In Republic of Congo, a revolution in maternal health

BRAZZAVILLE, Republic of the Congo – At first glance, Central University Hospital in Brazzaville looks like so many other hospitals in so many other African capitals – home to dimly lit waiting rooms and dirty floors. But inside the freshly painted mint-green walls of the hospital's maternity ward, a revolution is happening. 

In 10 years, the country has reduced the number of women dying in child birth by more than 50 percent, with most of that drop occurring in the last two years.

Before 2005, even, "there was nothing" in most health facilities, says Dr. Léon Hervé Iloki, a practicing gynecologist and director of the national Observatory on Maternal and Newborn Mortality, established in 2010 to audit the causes of maternal and infant death. "Forceps? You didn't have them. You didn't have other instruments for helping in delivery. Even beds were not always there.

"The difference today is spectacular," he says. "And for the women giving birth, it is incalculable."

It's also a rare rate of improvement in maternal health, on a continent that could use some good news: Fifty-six percent of women worldwide who die in childbirth are dying in sub-Saharan Africa. Less than half of all births in the region are overseen by qualified professionals, whether doctors or medically trained midwives. But peaceful Congo-Brazzaville's improvements on maternal mortality have gone largely unnoticed, overshadowed perhaps as bad news from Africa dominates the bandwidth.  

Yet the country is besting worldwide trends. Globally, maternal mortality has dropped by roughly 45 percent in the last 20 years, according to the World Health Organization (WHO) – far short of the 75 percent reduction envisioned by the Millennium Development Goals. Congo-Brazzaville has exceeded that global rate by a third. David Lawson, the country director for UNFPA, a partner in the maternal health projects, says that if progress continues at the same rate, Congo might, in fact, meet the Millennium Development Goal on schedule, in 2015. According to a recent study in the Lancet, only about a dozen countries are expected to meet that goal.

"The government is actually putting the resources and actions where they're supposed to be," Lawson says. "I have no doubt that the situation will continue to improve."

Doctors and public health experts here give much of the credit for that progress to a presidential decree that put this expensive birth in reach of even the poorest women: Since 2011, Caesarean sections, which had cost upwards of $500, have been a free public health service.

This, say Congolese women, is no small thing. Rose-Marie Moundélé, 55, shared her relief as she waited in the pediatric ward of CHU for her sister-in-law, who had brought her son, delivered by Caesarean four months ago, in for a checkup. He is her second nephew, and he was a surprise: the first was born 20 years ago, when Moundélé and her sister-in-law were still young women, and giving birth in Congo was much riskier than it is today.

"Back then if you had to have a Caesarean, it could cost maybe $600," she remembered. "If you don't have the money, you have to find it. Or you will die there, on the table."

The affordability of the procedure has done what doctors hoped it would: The number of Caesareans is going up around the country. Iloki says the national average should be about 15 percent, roughly the dividing line set by the World Health Organization between over- and under-use of the procedure. That fine line is a preoccupation in public health: In the United States, where roughly one-third of births are C-sections, there's widespread concern, even from the WHO, about the procedure's overuse. In Africa, on the other hand, women who need C-sections often can't get them: A recent WHO survey found that only 2 to 5 percent of women in sub-Saharan Africa birthed by Caesarean, low rates the study attributed to lack of access, especially among the poor. In Iloki's ward, by contrast, 17 percent of deliveries last year were C-sections.

If the availability of the procedure elicits gratitude from some women, it also makes others nervous. Even today, Congolese women prefer to give birth naturally, and when that expectation changes, it can create tension. Arlette Bouiti, 28, gave birth to her first child this summer. Unexpectedly, she had to have a C-section. "During the whole pregnancy, the doctors never said I might need it," she said. On the day of the birth, doctors noticed some complications, and they were concerned the slight woman's hips might be too narrow for her baby, she said. "I was frightened."

But with a healthy baby girl on her hip, she's also a little bit suspicious. "Is the increase in Caesarean because it's free, or because it's medically necessary?" she asks. "Is it women who need it, or is it the doctors who prefer to do it?"

The maternal health revolution in Brazzaville is about more than Caesareans. It's also about demographics – more than half of the country's 4.5 million people live in its two biggest cities – and about basic health infrastructure.

"Many women give birth in facilities – hospitals, maternities, health centers," says Dr. Marie Francke Puruehnce, the health advisor to the president and head of the national Department for Public Health and Population. That means there's staff to help, or make referrals, in the case of complications. It also means there's trained staff – not enough, Puruehnce points out – in the country's birthing wards, even if there aren't Paris-trained specialists like Iloki. The National Midwives Association, for example, has 2,500 members, and in health facilities far from urban centers, they are the experts in the delivery room.

It's clear Iloki, for his part, likes bringing babies into the world, whatever the process. On a recent Wednesday afternoon in his mint-green ward, he checked in on a Caesarean section, performed in a crisp room amid much modern equipment. The next morning, he handled a complicated delivery, a 41-year-old woman's first child, with deft skill and buoyant humor. It's evident that he enjoys showing off his facility, his staff and his skill. But it's also clear he's not satisfied.

"This progress is significant," he insists. "But it is not enough."

Indeed, a quick drive north, and everything changes. The city comes to an abrupt halt; the tightly packed storefronts and the sidewalk peddlers disappear, and emptied hills takes over. Chinese construction projects pop up along the drive, but for miles, there’s nothing to see.

Until you come to Ignie ("In-yeh"), a rural outpost of just over 11,000 people less than 30 miles north of Brazzaville. It's a quick strip of a place, with tissues and groundnuts and pay-as-you-go top-ups for sale in small wooden shacks on one side of the road, and a barren petrol station on the other. Next to the station is Ignie’s local health center, and its maternity ward.

Working at this ward, there are just two sages femmes, or midwives, and no doctor. Together, the sages femmes bring about 30 babies into the world in a month. The clinic has only two birthing beds, one of which is so worn and dirtied with age and rust that they don’t use it. The small maternity ward isn't especially warm or inviting. There’s dried blood on the walls, and there's no running water; a custodian heads out at 5 am, three hours before opening, to draw enough well water to fill two small plastic trash cans. It could easily be a frightening place, which the staff here seems to know. 

"We prepare in this room even in the prenatal consultations," says Odette Elembe, one of the clinic's two midwives, "so they know how to push, not to be afraid."  After the standard four prenatal checkups – which Elembe says most women here observe – the room feels familiar.

On a square metal table in the far-right corner of the room, there's a kidney-shaped tray of tools: a clamp for the umbilical cord, a blunt pair of scissors – one, and only one, of the most basic necessities of birthing. There’s nothing here to handle complications – no forceps, for example, and no one trained to use them, even if they existed.

There's also no ambulance. "If you’re in a difficult birth, we put you [on] to the road, and you wait for a taxi," says Guy-Noël Ntela, an administrator who runs the clinic. So far from town, there aren't many of those, either. "Then the vehicle stops and stops and stops," he says, letting passengers off and on during its 30-mile journey to the capital. 

And yet, Ntela and his midwives can recall only one maternal death in recent memory. They pull out a book of hand-written statistics, and the record backs them up: One woman died, after she’d delivered in Brazzaville, in July. Inside the walls of this clinic, stretching into numbers from last year, not a single woman has been lost.

That's not because Ignie has unusually abundant resources or uniquely trained staff. In part, it's because Elembe is available every day; she lives on-site, and if she gets a distress call, no matter what time of day, she moves immediately to the woman's home. It's also because the clinic has a well-honed referral system, which gets the most complicated cases to Brazzaville as quickly as possible – sometimes several weeks in advance of delivery.

More often, they make immediate referrals, and often because women artificially accelerate the birth. "They begin at home, pushing too early," sometimes with the aid of an herbal medicine from a traditional doctor, Elembe says. These births become complicated in those cases, and women have to be sent to the city. The prognosis for healthy birth for mother and child is still good, as the numbers bear out.  But still, Elembe worries. "The baby suffers," she says.

To be sure, there's more to be done for expectant mothers here, and health officials aren't shy about saying so. These days, nearly 95 percent of women pay for a pre-natal checkup, but 15 percent of them don't show up again – a rate of attrition even higher than in 2005, during darker days for maternal mortality. Each visit, Dr. Puruehnce explains, "requires money. That's money that can go to feed a family, or go directly to [paying for] the birth." 

"It would be great if these services could be free for everyone," she adds – and as his health advisor, she in particular has the president's ear.  But she acknowledges that this is unlikely to happen. "Realistically, if we could get the price down to 2,000-3,000 [CFA, or $4 to $6], that would be good."

And there are, in fact, rural women – including the comparatively disenfranchised indigenous community – birthing largely outside the reach of health infrastructure, referrals and trained personnel. "In the rural areas, they give birth traditionally, in the home, with a matron," an untrained traditional birth attendant, according to Clémence Otilibili, treasurer of the National Association of Midwives. "In some parts of the bush, it’s archaic.  When they need to weigh the baby, they put it in a wrap and rest it on the same scale they use for meat." And even in urban areas, Otilibili says, there are still training and personnel needs outside of the major referral hospitals.

Sylvie Niombo, who leads a women’s advocacy group called AZURE Développement, says that for indigenous women, who don’t live in urban centers, home births are not just about "tradition." They're also about financial means – and about marginalization. "Indigenous women in certain parts of the country are not considered as people. So they have difficulty even accessing health centers," she says. "There are these women in the villages who don’t give birth at health centers…because [the women] are stigmatized."

Meanwhile, experts and activists say, not all maternal health comes down to what happens in the delivery room.  Improving access to – and the acceptability of – family planning is another key goal. "They're directly linked," says Zéphirin Abel Moukolo, the director of programming for the Association for the Well-Being of Congolese Families, a partner in many governmental health initiatives and a local affiliate of the International Planned Parenthood Federation. "How to keep women under 18 from falling pregnant?” he asks, intoning the physical dangers of premature pregnancy.  “It’s family planning.”

Family planning still runs up against social taboos, which affect the well-being of more than pregnant mothers.  “We see reproductive health as a question of sexuality. In our country there are so many taboos on [discussing] sexuality," she says. "But what else is HIV/AIDS prevention but a question of sexuality, of sexual health? Same with youth…same with family planning."

All health issues, like so many other issues for women in Congo, run up against another big problem: Poverty. On the surface, Congo-Brazzaville isn't poor. A major African oil producer, it's a middle-income country, with a per capita gross national income of nearly $3,000. But that macroeconomic picture can also be deceiving.

Says Emma Tsoulou, executive director of the Association of Women in Solidarity: "Where there are riches, there are those who benefit, and there are those who do not.  In any country in the world, even ours."

This article was supported in part by the International Reporting Project.