Introduction:

Maternal mortality, as defined by the World Health Organization (WHO) is the death of women during pregnancy or within 42 days postpartum. This is irrespective of the duration or location of the pregnancy, as well as any causes related to or aggravated by the pregnancy or its management but not from accidental causes (Maternal mortality ratio). The maternal mortality ratio (MMR) is a number that indicates the number of maternal deaths per 100,000 women. Maternal mortality is a problem that healthcare workers are fighting on a global scale as it impacts society on multiple levels. As a result of the millennium development goals, maternal mortality has had a negative trend since the 1990s. It has decreased globally by 44%, however, there are still certain countries, particularly lower-income countries, that have fallen short of this goal. The average MMR in higher-income countries is 16 deaths for every 100,000 women, whereas, in lower-income countries, the average MMR is 230 deaths per 100,000 women (Maternal mortality).

MMR in Africa varies drastically from country to country. Ethiopia has one of the highest rates in Sub Saharan Africa, with an average of 497 deaths for every 100,000 women. Although this number has dropped considerably in the past few years, it is still significantly higher in relation to other countries. Within Ethiopia, these numbers vary from region to region, with the Somali and Afar region having the highest MMR of 743 and 717 per 100,000 respectively, and the capital, Addis Ababa, has the lowest of 234 per 100,000 women (the State of Inequality. 2008). 

 

Maternal mortality can serve as an indicator of the disparities between the rich and the poor within a country as well as its overall development. There are many economic and societal implications of maternal mortality, as it can cause a decline in child health, financial instability, and even loss of education within a community (Tolluch 2015). There are many different aspects that can influence maternal mortality. Its determinants can be understood on a social, political, and economic level, which then plays out on an individual, community, national, and global scale.

 

Part I: Political Economy of the Problem:

Effect of living conditions on Maternal Mortality: 

The majority of Ethiopia’s population resides in rural areas outside of the capital city. When comparing the number of individuals in each household, rural homes tend to have larger numbers over more urban areas. The average rural home has approximately 5.1 people whereas more urban homes only house 3.9 people (Central Statistical Agency & the World Bank, 2013). This has negative impacts on the health of all the members of the household as high capacity households can lead to the spread of diseases making it a dangerous environment. In addition to this, one of the main issues that the rural population must face is the lack of clean and reliable water sources. Out of the total population in Ethiopia, 61 million people lack access to clean water. A contributor to MMR in Ethiopia especially in rural areas is viral hepatitis, malaria, and maternal sepsis and accounts for 9.6% of all maternal mortality cases in Ethiopia (Tessema. 2013). One way in which hepatitis can be transmitted is through fecal matter being ingested. This is common in the more rural area of Ethiopia as some hygiene products such as soap are not readily available (Vivas 2010). Additionally, the lack of clean water prevents the maintenance of a clean and healthy environment which is important because many women in rural Ethiopia prefer home births. 

 

Effect of Traditions on Maternal Mortality:

One of the many determinants that can contribute to the overall MMR is the individual behaviors and practices of women in Ethiopia.  Strong social connections and traditions are a major contributor as to why women in rural areas choose Traditional Birth Attendants (TBA) rather than going to a healthcare facility to deliver their children. This not only puts the mothers at risk for postpartum complications such as maternal hemorrhaging, which accounts for 12% of maternal deaths but also contributes to the increased probabilities of hypertensive disorders, which account for 10.3% of MMR (Tessema. 2013). A study conducted by Solomon Shiferaw, a public health professor at Addis Ababa University, indicated that 78% of women prefer TBAs rather than going to healthcare facilities. Of the 78%, 42% of the women refuse to go to healthcare facilities because they felt as though it wasn’t necessary and 36% stated that it wasn’t customary (Shiferaw 2013). This can be detrimental to the health of both the mother and child due to the lack of clean water and training.

 

Effects of Environment on Maternal Mortality:

Aside from unsterile conditions and traditional values, there are also many environmental factors that may affect maternal mortality. Malaria is a big issue that healthcare workers must take into consideration when looking at MMR in Ethiopia. Malaria transmission peaks during the rainy season between the months of June and September. Form the total area of Ethiopia 78% of the country is malarious (Ayele 2013). Malaria levels are higher in areas that are mainly 1,000-2,000 meters above sea level, which accounts for the 48% Ethiopia specifically the Amhara, Oromia and Southern Nations Nationalities and People’s regions. Malaria, along with hepatitis and maternal sepsis is one of the contributors to MMR at 9.6% of the total cases (Tessema. 2013). If a pregnant women contract malaria, it becomes a high-risk pregnancy as it increases the chances of the mother getting severe malaria particularly if she was not previously exposed and is associated with anemia. It can also lead to spontaneous abortion, stillbirth, premature delivery, and low birth weight (Malaria in pregnant women). 

 

National and community-based determinants:

The Ethiopian government, in an attempt to increase health care coverage, has implemented the Health Extension Program (HEP), in which community-based health programs are introduced throughout the different regions of Ethiopia. With this initiative healthcare providers are attempting to improve primary health care in rural Ethiopia by training an individual household in a given community (Banteyerga 2011).They predict, as an individual household starts to practice a relatively healthy lifestyle, neighboring families would then try to emulate these characteristics, thus gradually improving the health of that community. This program has expanded the reach of healthcare providers and has increased primary health care coverage to 90% as of 2010 (Banteyerga 2011). This initiative also attempts to merge the health care system with the TBAs and possibly increase the number of mothers that would come into healthcare facilities. The HEP in addition to more community healthcare workers has also included the installation of multiple health posts, health centers, and is working to implement primary care hospitals (Fetene 2016). However, regardless of all these improvements to access to healthcare, many pregnant women, particularly those in more rural areas, still refuse to go to these healthcare facilities for deliveries. 

 

Many women in Ethiopia, particularly in rural areas, do not go to medical facilities as they either feel it is not necessary to feel as though it is not customary in their culture (Shiferaw 2013). Although these cultural influences are the primary aspects that prevent women in rural areas form going to healthcare facilities, there are infrastructural and systematic issues that play a role in determining their likeliness as well. Even with the HEP, the distance a community member would have to travel to get to the nearest healthcare facility is approximately 7.7 km on average as of 2000 (Shiferaw 2013, Adungna). Furthermore, finding vehicular transport is difficult, therefore of these community members are forced to walk to these healthcare facilities, this is particularly difficult for pregnant women. Many studies have also indicated, high user fees prevent mothers from going to the health care facilities as their families cannot afford them. Many of these facilities require payment in advance for treatment and typically charge the customers for the drugs and materials that will be used during their visit (Pearson 2011).  These high costs demotivate women from going to healthcare facilities and cause them to increase their risks during labor. 

 

Lastly, many families in Ethiopia both rural and urban use wood fire when cooking food. These numbers are higher in more rural areas because it is more affordable and readily available. Approximately 90% of the population in rural areas in relation to 49% in urban areas. The majority of the people also use the fires indoors while cooking, with no vents, chimneys, or hoods to channel the smoke outside, exposing themselves to harmful particulates which can be detrimental to the health of both the mother and the child (Demographic and health survey 2005). This decreases the air quality around the individuals that are burning the wood. This is impacted by the political economy of Ethiopia as the people in the more rural areas are not able to afford better methods of cooking food.

 

Effect of Globalization on Maternal Mortality:

Although there are many factors that influence maternal mortality on an individual, community, and national level, there are also global determi­nants that affected the MMR of Ethiopia. Globalization has had many positive implications for many low-income countries in multiple forms. One of the ways in which it has helped Ethiopia is by the influx of money through exports. Flowers are one of the major products that are exported from Ethiopia and sales have boomed by 19% due to the expansion of local production and were able to bring in $154 million USD in revenue in 2010 (Flowers 2010). This has helped many families in rural areas find jobs as a local farmer and has helped provide some financial support for their families. Also, the increasing demand for Teff, which is a gluten-free grain used to make a staple of Ethiopian food, has increased dramatically and could become a large earning point for the country. 

 

On the other hand, there are also negative aspects of globalization. Corporations such as Starbucks have failed to acknowledge the Ethiopian coffee trademark, causing another hindrance to the possible flow of income. Had Starbucks agreed to the trademarks of Ethiopian coffee it could create a steady stream of funding of up to USD$88 million annually (Flowers 2010). This impacts rural communities as they are not getting paid enough for the long periods they spend harvesting the coffee.  Moreover, one of the contributors to maternal mortality is malaria, its peak season is during the wet season which is between the months of June and September. Harvesting periods add to the number of malaria case as it overlaps with the wet season (Ayele 2013). This puts mothers and others that harvest at risk of contracting malaria as working in the fields increases their exposure.  Although there are negative aspects present, these components of globalization have helped create a source of income for Ethiopia, which can then be funneled into different projects such as the development of the economy, infrastructure, and the healthcare system. This kind of income can drastically boost the progress of programs such as the HEP and extend its reach to more remote areas of Ethiopia and provide community members with the health care they need.

 

Part II: Comparison of different approaches to health

There are three main models of approaching health care. There is the biomedical model, which implements healthcare solutions while viewing health and illness on an individual level. This model highlights the concept that the “body is a machine with constituent parts, i.e., organ systems, genes, and so on, that can be manipulated or repaired” (Birn.2009). An example of this with relation to MMR could be pills and prenatal vitamins a woman takes to maintain her health during pregnancy. This intervention focuses on the possible medical solution of a given problem. Next, the behavioral model dictates that ill health is primarily the consequence of either healthy living or the outcome of poor lifestyle choices and personal deficiencies. This model implies that health outcomes are a result of the individual’s behaviors. Interventions to reduce maternal mortality based on this model involve encouraging women to go to health care facilities to deliver their children and to be more hygienic and health-conscious in their day to day lives. Finally, the Political model considers the political, social, cultural, and economic context in which diseases and illnesses arise. It examines the ways in which societal structures interact with particular conditions that lead to good or ill health (Birn.2009). Interventions based on this ideology would be much more inclusive of multiple determinants of health. Programs such as the HEP is a good example of this model as it emulates to tackle multiple determinants that affect health overall throughout the country.

 

Part III: Prioritization of determinants

There are many contributing factors that influence the MMR in Ethiopia. Some of the major contributors are cultural practices, access to clean water infectious diseases, and distance to a healthcare facility. In using the behavioral model, Ethiopia can drastically reduce its MMR by tackling one of these factors such as cultural influences. These tables below summarize these main determinants that affect maternal mortality in Ethiopia and indicates their rating based on importance and feasibility. 

 

Importance     1 = most important, 2 = moderately important, 3 = least important

Feasibility       1 = easiest to change, 2 = moderately changeable, 3 = hard to change