciding to seek care
-Ignorance or non-recognition of danger signs of pregnancy, childbirth and postpartum period
-Lack of birth preparedness plan by family and community
-The delay in reaching the Facility

-Poor roads
-Poor communication network
-Lack of transport in most rural communities
-Delay in receiving prompt and appropriate care after arrival at the health facility
-Deaths can be averted if women receive prompt and adequate care
-75% of maternal deaths are preventable (Source: WHO/AFRO).
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In conclusion,  as noted by Charlotte Bunch women's rights activist (March 2001) that, all human rights depend on the recognition of women's human rights.  "When violations of women's rights and reproductive rights are tolerated in the home, on the streets, in the office, in the media and during wartime, then children learn early that human rights can be violated with impunity.

In contrast, according to (WHO,2003) awareness creation on rights can empower women, to know their sexual and reproductive health rights.  This provides the opportunity for better interaction at family level and ability to access and evaluate quality of health services, therefore, government and partners need to cater for human, material and financial resources on a sustained basis.
"The world and Africa in particular, must save women so that women can save the continent and the world" (Thoroy Obaid, UNFPA Executive Director)

Way forward
*High political will and budgetary commitment
.Coordinated partnership for concerted actions on RH/Maternal and Newborn health issues
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*Harmonization of sub-regional, regional and international days for better impact.
*More effort is needed in social mobilisation about family planning, this is a challenging area given that polygamy is allowed in the muslim faith and practiced by nearly half of all married women, but more than half of the female respondents intended to use family planning in the near future.  This is a positive result, which should be explored in order to bring men on board
*Domestication of the African Protocol on Women's Rights and its enforcement.
.Promotion of adolesent/youth S&RH