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Kante AM, Youssoufa LO, Mounkaila A, Mahamadou Y, Bamogo A, Jiwani SS, Hazel E, Maïga A, Munos MK, Walton S, Tam Y, Walker N, Akseer N, Jue Wong H, Moussa M, Dagobi AE, Jessani NS, Amouzou A. Challenges in reducing maternal and neonatal mortality in Niger: an in-depth case study. BMJ Glob Health 2024; 9:e011732. [PMID: 38770808 PMCID: PMC11085984 DOI: 10.1136/bmjgh-2023-011732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/22/2024] [Indexed: 05/22/2024] Open
Abstract
INTRODUCTION Recent modelled estimates suggest that Niger made progress in maternal mortality since 2000. However, neonatal mortality has not declined since 2012 and maternal mortality estimates were based on limited data. We researched the drivers of progress and challenges. METHODS We reviewed two decades of health policies, analysed mortality trends from United Nations data and six national household surveys between 1998 and 2021 and assessed coverage and inequalities of maternal and newborn health indicators. Quality of care was evaluated from health facility surveys in 2015 and 2019 and emergency obstetric assessments in 2011 and 2017. We determined the impact of intervention coverage on maternal and neonatal lives saved between 2000 and 2020. We interviewed 31 key informants to understand the factors underpinning policy implementation. RESULTS Empirical maternal mortality ratio declined from 709 to 520 per 100 000 live births during 2000-2011, while neonatal mortality rate declined from 46 to 23 per 1000 live births during 2000-2012 then increased to 43 in 2018. Inequalities in neonatal mortality were reduced across socioeconomic and demographic strata. Key maternal and newborn health indicators improved over 2000-2012, except for caesarean sections, although the overall levels were low. Interventions delivered during childbirth saved most maternal and newborn lives. Progress came from health centre expansion, emergency care and the 2006 fee exemptions policy. During the past decade, challenges included expansion of emergency care, continued high fertility, security issues, financing and health workforce. Social determinants saw minimal change. CONCLUSIONS Niger reduced maternal and neonatal mortality during 2000-2012, but progress has stalled. Further reductions require strategies targeting comprehensive care, referrals, quality of care, fertility reduction, social determinants and improved security nationwide.
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Affiliation(s)
- Almamy Malick Kante
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Aida Mounkaila
- Direction des Statistiques Sanitaires, Ministère de la Santé Publique, Niamey, Niger
| | - Yahaha Mahamadou
- Direction des Statistiques Sanitaires, Ministère de la Santé Publique, Niamey, Niger
| | - Assanatou Bamogo
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Safia S Jiwani
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elizabeth Hazel
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Abdoulaye Maïga
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Melinda Kay Munos
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Shelley Walton
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Yvonne Tam
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Neff Walker
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nadia Akseer
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Heather Jue Wong
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Nasreen S Jessani
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Knowledge, Impact and Policy Unit, Institute of Development Studies, Brighton, UK
| | - Agbessi Amouzou
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Bigirinama RN, Mothupi MC, Mwene-Batu PL, Kozuki N, Chiribagula CZ, Chimanuka CM, Ngaboyeka GA, Bisimwa GB. Prioritization of maternal and newborn health policies and their implementation in the eastern conflict affected areas of the Democratic Republic of Congo: a political economy analysis. Health Res Policy Syst 2024; 22:55. [PMID: 38689347 PMCID: PMC11061947 DOI: 10.1186/s12961-024-01138-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/30/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Maternal and neonatal mortality remains a major concern in the Democratic Republic of Congo (DRC), and the country's protracted crisis context exacerbates the problem. This political economy analysis examines the maternal and newborn health (MNH) prioritization in the DRC, focussing specifically on the conflict-affected regions of North and South Kivu. The aim is to understand the factors that facilitate or hinder the prioritization of MNH policy development and implementation by the Congolese government and other key actors at national level and in the provinces of North and South Kivu. METHODS Using a health policy triangle framework, data collection consisted of in-depth interviews with key actors at different levels of the health system, combined with a desk review. Qualitative data were analysed using inductive and then deductive approaches, exploring the content, process, actor dynamics, contextual factors and gender-related factors influencing MNH policy development and implementation. RESULTS The study highlighted the challenges of prioritizing policies in the face of competing health and security emergencies, limited resources and governance issues. The universal health coverage policy seems to offer hope for improving access to MNH services. Results also revealed the importance of international partnerships and global financial mechanisms in the development of MNH strategies. They reveal huge gender disparities in the MNH sector at all levels, and the need to consider cultural factors that can positively or negatively impact the success of MNH policies in crisis zones. CONCLUSIONS MNH is a high priority in DRC, yet implementation faces hurdles due to financial constraints, political influences, conflicts and gender disparities. Addressing these challenges requires tailored community-based strategies, political engagement, support for health personnel and empowerment of women in crisis areas for better MNH outcomes.
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Affiliation(s)
- Rosine Nshobole Bigirinama
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Avenue Michombero No. 02, Bukavu, Democratic Republic of Congo.
- School of Medicine, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo.
- Ecole de Santé Publique, University of Lubumbashi, Lubumbashi, Democratic Republic of Congo.
| | | | - Pacifique Lyabayungu Mwene-Batu
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Avenue Michombero No. 02, Bukavu, Democratic Republic of Congo
- School of Medicine, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- School of Medicine, Université de Kaziba, Bukavu, Democratic Republic of Congo
| | - Naoko Kozuki
- Airbel Impact Lab, International Rescue Committee, Washington, DC, United States of America
| | - Christian Zalinga Chiribagula
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Avenue Michombero No. 02, Bukavu, Democratic Republic of Congo
| | - Christine Murhim'alika Chimanuka
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Avenue Michombero No. 02, Bukavu, Democratic Republic of Congo
- Centre de Recherche en Sciences Naturelles, Lwiro, Democratic Republic of Congo
- Centre de Recherche Politiques, Systèmes de Santé, Santé Internationale (CR3), Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Gaylord Amani Ngaboyeka
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Avenue Michombero No. 02, Bukavu, Democratic Republic of Congo
- Centre de Recherche Politiques, Systèmes de Santé, Santé Internationale (CR3), Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Ghislain Balaluka Bisimwa
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Avenue Michombero No. 02, Bukavu, Democratic Republic of Congo
- School of Medicine, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- Centre de Recherche en Sciences Naturelles, Lwiro, Democratic Republic of Congo
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Schantz C, Coulibaly A, Traoré A, Traoré BA, Faye K, Robin J, Teixeira L, Ridde V. Access to oncology care in Mali: a qualitative study on breast cancer. BMC Cancer 2024; 24:81. [PMID: 38225594 PMCID: PMC10788985 DOI: 10.1186/s12885-024-11825-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/02/2024] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Breast cancer is the most common cancer in terms of incidence and mortality among women worldwide, including in Africa, and a rapid increase in the number of new cases of breast cancer has recently been observed in sub-Saharan Africa. Oncology is a relatively new discipline in many West African countries, particularly Mali; thus, little is known about the current state of cancer care infrastructure and oncology practices in these countries. METHODS To describe the challenges related to access to oncology care in Mali, we used a qualitative approach, following the Consolidated Criteria for Reporting Qualitative Research (COREQ). Thirty-eight semistructured interviews were conducted with health professionals treating cancer in Mali (n = 10), women with breast cancer (n = 25), and representatives of associations (n = 3), and 40 participant observations were conducted in an oncology unit in Bamako. We used the theoretical framework on access to health care developed by Levesque et al. a posteriori to organise and analyse the data collected. RESULTS Access to oncology care is partly limited by the current state of Mali's health infrastructure (technical platform failures, repeated strikes in university hospitals, incomplete free health care and the unavailability of medicines) and exacerbated by the security crisis that has been occurring the country since 2012. The lack of specialist doctors, combined with limited screening campaigns and a centralised and fragmented technical platform in Bamako, is particularly detrimental to breast cancer treatment. Women's lack of awareness, lack of information throughout the treatment process, stereotypes and opposition to amputations all play a significant role in their ability to seek and access quality care, leading some women to therapeutically wander and others to want to leave Mali. It also leaves them in debt and jeopardises the future of their children. However, the high level of trust in doctors, the involvement of international actors, the level of social support and the growing influence of civil society on the issue of cancer also represent great current opportunities to fight cancer in Mali. CONCLUSION Despite the efforts of successive Malian governments and the commitment of international actors, the provision of health care is still limited in the country, entrenching global inequalities in women's bodies.
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Affiliation(s)
- Clémence Schantz
- Université Paris Cité, IRD, Inserm, Ceped, F-75 006, Paris, France.
- Institution Convergences Et Migrations, Aubervilliers, France.
| | | | | | - Bakary Abou Traoré
- Centre de Santé de Référence de La Commune 2, Bamako, Mali
- Centre National de La Recherche Scientifique Et Technologie (CNRST), Bamako, Mali
| | - Kadiatou Faye
- Association Les Combattantes du Cancer, Bamako, Mali
| | - Julie Robin
- Université Paris Cité, IRD, Inserm, Ceped, F-75 006, Paris, France
| | - Luis Teixeira
- Pathophysiology of Breast Cancer Team, Department of Senology, Université Paris Cité INSERM U976, HIPIAP-HP, Hôpital Saint-Louis, Paris, France
| | - Valéry Ridde
- Université Paris Cité, IRD, Inserm, Ceped, F-75 006, Paris, France
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