Differences And Determinants Of The MMR In SSA Countries

Background: Reducing the maternal mortality ratio(MMR)was a primary target of the already ended Millennium Development Goals(MDGs),and it is also an essential objective of the current Sustainable Development Goals(SDGs).The SDG 3.1 aims at reducing the MMR in at least two-thirds from the 2010 baseline.According to the WHO,in 2015 the number of deaths in the world reached more than 300.000.Only 1% of these deaths occur in developed areas,whereas a 99% of them occur in developing countries.And what is even more dramatic,is that a high percentage,specifically a 66% of these deaths,occur only in Sub-Saharan Africa(SSA).In 2000,United Nations(UN)started working towards reducing the maternal mortality in the world,throughout the MDG5.This goal had two specific targets;5A was to reduce by three quarters the MMR between 1990 and 2015;5B was achieved by 2015 universal access to reproductive health.As per MDGs a major objective,the objective number 5,focused on maternal health by specifically reducing MMR by 75% during 1990 and 2015.In SSA,only two countries,Cabo Verde and Rwanda,achieved the MDG5 A at the end of 2015.Nonetheless,the MMR in SSA remains high with a point-estimate of 546/100,000,and it is one of the highest MMR in the world.The SDG 3.1,the newly postulated health target aims to reduce the MMR by at least twothirds from the 2010 baseline.Therefore,to achieve this goal,no country should have an MMR higher than 140 per 100 000 live births by 2030.For that reason,is important to focus the resources and investigations on places as SSA,where currently the MMR reach more than 500 deaths /100 000 live births in more than twenty countries.Objectives: The aim of this study is to analyze the data of SSA countries that did not achieve the objectives stipulated in the MDG5 A to study the influence of socio-economic and health carerelated factors on the MMR in this region.Using this information to identify the challenges of SSA to achieve the SDG 3.1 target related to maternal mortality.Methods: This is a descriptive study that used secondary data from open sites of: WHO,WB,and UNDP.Forty-one countries from SSA were analyzed and separated into three categorical groups based on the WHO classification system according to their progress in reducing the MMR,described in the “Maternal Mortality Trends 1990-2015”.The three groups categorical groups are: Making progress(MP),insufficient progress(IP),and no progress group(NP).Fifteen indicators were divided into two main areas: Social-economic factors and health-care related factors.A descriptive statistical analysis was applied to compare the countries from the three mentioned groups,with the reference countries(Cabo Verde and Rwanda).Selected countries were compared with Rwanda using the most representative indicators.A nonparametric test,Kruskal Wallis was performed to compare the differences among the three groups.Correlation analysis was performed to examine the relationship between the MMR and the indicators from the two main areas.Regression analysis was used to identify the variables that have the higher impact on the MMR in SSA.Results: A correlation analysis showed a significant correlation between the MMR and the Human development index(HDI)(-0.681),the female literacy rate(-0.627),the number of nurses and midwives(-0.608),the skilled attendance at birth(SBA)(-0.575),the expenditure on health(-0.548),the contraceptive prevalence(-0.545)and the total fertility rate(0.543).No significant correlation was observed between the MMR and the people living in urban areas.The comparison among the three groups using a non-parametric test(Kruskal Wallis Test)showed that the indicators with the most significant differences among the three groups are: the HDI(p=0.024),the percentage of contraceptive prevalence(p=0.033),and the number of nurses and midwives per 1000 people(p=0.039).The multiple regression analysis showed that the literacy rate has a significant impact on the MMR(B=-5.236;p=0.001).The descriptive analysis showed that the countries with the highest MMR per group have low percentages of contraceptive prevalence,a low number of physicians per 1000 people,less access to sanitation facilities,and a low female literacy rate when compared with countries with the lowest MMR per group.The three groups were compared using basic statistical parameters.The main results showed that the IP group has the lowest figures in most of the analyzed indicators(Contraceptive prevalence,number of nurses and midwives,improved sanitation facilities,and literacy rate).The MP group tended to have the highest values in the rate of female literacy rate,SBA,total health expenditure,public health expenditure,and nurses and midwives every 1000 people.The most substantial differences between Rwanda and selected countries were observed in the percentage of contraceptive prevalence and the percentage of access to sanitation facilities.Coclusions: In order to hasten the goal stipulated by SDG3.1,it is important to focus on key determinants affecting the MMR,within the health system,as the number of physicians,the number of nurses and midwives,and the percentage of contraceptive prevalence;but it is also critical to include determinants from outside the health system,such as improving the female literacy rate,the access to improved sanitation facilities,and adequate distribution of the health expenditure.These have been observed as important factors affecting the maternal health in SSA.Furthermore,international policies should focus on countries from SSA that have not made much progress in reducing the MMR during the last decades,especially in those countries classified as IP,and at the same time learn from the successful experience of those countries from the region that had achieved the MDG5 A.A higher level of education of women,more skilled health professionals(especially nurses and midwives),increasing the access to sanitation facilities,policies to promote family planning,and an adequate distribution of the resources on health,appear to be the requirements to reduce the MMR in SSA countries and to achieve the SDG 3.1 by 2030.