Angela Dramowski
Pregnancy and the newborn period (the first 28 days of life) are undoubtedly the most dangerous time in the lives of African mothers and babies. The risk of dying in pregnancy or childbirth in Sub-Saharan Africa is 50 times higher than in high-income countries.
While Africa contributes about 30% of global births, around 70% of the 287 000 global maternal deaths annually occur on this continent. For African newborns, the risk of dying on the day of birth and within the first month of life is higher than at any other time in childhood, accounting for nearly half of under-five child deaths.
Given these alarming statistics, it is fitting that the theme for World Health Day (7 April) “Healthy beginnings, hopeful futures” focuses on improving maternal and newborn health in Africa and the rest of the world.
Although preventable maternal and newborn death rates have declined globally, progress to improve maternal and newborn health outcomes in Sub-Saharan Africa is slow or stagnant, with the total number of one million newborn deaths every year remaining unchanged over the past two decades. At the current rate of decline, it will take another century for African newborns to attain the survival rates of newborns in high-income countries.
Four in five low-and middle-income countries will not achieve the Sustainable Development Goal (SDG) of reducing maternal mortality to less than 70 per 100,000 live births by 2030 (Target 3.1). At least 60 African and Asian countries are also unlikely to meet SDG Target 3.2, which aims to reduce preventable newborn death rates to fewer than 12 per 1,000 live births. Some African countries are even experiencing a reversal of gains, with newborn death rates rising.
The leading causes of maternal health complications and deaths in Africa remain haemorrhage, pre-eclampsia (a life-threatening pregnancy complication characterised by high blood pressure) and infection. Systemic challenges that contribute to adverse pregnancy outcomes in Africa include shortages of skilled birth attendants, failure to identify and manage underlying health issues, suboptimal monitoring of pregnancy and labour, and unhygienic delivery practices.
Although advances have been made in the early detection and treatment of pre-eclampsia, the burden and adverse impacts of this challenging pregnancy-related condition are highest in Africa. Among the most impactful maternal health interventions in Africa are enhanced access to high quality antenatal care (at least eight antenatal clinic visits) for early detection and treatment of nutritional deficits, underlying health conditions and infections, pregnancy complications, and the presence of a skilled birth attendant and clean care at delivery.
Among newborns in Africa, complications of prematurity, perinatal asphyxia (when a baby does not receive enough oxygen before, during, or shortly after birth) and infection remain the major causes of death, with congenital anomalies also featuring prominently in recent years. Preterm birth rates remain significantly higher in Africa than in other regions and could rise further due to global warming. Most newborn deaths from prematurity and asphyxia occur in the first week of life, whereas most serious bacterial and fungal infections are healthcare-associated, occurring several days to weeks after hospitalisation.
The dominance of gram-negative bacteria (bacteria with a hard, protective outer shell that makes them harder to kill with antibiotics) and antimicrobial-resistant (AMR) infections in Africa increases mortality from neonatal sepsis, causing the death of one in three affected babies. The overall number of newborn deaths due to sepsis is likely to be substantially underestimated because access to microbiological diagnostic testing is extremely limited, unaffordable or underutilised in most African countries. Enhanced laboratory testing at a large South African neonatal unit showed that gram-negative bacterial and AMR infections were the direct or indirect cause of death in up to 70% of hospitalised preterm infants.
A major contributor to sepsis-related newborn deaths is the lack of access to effective and affordable antibiotics. Only four new antibiotics have been licenced for use in newborns in the last 25 years, leaving few treatment options for newborns with healthcare-associated sepsis. The World Health Organisation’s antibiotic guidelines for neonatal sepsis are now inappropriate for use in many African and Asian countries, with studies reporting over 200 different antibiotic combinations being used globally to provide more effective treatment options.
Fortunately, a new global clinical trial (NeoSEP) to inform selection of effective antibiotics for neonatal sepsis will commence in several African countries, including South Africa this year. The near-term availability of vaccines to prevent maternal and newborn infections is most promising to treat the bacteria Group B Streptococcus, a leading cause of newborn bloodstream infections, pneumonia and meningitis. However, the prospects of developing a vaccine targeting Klebsiella pneumoniae, the leading neonatal bacterial pathogen in Africa, are less optimistic in the short term.
Given the slow progress in preventing stillbirths, preterm births, maternal and neonatal infections and deaths in Africa, urgent action is needed to optimise the implementation of the available evidence-based tools and interventions to achieve improved maternal and newborn health outcomes. These include enhancing access to clean water, sanitation and hygiene in communities; strengthening infection prevention and control programmes in maternity and neonatal healthcare facilities; ensuring uptake of currently available vaccinations in pregnancy and infancy; and redoubling efforts to implement essential newborn care interventions. These interventions include thermal care (measures to ensure the baby does not become either too cold or too hot), breastfeeding and kangaroo mother care (where the mother holds the baby in a ‘kangaroo’ position for skin-to-skin contact) for every baby, everywhere.
Ongoing global conflicts, forced displacements, natural disasters and shifts in international geopolitics resulting in abrupt withdrawal of funding for aid programmes and research on infectious diseases and maternal and child health, are major threats to maternal and newborn health programmes in Africa. Undoubtedly, 2025 will be a critical test of whether African countries can recommit to and accelerate efforts to meet the SDG Targets 3.1 and 3.2 and realise the World Health Day aspiration to deliver ‘healthy beginnings, and hopeful futures’. As African healthcare workers, we must recommit to working collaboratively, faster, harder and more efficiently than ever before to deliver on the promise of better health outcomes for mothers and newborns on this continent.
*Professor Angela Dramowski heads the Clinical Unit: General Paediatrics in the Department of Paediatrics and Child Health in the Faculty of Medicine and Health Sciences at Stellenbosch University and Tygerberg Hospital.
Cape Argus