Authors: Ghangha Jamin G. MPH, Sangwe Clovis N. MD, MSc, MPH, PhD(c), Njedock Nelson S. MD, Internist, Michael Budzi, MD, MPH.

Anasthasia, a woman in her late 40s from Bole, a village in the Meme Division of the South West Region of Cameroon tells the tragic story of her daughter who died a few months ago after giving birth at home. When she noticed that she was bleeding the next day, her daughter immediately informed her of the situation which required immediate medical attention. Living five kilometers away from the nearest health facility, she had to be transported by motor bike, but because it had rained and the road was impassable, no motor bike could move. With no choice but to resort to traditional practices to save her daughter, the bleeding continued and she died few hours later, Anasthasia said in tears.

The WHO defines maternal mortality as the death of a woman during pregnancy or within 42 days after abortion, regardless of the stage or place of pregnancy, from any cause related to or aggravated by pregnancy or its management, excluding accidental or unintentional injuries1. Maternal mortality remains a major problem for women of reproductive age throughout the African Region. Despite a global reduction in the maternal mortality ratio (MMR) to 34.2% between 2000 and 2020, the MMR in the African Region remains a disaster. More than two-thirds (69%) of maternal deaths occur in the African Region2. In 2020, countries were classified into four categories of maternal mortality: low, high/moderate, very high and extremely high, with Cameroon in the high/moderate category (100 to 499 deaths per 100 000 live births). By 2022, Cameroon will have a maternal mortality rate of 438 per 100,000 live births, which poses a public health threat, particularly in hard-to-reach and enclaved communities3.

Addressing the three delays in health care is a critical approach to tackling high maternal mortality rates. The three delays framework was developed by Thaddeus and Maine (1994) to identify the key factors contributing to maternal mortality in low-resource settings. The framework categorizes delays into three stages: delay in seeking care, delay in reaching care and delay in receiving appropriate care. Addressing these delays can improve maternal health outcomes4. However, for the purposes of this article, we will consider the delay in reaching care and how community solutions can be used to address these challenges.

The delay in reaching care refers to the time it takes for an individual, in this case a pregnant woman, to physically reach a health facility once she has decided to seek care5. This delay can be due to a number of factors, including geographical, transport, financial, cultural barriers, to name but a few.

  1. The state should consider training birth attendants and increasing the number of midwives: Training and deploying skilled birth attendants or midwives in communities, especially in enclaved areas, can ensure that women have access to skilled health professionals during childbirth. These attendants can provide antenatal care, assist with delivery and offer immediate postnatal care, reducing the need for women to travel long distances to reach health facilities.
  2. Appropriate use of Community Health Workers (CHWs): CHWs are the unsung heroes of our time. They could be trained to provide basic health services and health education. They can play a crucial role in identifying pregnant women, promoting antenatal care and referring women to appropriate health facilities. CHWs can also conduct home visits, educate community members and women about maternal health, and provide basic family planning counselling.
  3. Transport solutions: Establishing community-based transport systems can help overcome transport challenges. This can include initiatives such as organizing community ambulances or vehicles to transport pregnant women quickly to health facilities. In some cases, the use of bicycles, motorcycles or boats can be a practical alternative in areas with limited road infrastructure.
  4. Maternal Waiting Homes: Maternal Waiting Homes are residential facilities located near health facilities that allow pregnant women who live far away to stay closer to the facility as their due date approaches. This reduces the time spent travelling during labour and delivery and ensures prompt access to skilled care when needed.
  5. Community emergency funds: The establishment of community emergency funds can help address financial barriers that prevent women from seeking timely care. These funds can be set up to provide financial assistance or vouchers for transportation, medical expenses or emergency obstetric care, ensuring that cost does not impede access to care.
  6. Peer support groups: Establishing peer support groups within communities can provide pregnant women with a network of emotional support and information. These groups can facilitate the sharing of knowledge about maternal health, encourage care-seeking behaviour and provide assistance in navigating the health system.
  7. Mobile health (mHealth) solutions: The use of mobile phones and applications can improve access to health information and services. Mobile health platforms can provide educational messages, reminders for antenatal visits and emergency contact information. They can also facilitate teleconsultations with healthcare providers, allowing remote access to medical advice. It should be noted, however, that this intervention is best suited to communities with an adequate communications network.

These community-based solutions empower local communities, increase access to care, and address delays in reaching health facilities. They use existing social structures, knowledge and resources within communities to improve maternal health outcomes and reduce maternal mortality.

References

  1. WHO, 2017. Reducing Maternal Death https://www.afro.who.int/sites/default/files/2017-06/mps%20brochure_reducing-maternal-deaths.pdf
  2. WHO, 2022, Atlas of African Health Statistics https://apps.who.int/iris/bitstream/handle/10665/364839/9789290234845eng.pdf?sequence=1&isAllowed
  3. Cameroon Maternal Mortality Rate 2000-2023. https://www.macrotrends.net/countries/CMR/cameroon/maternal-mortality-rate
  4. Mgawadere et al. BMC Pregnancy and Childbirth (2017) 17:219. DOI 10.1186/s12884-017-1406-5
  5. Shah B, Krishnan N, Kodish SR, et al. Applying the Three Delays Model to understand emergency care seeking and delivery in rural Bangladesh: a qualitative study. BMJ Open 2020;10:e042690. doi:10.1136/ bmjopen-2020-042690