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“I am appalled when I read various reports and publications on maternal and child health which show that in Chad maternal mortality remains high. In 2004, 1,099 women died for every 100,000 births, an increase from 827 in 1996/1997. This high rate of maternal mortality is caused by factors we fight each day: inequality between the sexes and the denial of women’s sexual rights; poverty and women’s poor access to health care services; the high fertility rate; violence against women in all its forms; young marriages and unwanted pregnancies”. Hinda Déby Itno, First Lady of Chad, 15th October 2009, during the launch of CARMMA (The Campaign for Accelerated Reduction of Maternal Mortality in Africa).
Three years after the First Lady made this declaration little progress has been made in fighting maternal and child mortality in Chad and women remain the primary victims of the precarious situation in which Chadian people live. Inequality between the sexes can be measured according to four principle indicators: participation in economic life; education; health and political empowerment. In terms of economic life, huge numbers of rural women are victims of poverty. They are largely illiterate and have a very poor level of human development, especially in terms of their health. Female participation in the formal sector of the economy is weak and women represent just 13% of civil servants. Women are also underrepresented in leadership positions, with around 20 female heads of department in central government out of a total 150. All of these indicators contribute to Chad’s ranking as number 133 out of 134 countries in the Global Gender Gap Index published by the World Economic Forum in 2011.
In addition to these sorry indicators, Chadian women constantly fall victim to sexual violence, forced marriage and unwanted pregnancies. These forms of violence are not considered to be violence as such, since they are very often committed in the context of marriage. In marriage the husband is traditionally ‘allowed’ to be the master and to treat his wife as he wishes. The socio-economic and cultural burdens which women in Chad are made to shoulder simply do not allow them to see a way out of their predicament.
The adoption of a family code could help put into place a legal system able to protect women from all these forms of violence. Yet the National Assembly does not seem to be passing this any time soon and in this context, the consequences for maternal mortality remain. As Mamadou Dicko, a representative from UNFPA, affirms, the situation on the ground is bleak: “a woman dies as a result of pregnancy or child birth ever two hours”. It is enough to consider just a few of these wasted lives to understand that the causes of these deaths are tragically avoidable.
In the last quarter of 2011, a woman employed in a local bank was admitted to hospital to give birth. The personnel in charge believed that she could deliver the baby, who was in breech position, by simply pushing. It weighed almost 6kgs, and she could not; she died trying on the hospital bed, and her child died too. Another woman, a housewife, was admitted to the hospital prematurely because of heavy bleeding. She lay there bathed in her own blood under the indifferent eyes of the midwives until she passed away.
These terrible tragedies occur on a daily basis and affect both rural and urban women. Their recurrence is all the more appalling since they are the product of the same old issues of limited access to health care, insufficient training of the personnel, poor awareness by health professions, and the lack of availability of medicines, technical services and appropriate equipment. A lot of work certainly needs to be done in order to reduce the level of maternal and child mortality but many issues can be easily resolved: “The Health Ministry must send qualified personnel in to the field and give them the resources they need” says Doctor Tchindjibé, chief doctor at the Baptist Centre in the Koumra District in the South of Chad.
In 2009, if we count all types together, Chad had around 4,936 health professionals. The Ministry of Public Health employed around 4,065 of these (82.3%) including 195 midwives. These numbers mean that only 16% of the female population benefited from contact with a professional when giving birth. According to estimates by the World Health Organisation in 2006, a minimum number of 2.3 doctors, nurses and midwives are needed for every 1,000 inhabitants. Today this estimate remains the same.
The government has invested in constructing a healthcare infrastructure in Chad and extolled the virtues of emergency obstetric care, yet these efforts have been misdirected. Many experts believe it would have been more logical to focus from the offset on training specialist doctors and health auxiliaries in order to directly improve access to specialist care for women. “I demand 275.344.600 CFA francs (around $500,000 US dollars) to save the lives of thousands of women” said the late Mme Achta Toné Gossingar, Goodwill Ambassador for CARMMA, during an interview with the national weekly newspaper Notre Temps (‘Our Time’). This was a paltry sum in its time, judged to be too high by the Minister of Public Health. Yet Gossingear's was a budget that would have given thousands of Chadian women better access to health care services for antenatal and post-natal consultations. Instead of this, the government invested in infrastructure: a national Mother and Child Hospital, 255 health centres, 60 district hospitals and 5 regional hospitals. These new centres are all very well, but they experience a significant shortage of medical cover and the quality of the service provided is weak. This is mainly due to the lack of qualified staff. Staff employed by the Public Health Ministry include 1,158 care assistants, 846 support staff, 489 state qualified nurses, 274 doctors, 221 laboratory technicians, 196 executive directors, 195 midwifes and 164 cleaners.
The Faculty of Health Sciences of N’Djamena is a public institution created in 1990. It has trained more than 200 doctors to date, however it faces significant challenges due to the insufficiency of available qualified teaching staff and poor infrastructure and equipment which place it below international norms. The trained doctors soon become disillusioned because of the poor wages, which are completely out of sync with the high cost of living in Chad. To make ends meet they become business men and open private clinics. In addition to these clinics they fish for stints at various conferences and workshops which allow them to increase their income. The commercialisation and profiteering of doctors constitutes the biggest threat to securing better antenatal and post-natal care for women. Most of these doctors become so indifferent to their patients’ suffering that one has to question not just their qualifications, but their level of integrity. It is enough to look at a few specific cases of obstetric neglect, such as that of Madame T and Madame Z.
Young Madame T was expecting her first child and experienced pain in her lower stomach one evening. In spite of repeated calls by her husband, the gynaecologist responsible for monitoring her pregnancy refused to come out on a visit. He was busy on a night out and couldn’t get away. The young woman was brought in as an emergency patient the following morning and she lost her child. When the gynaecologist made his way to the hospital the next day he was fortunate enough to have missed the unpleasant business of the curettage…
Young Madame Z was also expecting her first child. She felt pain in the bottom of her stomach in the early hours of the morning and her husband drove her to the health centre. Here the midwives tinkered with her body for a while and declared that her child has been dead for two days. The verdict was false. She was driven to the Mother and Child Hospital where she was received by her gynaecologist who made her push out the baby, who was still alive, because of low levels of amniotic fluid. Later the gynaecologist admitted that he had forgotten to prescribe her a medicine that could have stopped the bleeding which was noted during a prenatal consultation.
Stories such as these are common currency, yet they cannot be explained or justified. How many women and children will it take to suffer, or at worst lose their lives, before our politicians offer effective solutions to the tragedy of maternal and child mortality? Women have this incredible gift of carrying life, and it is this life which brings hope for the whole nation. It is the duty of doctors to take care of them. They have taken the Hippocratic Oath and they must give the very best of themselves, remaining committed to saving lives and nothing more. If political decision makers actually attempted to mitigate the difficulties which our health system currently experiences, they could contribute to stopping the maternal mortality and stillbirths which have, and which continue to, cost the lives of too many Chadian women. The only way to tackle the tragedy which is tormenting our country is to invest in training and also awareness raising among the target population, the pregnant women themselves. The competitive entry exams which doctors take should be based on quality and competence, not one’s ability to land oneself a job. Healthcare workers need the right equipment, and this should be constantly replenished because health is in perpetual evolution. Women should be educated so that they know that they can go for a prenatal consultation and so that they frequently do so. It is only once they receive the care necessary for the successful completion of their pregnancy, and can give birth in complete security, that we can talk of the social mandate in Chad.
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