1 Poverty and Healthcare: A Meta-Analysis of Three Developing Nations; Comparing Maternal Mortality Rates By Haven Casaday A thesis submitted to the School of Radiologic Sciences In partial fulfillment of the Requirements for the degree of MASTER OF SCIENCE IN RADIOLOGIC SCIENCES DUMKE COLLEGE OF HEALTH PROFESSIONALS WEBER STATE UNIVERSITY Ogden, Utah December 10, 2020 _________________________ Dr. Laurie Coburn, EdD Director of MSRS RA 2 Literature Review To set the stage for the reduction of maternal mortality rates globally, the problem first needs to be explained with supporting data. The article by Brown et al explains the trends in maternal mortality and understanding the problem globally. The articles provided by the Global poverty report (2002) and by Hollander (2010) are the foundation of the Millennium Development Goals stating that maternal mortality is indeed a problem and introduce strategies for governments and non-governmental organizations to begin tackling this problem. The articles listed here by multiple authors provide data and supporting points of interest to the leading causes, lack of funding, and lack of medical treatments/facilities available to the words most vulnerable population. These articles are similar in that they describe the abuses that girls in lower income homes within impoverished countries face including lack of education and early marriage. Marriage is often the only choice an impoverished family has for young girls when they are unable to provide for their children anymore due to lack of monetary means. The article developed by the United Nations Population Fund establishes the connection between gender, reproductive health and population within countries struggling to find ways to improve maternal mortality rates. The dedicated sources to Eritrea, Ethiopia and Kenya by multiple authors explain why these countries are the three with the highest maternal mortality rates globally. These references explore the reasons and the steps taken to reduce the amount of maternal deaths. These references include statements made by the country program researchers and directors. 3 They include data points and research dedicated to attempt at reducing the maternal death rates in concordance with the Millennium Goals set by the African Union. Ethiopia has the highest worlds maternal mortality rate and has taken great strides to become Africa’s example in reducing these numbers. The government has taken multiple actions to improve women's health and well-being within the impoverished nation. With help from many, many NGO’s Ethiopia is slowly recovering from famine and multi district unrest. These articles, along with a personal interview with Dr. Marc Karnes provides insight into the problem, the solutions and the strategies to achieve the Millennium Goals. Articles by the National Council for Population and Development are dedicated to supplying data and research from Kenya’s attempt at reducing maternal mortality rates. Currently, Kenya is the leading nation with the greatest change in terms of women's health. The above articles support the data that Kenya’s making real strides towards the overall improvement of maternal mortality. The governmental policies set forth by Kenya’s president and prime minister has made a great difference in the reduction of maternal mortality. In 2008, the World Bank, the United Nations and the Millennium Development Goals Committee gathered data and created goals set forth by the African Union to begin the reduction of maternal mortality rates across the continent. These references lay out specific country overviews along with the Millennium report goals individualized for the countries in question. Just as the Millennium Development Goals set out step by step solutions, Kays article begins to describe the connection between empowering girls through education and the long-term effects this may have on an African nation. The author makes the connection between 4 education, choices and overall well-being of a girl who then is able to make informed decisions based on the fact that she's had an education. The articles by Ray, Sanders and Spector also describe actions and steps needed to alleviate the problem of maternal mortality through the use of essential medical personal. Sanders et al discusses whether the goals set out by the African Union are really achievable. 5 Purpose Section Around the world women are dying every day before, during and after childbirth. The term “women” is used loosely as most are young girls in a reproductive age range of 12 and up. Medical options are limited when they become pregnant and often this results in maternal death. Despite improvements in healthcare, the World Health Organization (WHO) estimated that “300,000 women died from pregnancy related causes worldwide in 2015” (ourworlddata.org 2019). Africa still carries the “largest burden of maternal deaths in the world, with 56% of the global burden of deaths in 2010” (MDG 2013 Report p.57). This is not a new issue and while countries have made great strides towards solving the complex nature of maternal death, Sub Saharan Africa alone accounted for roughly two thirds of the total number of reported deaths; 196,000 in 2017. In September of 2000 the United Nations (UN) and world leaders created the first draft of the Millennium Development Goals (MDGs). The objectives determined by their collaboration were intended to improve eight detrimental factors effecting developing nations, among them, maternal health and poverty. “The Millennium Development Goals are eight international development goals that were established following the Millennium Summit of the United Nations in 2000, following the adoption of the United Nations Millennium Declaration. All 189 United Nations member states and at least 23 international organizations committed to help achieve these goals by the year 2015” (Aleyomi, IseOlovunkanmi, 2012 p. 54). These member states have committed to reducing several factors that hinder a nations development including maternal mortality. The MDGs are as follows: 6 Millennium Development Goals Table 1 1) Eradicate extreme poverty and hunger 2) Achieve universal primary education 3) Promote gender equality and promote women 4) Reduce mortality 5) Improve maternal health 6) Combat HIV/AIDS/malaria and other diseases 7) Ensure environmental sustainability 8) Develop a global partnership for development Maternal death is defined as the “death of a woman while pregnant or within 42 days of the termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes” (Falola, Heaton p. 21). According to researchers, most of these deaths are preventable had the proper resources’ been available (WHO). Maternal mortality rates (MMRs) are considered high if more than 300 deaths per 100,000 love births occur (MDG report 2013 p. 58). Maternal death ratios are highest in developing nations due impart to lacking healthcare infrastructure and poor resources when it comes to prenatal and post-natal care. Maternal death is the result of the delicate interplay between the availability of healthcare and poverty. It happens because of the disparities between certain demographic processes and the human right to life. The culturally acceptable low social status of women along 7 with the contributing factor of poverty and insufficient healthcare to support them often place them in a detrimental position. An African woman has a 1 in 16 chance of dying while pregnant, during labor or shortly after, while in developed nations, those chances skyrocket to 1 in 4,000 (United Nations Children Fund, 2012). The web of root causes leading to maternal death is complicated and so interconnected that one outcome is often the symptom of another. What is interesting about this topic and its importance is that the success of a developing nation is often gauged by its success of its female population. However, despite countries in Africa making this a priority by suggesting new policies to enforce change, there are countries in which very little implementation of new health policies has happened despite decades of “how to” strategies. Among these countries are Eritrea, Ethiopia and Kenya. All three have differing MMRs. What explains their progress or lack thereof in regard to these different outcomes? What are the differences in healthcare infrastructure that these countries offer women? In trying to answer these questions I will focus on two subtopics that impact maternal mortality: poverty and the availability of a supportive healthcare system that could increase the survival rates of these women. These two specific areas seem to be the determining factors in what is making a difference. Whether it be policy implementation that is affecting hospital technology and growth or a better healthcare system in general, something is working for Eritrea and Ethiopia while Kenya still lags far behind. Within the context of extreme poverty, and with research conducted, there is no doubt that the health of a nation’s female population in regard to its maternal health can be traced back to poverty and the ability to seek available and timely health care. Poverty is the first factor to be considered when researching maternal death. Without the necessary means to afford the appropriate healthcare poverty is a direct link to 8 higher MMRs. Income level determines access to healthcare, food and water as well as emergent obstetric care. 9 Methodology Maternal Mortality is a global issue with this greatest numbers in Africa. Nations within Africa have agreed that maternal mortality rates need to decrease within the continent's developing countries. In order for them to participate globally more emphasis needs to be placed on Women's Health. To better understand this issue, I have researched three countries that have differing MRRs: Eritrea, Ethiopia and Kenya. Two subcategories researched in regard to their intersection with maternal mortality Our poverty and health care. In order to understand the depth of maternal mortality and the significance of the problem, I first looked at statistics. This allowed me to answer the basic question of how many mothers are actually dying within the timeframe of during and 42 days post birth defined by the WHOs the definition of maternal death. To get raw numbers, primary sources such as United Nations International Children's Fund (UNICEF), the World Health Organization (WHO), the Organization for African Unity (OUA), in the United Nations Population Fund (UNFPA) Were used to explain where these countries rank in terms of maternal mortality rates. I also looked at articles published by the World Bank and the UN Millennium Development Goals report from 2008 to 2013 As well as the MDG gap task force report of 2015. Kenya posed a unique challenge as recordkeeping regarding this issue was and remains very poor. Current statistics are mostly unavailable. There is one article from the East African medical Journal that dates back to 2001 that was obtained in order to gain some insight. The World Bank in the United Nations population fund our resources that I researched regarding donors and programs to help pregnant women and the cycle of death due to poverty. I then researched sources related to the United Nations Millennium Development Goals 1 to 10 better understand the depth of the crisis. This included looking at global poverty reports, individual country scorecards throughout the Campaign on Accelerated Reduction of Maternal, Newborn and Child Mortality in Africa (CARMMA) and the United Nations development programs. Lastly, I was able to have two one on one interviews. The first regarding poverty with Caleb David, founder of The Table Initiative who facilitates short-term medical trips to Ethiopia and has been a pioneer in understanding Ethiopian culture of poverty and why the cycle of extreme poverty is so hard to break. The second interview was with Dr. Mark Karnes, a obstetrics and gynecology specialists that serves at Soddo Christian Hospital in Ethiopia. In 2014, while on the ground in Ethiopia I also had the distinct privilege of visiting the Hamlin fistula hospital founded by Catherine Hamlin, for deeper insight into the perils of childbirth within Ethiopia. The second component contributing greatly to maternal mortality is access to health care and two sub questions are answered. Why is healthcare inaccessible and what level of health care is available? To answer these questions, I looked at several articles by scholars with varying opinions on the issue of health care for African women. Specifically, the articles Access to essential technologies for safe childbirth a survey of health care workers in Africa and Asia published by BioMed Center in 2013 and what is needed for health promotion in Africa band aid, Live Aid or real change? by Sanders ET al. These two articles define what essential health care is, how Healthcare is affected by poverty and gives recommendations to solve the crisis. Another article used that showcases the intersection between gender disparities and health determinants of women is by Nancy Fugate Woods. Her article A Global Imperative: Development, Safety, and Health from Girl Child to Woman argues that gender disparities from 11 birth of a female child into her adult womanhood caused the health determinants she will experience all her life. Activism on this topic of human rights was also explored by reading the article activism working to reduce maternal mortality through civil society and health professional alliances in sub-Sahara Africa by Ray, Madzimbamuto and Fonn. Both of these articles mentioned support the idea that having available health care is a human rights issue. The question about health care for women was explored by reading the articles Understanding Global Trends in Maternal Mortality by Brown at all, as well as Africa and the Millennium Development Goal Constraints and Possibilities by Aleyomi and IseOlorunkanmi. The book Endangered Bodies: Women, Children and Health in Africa by Falola and Heaton was also a general reference for healthcare in Africa. Reproductive health reports and policy involving strategies for each country were also researched. Several articles from the individual countries were analyzed. For Eritrea these included the Journal of Eritrean Medical Association 2007- 2008. Country specific government documents were researched such as the Executive Board of the United Nations Development Program, the United Nations Population Fund and the United Nations Office for Project Services: Final Country Programme document for Eritrea 2013- 2016. UNICEF articles such as Eritrea Country Programme Document, 2013 2016 were read. Lastly World Bank country overview for 2012 was researched. Articles that were country specific to Ethiopia included the Federal Democratic Republic of Ethiopia Ministry of Health National Reproductive Health Strategy 2006- 2013, and the World Bank country overview for 2013. I had the opportunity to travel to Ethiopia in 2013, 2014 in 2015. I was able to visit two hospitals: Sodo Christian hospital located in Sodo, Ethiopia (about 12 five hours Southwest of Addis Ababa) and the Hamlin Fistula hospital founded by Catherine Hamlin. While at Soddo Christian Hospital I interviewed Dr. Mark Karnes, the only OB/GYN on staff. This discussion included questions regarding the biggest obstacle he faces while practicing, what types of complications he sees, how many deaths occur regularly and what the current state of Women's Health is at this point based on his experience. Researching Kenya's current state on poverty and healthcare proved more difficult. Finding recently written articles, whether scholarly or government policy documents proved challenging. First, I looked at the World Bank's country overview that was updated in October of 2019. Next, I read articles from USAID on the health policy initiative, specifically Achieving the MDGs: The Contribution of Family Planning in Kenya and the Adolescent Experience in depth using data to identify and reach the most vulnerable young people, Kenya 2008 to 2009 by the UNFPA and the population council. This provided Maps, tables and graphs to better comprehend data based on demographic health surveys for Kenya. Other articles used specifically geared towards Kenya's economic and social improvement was the Final Country Programme Document for Kenya 2009- 2013 by the Executive Board of the United Nations Development Program as well as the United Nations Population Fund. These articles outlined Kenya’s current problems, what had been done to correct them in the past and what was learned to push forward for better achievement of the country’s goals. Other articles that contributed some helpful information were Kenya Adolescent Reproductive Health and Development Policy: Implementation Assessment Report 2013 prepared by the National Council for Population and Development (NCPD), Division of Reproductive Health (DRH) and the Population Reference Bureau (PRB), the Community 13 Midwifery Implementation Guidelines in Kenya prepared by the Ministry of Health and the Use of Personal Digital Assistance for data collection in a multi-site AIDS stigma study in rural South Nyanza, Kenya published in African Health Sciences Journal by Onono et al. This last article touched on Kenya's lack of record keeping and experimented with using PDAs to assist physicians and medical staff with better record keeping habits. 14 Research Results: Poverty According to the World Bank there are approximately 21% of people in the developing world living in extreme poverty. Extreme poverty is defined by “a condition characterized by severe deprivation of basic human needs, including food, safe drinking water, sanitation facilities, health, shelter, education and information” (Webster’s Dictionary). This translates to roughly one point 22 billion people living on less than $1.25 a day period of the people living in extreme poverty 70% of them are women (Woods, 2006). Africa carries the largest burden with approximately 40% of people living in extreme poverty. Given these statistics there is no question that poverty is the beginning linked to increases or decreases in maternal mortality rates (MMRs). This is why eradicating poverty is listed as the number one goal in the Millennium development goals (MDGs) agenda. The thought is by eradicating poverty people are lifted to a higher standard of living and all other seven MDG's would be obtainable. All of the MDG's work closely together, therefore achieving one goal would mean achieving success of the other seven goals would likely follow. The problem with this theory is finding the link between the other goals and MDG one (see pg 4 & 5). MDG 5 “is often challenged to explain its linkages to other parts of the MDG agenda, such as the conventional poverty targets in the MDG 1” (Haug 2011). poverty has many dimensions and for it to be analyzed, all sections of the demographic processes, like gender inequality, reproductive rights and the low social status of women must somehow fit into the puzzle. Werner Haug and the UNFPA agree that certain demographic processes affect both the micro level (directly affecting the household) and macro level (policies and strategies that affect infrastructure and economies) that eventually affect those same households indirectly. 15 Poverty reduction is not just about providing a higher income, but “in the wider sense of providing decent minimum living standards and social services to all” (Haug, 2012). poverty reduction is not about paying people more money for a service but implementing strategies that include protection of the non poor from falling into poverty situations (United Nations population fund, 2012). it also includes strategies containing sustainable infrastructure that keeps groups from falling back into poverty situations once progress is made. There are two approaches to understanding poverty; the capabilities approach in the income approach. Both are used to conceptualize poverty and in order to understand why one is favored over the other, it's important to understand both. The capabilities approach is broken down into three categories that look at an individual's life as a whole rather than just their income. By definition; The capabilities approach distinguishes between 3 levels of conceptualization of poverty: the resource level (income, rights, and entitlements), an intermediate level of “capabilities “, in the level of so called “functioning’s”, IE actual results in terms of the different elements of the quality of life that individuals may aspire to: health, education, material comfort, quality of the environment, political participation, dignity and respect, etc. Capabilities are defined as the set off possible functioning’s from which an individual can choose (UNFPA, 2012) This is a sufficient approach when looking at how a person's life changes as a whole with poverty reduction, however it is limited by the assessment of what an individual chooses to do with and improvements in one's functioning’s. The capabilities approach is often confusing with its terminology because options used by the individual are personal choice, making it almost impossible to measure. The second approach used to assess progress of the MDG one is the income/ consumption option, but with elements of the capabilities approach included. this approach not 16 only takes into account the income being brought into a household “but also rights and other entitlements “of those individuals (UNFPA, 2012). income solely by itself cannot be the only measurement used to determine whether or not a household of people is impoverished. “For household income to translate into poverty reduction it must be complemented by a set of other resources” (UNFPA, 2012). For this research paper and the probable links to maternal mortality, I have used the poverty by income and consumption approach. Using this approach, it was clear that there are indirect and direct effects that contribute to poverty, thereby affecting MMR's. “for example, direct affects act on the components that define poverty; Namely income or consumption, indirect effects act on the ability to earn an income such as lack of education or disease. These are further divided into actual consequences of poverty such as the health of children, early marriage (any union before the age of 18), or maternal mortality. While it is necessary to understand what directly and indirectly affects one's poverty level and the consequences that stem from poverty, maternal mortality rates have little to do with poverty itself according to the United Nations population fund. “Poverty is about living condition of individuals and households” not the health and well-being of a nation's female population. Their stance is poverty has more to do with population, economics and human capital than an increase in reproductive services being utilized. human capital is defined as the skills, knowledge and experience possessed by an individual or population, viewed in terms of their value or cost in terms of an organization or country. Yet other researchers have determined this is not the case. The same direct causes of poverty such as education, early 17 marriage and harmful traditional practices (HTP) most certainly act as determinants of Women's Health including maternal mortality rates (Woods, 2009). Maternal mortality rates themselves have direct and indirect causes, which may or may not stem from poverty itself but from a lack of resources. Without access to improved health care before, during and after childbirth due to socioeconomic status health would decline. many may believe that poverty does not have a strong direct link to maternal mortality, but it certainly has a direct link to overall health which includes health during pregnancy. Comparison of Three Countries Eritrea When trying to connect the economy of a nation with maternal mortality rates and comparing the three economies of differing countries (Eritrea, Ethiopia and Kenya),eritrea's MERS are on track to meet the MDG five goal. They were also “one of the fastest growing economies in 2011” (World Bank, 2012). this allowed for the Eritrean government and stakeholders such as UNFPA, World Bank and UNICEF to invest more money into developing strategies to increase health infrastructure to support its people. Increasing health infrastructure has a chain reaction that reduces the number of people living in poverty and increases the number of those same people that have access to health services, therefore reducing the country's maternal mortality rates. In 1990 the estimated number of maternal deaths in Eritrea was 1400 per 100,000 (UNICEF, 2013). that number has steadily decreased to 240 per 100,000 in 2013. With this type of number and percentage change Eritrea “appears to be one of the few African countries set 18 to achieve MDG 5” (UNICEF, 2013). again, the World Bank realizes data collection is lacking stating “although up-to-date comprehensive data on outcomes has been a challenge” Eritrea is fast improving. The Eritrean government along with donor support has been able to invest in its own health infrastructure at a higher percentage rate of the government's overall expenditures on poverty reduction in health. The population continues to grow and while the government is able to invest more increasing human capital, 65% of the population remains impoverished (UNICEF, 2010) yet progress is still being made. Ethiopia While Eritrea is on track at eradicating poverty an effectively reducing MERS, it's African neighbors Ethiopia and Kenya are at differing points developmentally. Ethiopia's population stands at approximately 109.2 million people (World Bank, 2018) making it the second most populous nation on the continent. It is also one of the oldest and poorest in terms of living conditions ranking number 20 in the top 20 poorest countries. However, the economy “has experienced strong and broad-based growth over the past decade”, averaging 10.6% per year from 2004 to 2012 (World Bank, 2013). Ethiopians per capita income is 953 US dollars annually and is lower than the regional average. Due to the rapid growth of the economy the percentage of Ethiopians living in extreme poverty has steadily dropped since 2000 which was 44% (World Bank, 2019). Currently the percentage hovers around 29.6% which is measured against the countries national poverty line of $6 per day. This rapid growth has allowed the increase of human capital allowing the government to slowly devote “a very high share of its budget to pro poor programs and investments” over the last decade (World Bank, 2013). 19 In fact, in 2009 the African Union launched CARMMA, the Campaign on Accelerated Reduction of Maternal, Newborn and Child Mortality. At that time, 15% of The Ethiopians government expenditures were designated to health-related investments including emergency obstetric care recognizing the link between poverty reduction, government investment in health infrastructure and MRRs. With the help of the African Union (AU) the “crisis of high maternal death was placed firmly on its agenda” (CARMMA, 2020).These pro health programs supported by the government are beginning to shift the maternal mortality numbers into a more positive direction this is most certainly a reason why Ethiopia’s MRRs have dropped since CARMMA's launch in 2009. With greater infrastructure the benefits of investing to reduce poverty allows for the success of and the transition into, the Sustainable Development Goals of 2030. Caleb David, founder of The Table Initiative, which facilitates short-term medical missions’ trips to several countries, including Ethiopia, states “Solutions to poverty are going to be different because the cultures within these communities are different. There cannot just be one answer that fits all. Just pushing aid through does not educate a culture or community on sustainable poverty reduction strategies.” Nancy Woods (2006 ) agrees stating “to be effective, these interventions also must be sensitive to the specific values and constraints of the ethnic, cultural, racial or social group” in which these marginalized groups namely women, live. David spoke to the detrimental effects of policy and aid that continues to pour into these countries seemingly without an afterthought of how this creates a culture of dependency the dependency happens “because there are so many factors that contribute to poverty; health food insecurity, cultural constraints for groups that literally have nothing.” 20 When asked about the role of women within poverty reduction strategies, David's first response was to comment on the total absence of men, at least within the sphere of the Ethiopian culture. He explained that the absence of men helping to carry the burden within the family was a huge issue stating “if you put women to work 90% of their paycheck, no matter how small, will go towards her family but if it is a man he is more likely spending it on himself and roughly only 40% of his paycheck comes back to the family .” In considering these numbers, evidence shows that women tend to put the needs of their families before their own, even to the detriment of her own health. When asked about the roles of Non-Governmental organizations (NGO’s) and their role within the cycle of poverty David's belief is that a complete overhaul is necessary within their system. When governments make policy regarding social or economic change, most of the time it helps the already rich and the middle class leaving those in the most desperate need suffer more. “That is where the safety net of having the NGOs step in helps,” he states. However, in David's opinion aid is often a crutch and should only be used for a limited amount of time and not something to sustain a group of people. Aid creates a culture of dependency not empowerment. Some marginalized groups realize that they get more help by not working and depending on handouts rather than trying to escape the poverty trap. At the same time a helping culture has been created where mostly westerners go into a country on the ground wanting to fix problems by providing a solution rarely is it thought all the way through to the end and oftentimes there is no follow up years later to see if the solution is even working. 21 Organizations must understand what the core issues are, and there needs to be long term commitments to understanding cultures if real poverty eradication is to happen it is right to supply aid, yet it has to be monitored very closely so that resolution can occur. Kenya In contrast to Eritrea and Ethiopia, poverty reduction in Kenya is stagnant. Almost no progress has been recorded since the development of the MDG's. In 2005, 47% of the Kenyan population was below the poverty line, almost half of Kenya's estimated 43.2 million people. Based on the last household survey conducted in 2006, that number had only declined to 42% (World Bank, 2013). In 2012, only 6% of the government expenditures were designated for the progression of healthcare related infrastructure. no further data has been collected or reported due to the “high illiteracy levels in the local communities, lack of skilled data collectors, and inadequate infrastructure including unreliable telecommunications networks” (African Health Sciences, 2011). Kenya is still a relatively young country having achieved independence from the United Kingdom in 1963 in comparison to Eritrea and Ethiopia. Their last election was held in August of 2017. Their government has only cycled through 4 presidents and has been riddled by unrest, corruption and election fraud. In 2017, 37,000 voter cards were rejected due to invalid or blank notes. Intergovernmental party violence has occurred after every presidential election, which are routinely contested. In August of 2013, a major fire at Jomo International Airport left it inoperable and then in September of 2013, terrorist attacks at an upmarket mall in Nairobi 22 crippled the government. These have been only a few events which have distracted the government, disrupting policy making and then implementation. Factors that continue to affect Kenya's poverty reduction strategies include week health infrastructure, a weak public sector in new developing governance. Kenya's economy is predicted to grow based on World Bank estimates from 4.6% per year in 2012 to 5.8% per year in 2013. This growth trend is sure to bolster the infrastructure that is severely lacking. However, these estimates are based on information and data sporadically updated since 2006. Kenya's “economy is still operating below its potential and remains vulnerable to external shocks which undermine its prospects for growth and poverty reduction” (World Bank, 2013). While government programs are working hard to increase human capital creating jobs the population continues to grow making the percentage of those living in extreme poverty difficult to tackle. The list of major challenges for Kenya to achieve the MDG's by the deadline of 2015 included “delays in the flow of funds from Treasury to government agencies” (UNFPA country program 2008) along with lacking managerial skills and preparedness for political and humanitarian crises. It seems that through research Kenya has plenty of policies and programs initiated but implementing them proves to be the biggest challenge. The lack of implementation is what's driving Kenya’s maternal mortality rates higher rather than reducing them. The lack of adequate funds to help Kenyans lift themselves out of poverty thereby achieving MDG one is what will keep Kenya from essentially achieving MDG 5 along with the others. Poverty reduction has a synonymous relationship with key factors that contribute to either the reduction or increase in maternal mortality rates for example, Kenya’s population 23 continues to grow increasing the amount of people living in poverty. When the Kenyan government is able to have higher investments in factors such as reproductive health, fertility rates dropped because this enables women to have more decision-making power over their own fertility. This allows for smaller families “to share income among fewer people” (UNFPA, 2012) thereby increasing the overall household income. Smaller families also tend to make higher investments in their own children, which continues to break the cycle of generational poverty. Policies and government programs, outside stakeholders and donors have to realize that country program strategies may appear to reduce poverty on paper but without implementation and measurement no real success of reduction is possible. 24 Research Results: Healthcare Second to poverty eradication, the need for sufficient health care still remains a huge obstacle even though Africa is making some progress. Healthcare and MMR's have a direct link in terms of success rates. “The combination of factors that contribute to maternal death flags fundamental health system failings and can seem so complex that it is hard to know how to start the chain of actions to address them” (S Ray et al, 2012). Government owned facilities have traditionally provided adequate or essential health care in most African nations yet resources to these facilities are lacking. “Resource allocation to the health sector remains inadequate to support the delivery of quality services that would promote health” (CARMMA, 2012). The monetary resources allocated within these governments to provide health care are often insufficient and “few have developed health promotion policy, and even fewer have implemented them” (critical public health, 2008). Essential health care must meet specific guidelines published by the World Health Organization (WHO) along with other contributing medical associations who have expertise in “standard practice is proven to promote the safety of mothers” (BioMedical, 2013). these guidelines offer structured that when adhered to, reduce MERS. These guidelines addressed the whole spectrum of obstetric care including training essential health care workers, how many antepartum visits should occur, the necessary steps in recognizing and preventing pregnancy related complications and postpartum care. While researching this portion, it became evident that healthcare in Africa generally has two major problems, the lack of available healthcare altogether and the lack of trained health care workers necessary to provide services when available. An outlying problem also affecting 25 available health care for women is gender inequality and the right to health care in the framework of a human rights approach. Nancy Woods (Global Imperative, 2009) contends that the disparities in health that women experience are a direct effect of gender inequality. She argues that demographic processes of social behavior not only affect poverty and a woman's household but also cause distal and proximal determinants of health in women until cultural change occurs women will continue to receive substandard health care period therefore gender inequality is a part of the health and directly linked to maternal health. Addressing health care as a whole is overwhelming and very complicated. The term “health care” is broad when actually Healthcare is made of many smaller pieces that work together for a successful outcome. These pieces include but are not limited to, the number of health care workers such as physicians, nurses and midwives, supplies and essential health technologies. Essential health technologies are defined as equipment, medicines and consumable supplies essential to ensuring successful childbirth practices proven to prevent maternal death (BioMedical, 2008). health care also refers to the quality and types of services provided at differing types of facilities. Maternal mortality has many causes and “most maternal deaths are clustered around the time of delivery” (BioMedical, 2013). maternal death has direct (a complication of the pregnancy) and indirect (pregnancy related death with a preexisting health problem such as HIV or malaria) causes with associated risk factors. These risk factors have three major components that researchers agree contribute to maternal death: delays in seeking care, reaching care in the care provided. The leading causes of direct maternal death are “maternal hemorrhage (34%), preeclampsia/eclampsia (19%), unsafe abortion (9%), sepsis (9%) and obstructed labor 26 (African Union, 2012) all of which “can be treated at a well-staffed, well equipped health facility” (UNFPA, 2012). Definitions of these terms are as follows: preeclampsia is when a pregnant woman develops high blood pressure in protein in the urine after the 20th week of pregnancy, eclampsia is the progression of preeclampsia into seizures not related to an existing brain condition (National Library of medicine), and sepsis is a total body infection in response to bacteria or other germs and is extremely life threatening. Comparison of Three Countries Eritrea Since the establishment of the MDGs, Eritrea has come a long way in reducing the nation's maternal mortality rates. The Eritrean nurses Association (ERINA)and the Ministry of Health report that since 1990, when MMRS were as high as 1400 per 100,000 live births, the rate has dropped to approximately 240 deaths per 100 live births in 2014. The infrastructure of the Eritrean health system is based on the levels of care that a facility can provide in terms of maternal health this simply means how well and how equipped a facility is to handle an obstetric emergency. When analyzing the Eritrean healthcare system it is important to understand which facilities are responsible for what type of care in order to understand the successes and failures that lie within this type of health care system. Eritrea is almost 47,000 square miles in size. The population hovers around 3.5 million and “60% of the population consists of women of childbearing age” (World Bank, 2010). Eritrea is divided into 6 zones called zobas, 58 subzones, 704 administrative areas and 2580 villages. There are approximately 258 facilities, 18 hospitals, 27 47 health centers and 50 three health stations. Eritrea's health facilities are divided into 3 levels and are supposed to work as a referral system with patients arriving at the lowest level capable of treating them. The government owns most facilities, while 12% are NGO related and one for profit National Hospital owned by the Ministry of Health. The 50 three health stations have the lowest level of care and are found in the most rural areas of the country. They can handle prenatal visits and could assist in a normal delivery but with untrained staff. Visits include information on family planning such as spacing birth but nothing further. These health stations are totally unequipped to treat any major birth complication or obstetric emergency such as obstructed labor or unsafe abortion. Due to the lack of quality care at these lower level stations most women go directly to the National Hospital even for normal deliveries when they are able. The second level of health care is available at the 47 health centers or community hospitals. “Most health centers only managed normal deliveries” and they “focus on management of normal deliveries, provision of basic emergency obstetric care and the referral of mothers and newborns with complications” (Journal of Eritrean Medical Association JEMA, 2008). basic emergency obstetric care includes the administration of antibiotics in oxytocin, anticonvulsants/sedatives, manual removal of a retained placenta, retained products from unsafe abortion, assisted vaginal delivery as well as breach, sometimes blood transfusions, administration of magnesium sulfate which stops preterm labor and neonatal resuscitation. The system relies on referrals and because women go straight to the highest level, these community hospitals which could offer assistance never reach full capacity. This causes the National 28 Hospital to be overcrowded and the staff overworked by an unrealistic workload While leaving these lower level facilities with untrained staff. The National Hospital provides the highest level of care necessary called comprehensive emergency obstetric care (CEmOc)for complicated births including all of the aforementioned basic emergency obstetric care (BEmOc) plus blood transfusions and cesarean sections. The National Hospital however is not the only facility to offer CEmOc, as eleven out of the 18 hospitals (some community hospitals) we're able to offer this service because they had surgical theaters. Women receive better quality care at these facilities because most of the hospitals are equipped to perform comprehensive emergency obstetric care in most health facilities in “Eritrea have at least the minimum acceptable level of essential equipment, supplies and drugs for the functions they perform” (Journal of Eritrean Medical Association, 2012). The air train health system has many successes yet has areas where it is lacking. Due to the high number of available hospitals, one in every zone, Eritrea is successful in providing accessible care to most women. The downside is most of these hospitals are clustered around the central part of the country making it difficult for women in rural areas to travel the distance in case of emergencies. “The mean distance from Zoba referral hospital to the nearest referral facility Is 191 kilometers (118.6miles). similarly, on average the patient has already traveled at least 81 kilometers (50.33 miles) to even reach a referral facility from a Community Hospital” and at least 42 kilometers (26 miles) from the smaller health stations (World Bank, 2010). to make this clearer, if a woman experiences complications in a village at her home Anne she follows the referral system, she will travel to a health station first, which then would refer her to a community or Zoba hospital, which then in turn may send her to the National 29 Hospital (or a hospital with emergency obstetric care capabilities) for a C-section (or whatever emergent care she may need). this may take her well over 200 miles before she receives any immediate care. This is a good example of the delay in care that increases her chance of death among other consequences of delayed or prolonged labor such as birth injuries. “Traditional practices around childbirth, which encourage women to give birth at home, especially for the first time with people around her who lack the appropriate training, increase her chances of maternal death significantly (World Bank 2016). Other hindrances include the lack of transportation from health centers to the community hospitals and then on to the referral hospital. The distance and time taken to reach a facility is often detrimental as yet again the care needed is delayed. The availability of “an ambulance or vehicle is the worst for health stations and centers which are the facilities that should refer the most” (JEMA, 2007). having a clean water supply is always an issue in almost all the facilities “needed to improve access to functioning washrooms” especially in those that admit patients “namely community hospitals and health centers” (JEMA, 2007). the same hospitals need to also address the lack of functioning laboratory services as well as an on-site blood bank's only seven of air tray is 118 facilities have one (World Bank, 2010). If a woman is able to reach her destination, staffing remains an issue. There are approximately 17 obstetricians/gynecologists available within the entire country of Eritrea. They are mostly based at the Community Hospital level in the referral hospital. Nurses and midwives who in actuality have very little training, staff health centers and stations. This “creates a high degree of pressure on the existing workforce at the higher levels” (World Bank, 30 2010). The inexperience and inadequate training caused women to bypass these lower level facilities and seek care at the community hospitals whether they have complications or not, thus overcrowding and overworking the providers at the higher-level facilities with normal uncomplicated births. “Providers at the lower level facilities do not receive a large number of patients and so are not sharing the proportionate burden of work” (World Bank, 2010). “The biggest constraint facing the air train health system in general, in providing good quality of septic care specifically, is the severe shortage of health care providers” (World Bank, 2010). until the air train education system becomes better at equipping potential providers and appropriately training clinical staff the lack of professionals will always be an issue. Midwives and nurses seem to be available, yet they are unable to perform complicated procedures and usually have very basic clinical skills. With this being said, the government cannot tell a woman where she must deliver nor can a referral facility turn her away because she is not having complications. Despite all this the Eritrean health system seems to be maintaining and in fact improving each year, but “appears to be walking a fine line between maintaining current levels of quality and becoming potentially overwhelmed by higher demand” (World Bank 2010). the increase in patient load at the community hospitals is clearly an indication that there is immense pressure on the health care infrastructure and referral system at this time in date. Ethiopia Ethiopia, like Eritrea, with each level providing various types of care these health services are provided by the public sector in between 2000 and 2005 Ethiopian government, to 31 increase the number of available facilities, initiated a huge push. As stated in the national Reproductive Health Strategy for 2006-2015, the number of hospitals raised from 110 to 131, health centers increased from 382 to 600, and health posts increased from 1,032 to 4,211. This may seem like a drastic increase in services and facilities yet considering Ethiopia's vast 1,104, 300 square kilometers and it's 109 million people, access to some type of facility still remains a great challenge. Ethiopia’s hospitals have a total of 11,296 beds which comes to 1 bed per 3,734 people. The increase in health centers and health posts has proved to increase the availability of care, but many have no physician. Overall there is one physician for 57, 876 people but in the Southwest in West central Ethiopia one physician can serve as many as 200,000 to 300,000 people. In rural areas where 90% of the population lives, 85% live at least three days by foot from a rural health unit. In 2009, the African Union (AU) located in the nation's capital Addis Ababa, implemented the Campaign on Accelerated Reduction of Maternal, Newborn and Child Mortality (CARMMA). With this new organization in the policies set in motion, there was a great push to expand and improve Women's Health in order to achieve MDG five. Due to Ethiopia’s high MMR at the time, it was part of the continental launch prioritized by CARMMA to increase the health sector funding to improve maternal health. This new initiative has worked, and Ethiopia’s MMR has dropped from one of Africa’s highest at 870 deaths per 100,000 live births to 350 deaths per 100 1000 live births. This drop is partly due to the number of women seeking prenatal care as a result of karma, where complications may be determined early on and prepared for. However, access in the “underutilization of modern healthcare services are major reasons for poor health” 32 (Ragassa, 2011) among Ethiopian women. Health care strategies within Ethiopia face a unique challenge of overcoming longstanding traditional cultural practices that perpetuate women's low social status. “Women's Health is directly affected by the social an institutional context in which they live” (ET national reproductive health strategy 2006 to 2015). the government in participating NGOs must also involve and educate the community in which women live. Due to high fertility rates with the average Ethiopian woman having a total number of seven pregnancies (CARMMA) and approximately 5 to 6 live children (UNICEF) the causes of maternal death are different in Ethiopia than its neighboring country of Eritrea. Unsafe abortion is the leading cause along with uterine rupture (32%). Other causes include obstructed labor at 22% (Ethiopia being the country with the highest fistula rate in sub-Sahara Africa) sepsis at 12% hemorrhage at 10% and hypertension at 9%. Within the last several years the government has tried to increase the number of women delivering in a health facility. In order to implement this, the health care system is currently being reorganized from a 6 to a four-tiered system. These systems will include Primary Health care units, district hospitals that will serve 250,000 women, zonal hospitals that will provide “services in four basic specialties for one million people” and “specialized hospitals that provide subspecialists care in clinical training” (Ministry of Health 2006 to 2015). Ethiopia is trying to include all areas of basic health together to reach the more rural populations outside of its major cities. Family planning, disease prevention, personal hygiene and health education will be provided by health extension workers (HEW), which will accelerate the effectiveness of the outlying health stations. The HEW will provide community-based education as well as health services. The government is implementing strategies that include 33 the communities in which these women live to systematically reduce the health system's shortcomings. The Ethiopian government realizes that households and communities “are vehicles of change” in reducing the country's maternal mortality rates. The government is providing care where it is needed most, and they understand that family and community is key (Ministry of Health 2006 to 2015). The biggest hindrance facing the Ethiopian health care system at this time is the lack of facilities and human resources available it is important to begin training and using Nationals as staff in order to build the infrastructure of a solid and sustainable healthcare system. The demand is there but the providers and facilities are not. According to Dr. Mark Karnes from Soddo Christian Hospital, women in Ethiopia want to deliver in a hospital or a health center. The problem is there are simply not enough resources, facilities or trained staff. Just for perspective, Dr Karnes in 2014 was one of only three OBGYN's to serve the entire country of Ethiopia. There are less than 7,000 trained midwives in Ethiopia (Hamlin Fistula Hospital). In 2009 statistics showed there were only 78 radiographers located in Addis Ababa, 20 of which were considered radiologists and none in three hospitals. Ethiopia’s government recognizes this Shortcoming and has worked tirelessly to engage young people in medical health care professions. Dr. Karnes states that “within the next several years or even decade, these health care facilities will be fully staffed and ready to take on the population of women ready to give birth in a hospital rather than at home.” Kenya In comparison to Eritrea and Ethiopia who are making great strides in reducing their maternal mortality rates, Kenya is far below acceptable standards. Maternal mortality is an 34 issue the Kenyan government has been trying to address for several decades starting in 1987 with the Safe Motherhood Initiative launched in Nairobi. Kenya’s “Objective of reducing MMR's by 50% within 10 years” (East African medical Journal 2001) was just the beginning of a long battle in which not much has changed. The health care sector within Kenya is lacking on all levels. The Ministry of Health is the major health provider and operates 1957 facilities; Of which 97 are hospitals, 487 R health centers, 1322 dispensaries and 57others (East African medical Journal 2001). research and data collected from these facilities is outdated and essentially nonexistent in some situations. Kenya does use ICD 10 codes (international statistical classification of diseases and related health problems) for diagnosis during care, which is progressive as the United States is still transitioning from ICD 9 to ICD 10's, yet “all records kept in the facilities were extremely poor and did not therefore give a true reflection” (East African medical Journal 2001). unorganized record keeping or a total lack thereof makes it extremely hard for outside stakeholders in groups like UNFPA or UNICEF to analyze the problem making it difficult to know where to funnel funds for health infrastructure improvement. “Records were poorly kept in almost all 30 facilities. Entries in the registers were erratic, in some cases missing for several months. Most facilities did not have a specific register for obstetrics. Where present, much of the important information such as maternal/fetal outcome in complications would be missing. It was evident that no effort had been made to organize records making it obvious that they were not being used regularly for any purpose, including planning monitoring and supervision” (Rogo et al 2001). Without accurate records, strategies to combat maternal mortality are hard to conceptualize. No one knows where to begin when real numbers are unknown. The Kenyan government is aware that there is a definite problem, but statistics are unable to be gathered due to the poor record keeping. 35 As in the two countries previously discussed, the shortage of staff and medical supplies is another major setback to achieving any progress within the Kenyan health sector. Research conducted by the East African Medical Association found most facilities within Kenya were both understaffed. When medical staff were available, the EAMA found them to be grossly undertrained and lacking the appropriate credentials. Basic medical supplies like syringes, intravenous supplies, speculums or forceps were lacking or non-existent. Most staff accepted this to be the norm. Drugs such as Oxytocic’s or anti-convulsants were either permanently out of stock or only available in short supply. The District Hospital was the only facility able to handle an emergent cesarean section due to available operating theatres and equipment, as well as the only available OB/GYN capable of performing surgery. “The District Hospital, for example had as establishment for six physicians” on of which was an obstetrician/gynecologist. The hospital usually runs with one, maybe two physicians and no OB/GYN is available even for consultation on complicated cases. Transportation is the second issue. Almost all of Kenya’s health facilities lacked any type of transportation whether from a health center to a referral hospital or from a home to the nearest health station. Any sort of “ambulance” service is non-existent. Patients either had to walk or “were carried bare back or on a wheelbarrow” (JEMA Rogo et al.). Women needing immediate attention, in more suburban areas could hire taxis if they could even afford them. “Time is crucial to the survival of women with complications” and transportation must be addressed by Kenya’s Ministry of Health if MMRs are to improve. 36 Conclusion Despite many differing variables between these three countries, one common factor that cannot be ignored when addressing maternal mortality and healthcare is human right. The monitoring of progress and implementing strategies that influence these rates has traditionally been assigned to the countries governments. The low social status of women and gender inequalities they experience often leave them powerless over their own reproductive health which leads directly to maternal mortality rates. This lack of choice along with the associated powerlessness perpetuates the cycle of maternal death, which ultimatly violates a women’s right to life. “Failure to reduce preventable maternal deaths represents a violation of women’s right to life, health, non-discrimination and equality” (S Ray et al, Reproductive Health Matters, 2012). States that signed the United Nations MDGs are “obliged to provide the necessary services of sufficient quality to prevent these deaths” (S Ray et al 2012). Researchers agree by turning the availability of healthcare into a matter of human rights will allow for these countries to be held accountable to act. By signing the MDGs the possibility of legally holding these countries responsible for human rights violations is an option, however, “women have to feel empowered enough to demand these types of rights” (Ray, Madzimbamuto, Fonn 2012). Healthcare may seem like an obvious right, especially to those that have it so freely. Yet healthcare in these countries is often seen as “a commodity to be bought by those who can afford it (S Ray et al., 2012). By framing maternal health in the context of a human rights-based approach, relationships between healthcare providers and patients become partnerships ensuring a good 37 outcome. The dynamics between gender equality and culturally traditional practices, such as women having babies by themselves or with a village doctor, must be addresses in order to see the links to maternal death. That is why it is vital important for community-based strategies to be implemented. Women and their surrounding communities must realize the importance of community support and play an active role. There are multitudes of contributing factors to maternal mortality. One of the easiest ways to organize the variables and how they link is by formulating a mind map. It is easy to see the consequences that a woman may face based on poverty, reproductive health and the availability of healthcare. The explanation and mind map follows: Mind map created by H. Casaday This mind map helps demonstrate the connectiveness of one variable to another that may affect the outcome of a young woman’s life. The red arrows indicate direct links from one variable to another. The green arrows indicate the consequences of one variable affected by another. 38 When a household lives in extreme poverty, the amount of money available to invest in children within the home already sets girls at a disadvantage as they are the most likely to leave school when funds become unavailable. This is a common situation that has several branches, each brand representing inconsequence. The first split occurs when she is pulled out of school to either find menial work, help at home or she is married at a young age. In these situations, her education stops. Without the continuum of her education she grows up less informed and with no job skills and unable to negotiate her rights. This is where the graph begins to branch again. If she becomes married, it is most often to an older man who may or may not already have several wives. With the increased exposure of several sexual partners within this union, the rates of HIV/AIDS begin to climb. These girls have no power within their relationship to their husband, which often leads to early sexual experiences an early first pregnancies. These girls are physically immature resulting in obstetric complications such as prolonged labor, obstructed birth or suffer from birth injuries such as fistula. In worst case scenarios, a complicated, unattended birth will result in the death of the mother and most likely the infant either at birth or several days after. Another branch of consequences follows. If she makes it through a complicated birth but is left infertile due to these complications, her husband may divorce her leaving her without a home, dependent children and no way to make money. In this case she may migrate to an urban area where she then often enters the sex trade in order to make a living and provide for her children. Within this context the rates of reproductive health issues, and HIV/AIDS is again increased, as well as the re occurrence of pregnancy thus continuing the cycle of possible maternal death along with increased poverty risk. 39 The other side of the graph has a much better outcome. If poverty is reduced, families have more expendable income to invest in their children. Girls stay in school, typically delaying marriage period this further education empowers them to make decisions regarding their own sexual health. This delays pregnancy allowing these girls to mature physically and have better family planning skills. As they are not a monetary burden to their family, they often stay at home longer which reduces the chances of early childhood marriage. As they continue their education and learn job skills, they enter the labor force enabling them to earn money that will eventually come back to their own families. The rate of HIV/AIDS begins to drop because they have more power to negotiate their own sexual rights because they are more informed. They tend to have fewer children themselves and are able to better care for a smaller family breaking the cycle of extreme poverty. All of these risk factors lead to lower maternal death rates as is displayed using the mind map. Maternal death is preventable. Policies, government programs, outside stakeholders and owners must realize that country programs are useless unless implemented. What explains progress or lack of progress in reducing maternal mortality rates? Implementation of strategies already in place is the factor that explains the reduction in maternal mortality ratios in these countries. The strategies have been created to combat poverty and health care issues directly affecting the statistics. Governments must decide that maternal death and health care are important enough to create real sustainable change throughout implementation period Eritrea has hit its target goal because the government, who has the ability to create strategies that affect maternal health, has done so and has made the health of the nation's women a top priority. Ethiopia is on track to having its maternal mortality rates because the 40 government is backing and implementing programs that work, even though Ethiopia remains one of the poorest countries in the Horn of Africa. Kenya has not implemented nor produced effective strategies that would enable the success of MDG five. Their government has taken on the responsibility to provide health care, yet they have failed to execute any real change. They have plenty of policy, plenty of ideas and programs on paper but are getting nowhere in terms of numbers due to the lack of implementation. The second factor that explains progress or the lack thereof in terms of maternal mortality is improvements in health care period Eritrea and Ethiopia both have made great advances in their health care system. Women want to deliver in a hospital. Providing the facilities to catch up with the demand in terms of health care workers still proves to be a problem. Kenya's health care system is proof that providing essential health care to women is a factor in whether or not a country is making progress in terms of maternal mortality. Kenya's health care system according to recent research needs a complete overhaul and then maternal mortality rates still continue to rise. Again, the government has plenty of policy in place even providing a community midwife free program, yet the implementation on most of these strategies is nonexistent. The differences in these countries that are achieving better rates is that they are moving forward with real programs, real change that affect women as a whole and implementing the ideas that work. It is important for future research to continue to find out what works. Research results can be broad and no one solution is going to work for every single community nor country. There has to be a real commitment from governments, NGOs, donators and other stakeholders if real sustainable change is going to occur. Outside pressure from other states needs to be 41 persistent. Big organizations like UNICEF, The Who and the UNFPA need to continue to address maternal mortality as a human rights issue and advocate for these women who are dying unnecessarily. The demand is there, now these African countries need to meet that demand. NGOs need to continue to stay informed listening to what people need being culturally sensitive to traditional beliefs not just implementing a program that may work somewhere else. As David states “people cannot just fly in and fly out, doing good for a short amount of time, but lack the follow up and the compassion and care needed for real change to happen.” There is no blanket solution to the problem of maternal mortality. Women will continue to die as long as the factors of poverty and insufficient healthcare remain. 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