A Systematic Review of Maternal Mortality in African Countries

Abstract

Introduction: The goal of this review is to investigate maternal mortality rates (MMR) in African countries. Because the MMR of Black women in the United States is 3-5x higher than in White women, this study aims to identify if a similar racial disparity is present in Africa where the majority of the birthing population identifies as Black. Methods: Four bibliographic databases were searched - PubMed, Web of Science Core Collection, Scopus, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) – and a variety of search terms were identified, including “Maternal Mortality”, “Ethnic Groups”, “Minority Groups”, “Continental Population Groups”, “Medically Underserved Area”, “Race Factors” and “Racial Disparities”. Inclusion criteria were manuscripts with statistics on maternal mortality or severe maternal morbidity in African countries or regions; exclusion criteria included “wrong outcome”, “wrong study type”, and studies only discussing maternal morbidity without mention of mortality. Papers that were not written in or that did not include information about an African country or region were excluded. Results: Overwhelmingly, hypertension-related mortality was identified as a leading cause of death in nearly every study, followed closely by post-partum hemorrhage, often due to over- or underuse of anticoagulation therapy. Unsafe abortion contributed to higher rates of adolescent mortality (37% of adolescents in one study) while accounting for 9-27% of the overall mortality rate. MMR across the continent varied significantly. Countries with the highest average recorded MMRs include Tunisia (1,820/100,000), Sierra Leone (1,800/100,000), Guinea (1,600/100,000), and Somalia (1,600/100,000). The lowest average MMRs found in this study included Tanzania (120/100,000), Egypt (124.5/100,000), Algeria (160/100,000), and Libya (220/100,000). Factors contributing to higher rates of mortality included extremes in maternal age, with the highest rates being in those older than 40 and younger than 20. Educational status played a large role, with up to 68% of mortality in one study occurring in people considered to be illiterate. Low socioeconomic status and being a member of a minority religious and/or ethnic group within a population corresponded with higher mortality rates, in addition to either late or minimal access to antenatal care (up to 28x higher MMR). A common comorbidity related to maternal mortality was patients having an established HIV diagnosis. Though mortality rates were significant in both HIV-positive and HIV-negative patients, most deaths in HIV-positive patients were related to advanced disease as opposed to obstetric complications, with one study finding the MMR of HIV-infected patients to be 6.2 times higher than HIV-negative patients. Among these deaths, tuberculosis, pneumocystis jirovecii pneumonia, and meningitis were among the most common causes. One study investigated the association between antiretroviral (ART) therapy and decreased rates of HIV-positive mortality. The recorded MMR of both HIV-positive and HIV-negative women decreased over the 10 years in this study; however, the HIV-positive MMR in the third time period was still 3.2 times higher than that of HIV-negative women (4.1 times higher in the second period, 7.1 times higher in the first period) with HIV-positive patients making up 33.3% of maternal deaths. One 2021 study focused on the effects of a COVID-19 infection on maternal outcomes – identifying no statistically significant difference in MMR, except that HIV-positive patients were twice as likely to contract COVID than controls. Conclusion: According to US CDC, the 2020 US national MMR was 23.8 per 100,000 live births, compared with the lowest national MMR in this study - Tanzania at 120/100,000; 6-fold higher than the US national average. In this systematic review, multiple factors were found to contribute to higher MMR, including low socioeconomic status, poor access to trained medical professionals, and patients having untreated or severe comorbidities such as HIV or tuberculosis. Two studies used a data collection method called ‘The Sisterhood Method’ which gathered retrospective data via interviewing women about the maternal outcomes of their biological sisters. Though this method of collection is useful for countries and/or regions that have limited access to electronic medical records (EMR) or census data, it relies on the memory and the willingness of interviewees to provide information, which may create recall bias and alter the validity of those studies. Our work identifies a need for further maternal mortality research to identify differences in healthcare systems across countries (both in Africa and worldwide) leading to higher death rates in some nations. Additionally, training programs (such as “Human Resources for Health,” “Pan-African Academy of Christian Surgeons [PAACS]”, “East, Central, and Southern African Health Community [ECSA-HC]”, etc.) should be supported with funding and other resources to address this crisis, while also supporting ongoing initiatives to expand medical education and training in African countries. Efforts should also be made to increase patient education about early signs of obstetric complications. Though maternal mortality rates have trended downward in recent decades, further research is needed to highlight and address disparities across countries and populations to provide equitable care to all.