3 M ETHODOLOGY
R 2 Deviance statistics AIC Mean Errors
6 D ISCUSSION
6.1 Introduction
South Sudan is in urgent need of mitigation measures to reduce the current MMR of 730 maternal deaths per 100,000 live births annually to as low a rate as possible within the shortest possible time. However, a lack of data on the actual mortality rate and mathematical models for estimations and projections towards the future are the two biggest bottlenecks hindering any concrete steps. There is no method to evaluate the likely impact of an intervention strategy to reduce the rate. To serve these three objectives, this study used secondary data on actual death rates from the Juba Teaching Hospital, the sole authentic source in the country for the period of 1986–2015. Different models were tested. The WHO log regression and Poisson regression equations, using Gross National Product (GDP), Skilled Assistance at Birth (SAB) and General Fertility Rate (GFR) as variables predicting MMR, were found to be the most suitable, when tested for efficacy over a range of years. Further, Poisson regression was used to develop the model based on physiological causes of direct causes, e.g. haemorrhaging, sepsis (infections), prolonged (obstructed) labour, unsafe abortion, and indirect causes, e.g. anaemia, malaria, HIV/AIDs, and heart disease, as independent variables.
The results obtained in the previous chapter are explained and interpreted in this chapter. Part of the explanations and interpretations are given in the Results chapter. Literature support for those conclusions will be examined.
6.2 Overall result
The results demonstrate that providing skilled birth assistance can decrease the maternal mortality ratio. Although reduction of GDP also reduced MMR, the economic growth of the country cannot be stopped by reducing the GDP. GFR is an inherent demographic factor. Increasing GFR will increase MMR. Regression equations show to what level MMR can be reduced by increasing SAB and reducing GFR to a predetermined level. Since GFR cannot be changed quickly, reducing a long-term strategy is crucial. What happens in each year when such a strategy is used over a pre-determined long period was estimated using trend analysis equations.
Optimisation methods were used to determine the strategies required to reduce MMR to predetermined levels. Strategies to manipulate SAB and GFR for yearly targets of reduction of MMR to desired levels were estimated. The Millennium UN Goal is to achieve an MMR of 70 (minimum) and 140 (maximum), by 2030. To achieve 140 by 2030, the current SAB value of 19 needs to be increased to 50 and GFR should decrease from its current value of 175 to 97. So, to reduce MMR to 70 by 2030, GFR should decrease from the current value 175 to 75 and SAB should increase from the current value 19 to 76 by 2030.
One limitation of the estimation could be that GDP was assumed to remain constant. This assumption was based on the barriers that exist currently for economic progress.
6.3 Literature support for overall results
The need for a model to estimate MMR due to the absence of reliable data was explained by AbouZahr and Wardlaw (2001) and by Hill et al. (2007). Even if data are available, inherent weaknesses render them unusable. The data weaknesses of different types are generally found in the case of developing and poor countries. The main reasons are the absence of vital civil registration system and lack of resources to establish adequate institutional mechanisms and to meet the cost of data collection and processing.
De Brouwer et al. (1998, 2001) studied how western countries achieved low MMR. There was early awareness of the magnitude and seriousness of the problem. It was realised from studies
that most maternal deaths are avoidable. For this purpose, both professionals and the community were mobilised. The timing and speed of these factors determined the countries’ variations. Professionalism in care delivery was done in a professional manner with willingness of decision makers to take responsibility. The most modern obstetrical care was provided and was accessible to the entire population. In some countries, midwifery care was discouraged. The accountability of professionals was clearly defined for addressing maternal health in an effective way. However, the Swedish model, adapted by Norway, the Netherlands and Denmark, consisted of the selection of good midwives and training them for modern care practices, rather than discouraging midwifery altogether. Hygiene and technical specifications were prescribed and their compliance was monitored closely.
However, applying these strategies in South Sudan to reduce the current MMR of over 700 to 140 or 70 by 2030 appears difficult for the following reasons:
1) South Sudan only became independent in 2011. Many national developmental factors have priority over MMR reduction. Frequent internal conflicts pose a major barrier for development;
2) The economy is not sound due to oil pricing problems with Sudan. Although South Sudan is rich in oil resources, being a landlocked country, it must depend on Sudan for its oil export;
3) Public awareness of the problem is limited. There had not been any attempt in this direction by South Sudan;
4) There are very few healthcare professionals who can provide effective leadership for the reduction of MMR. Poor infrastructure limits access to quality healthcare for most pregnant mothers;
5) Only traditional midwives are available in villages. Training them professionally is a long process due to a lack of resources. Although some international agencies are assisting in
The importance of early information and action to professionalise with accountability, and access to quality care, was demonstrated by the differences in MMR reduction achieved in 2015 by Sri Lanka (30), Malaysia (40), and Thailand (20), as highlighted in the Literature Review (LR) chapter.
Possible further problems are: administrative delays, procedural delays, and clinical mismanagement. Thus, there are many ‘ifs’ and ‘buts’ in the entire care-seeking process, affecting MMR.
It is possible to avoid 16%–33% of all maternal deaths by primary or secondary prevention of the four well-known complications of obstructed labour, eclampsia, puerperal sepsis, and obstetric haemorrhaging, through SAB. The results of the present study show a significant contribution of SAB in reducing MMR in South Sudan.
In the case of South Sudan, healthcare expenditure as a percentage of GDP increased from 0.922% in 2013 to 1.137 in 2014. The global average was 5.917% in 2013 and 5.959% in 2014. Thus, although increasing, South Sudan spends a very low portion of its funds for healthcare. This demonstrates the need to improve healthcare expenditure and for it to be awarded a higher priority by South Sudan government.
A more detailed analysis of MMR with HIV/AIDs, MMR without HIV/AIDs, and total MMR was described in the Results chapter. Non-HIV/AIDs MMR accounted for about two-thirds of the total MMR. The fact that the remaining one-third of MMR was related to HIV/AIDs and the slower rate of its decline compared to the total and non-HIV/AIDs MMR, demonstrates the need for specific strategies to reduce HIV/AIDs, which should also reduce MMR.
The findings of this study show that the percentage decline from 1986–2008 to 2009–2015 was 60.2% in the case of non-HIV/AIDs MMR, compared to only 28.3% in the case of HIV/AIDs MMR. This result demonstrates the difficulty of reducing MMR if HIV/AIDs complications are present. In the analysis by Khan et al. (2006), for Africa, among global continents, HIV/AIDs were associated with maternal mortality to the extent of 6.2%. However, interventions such as antiretroviral therapy (ART) may not be useful, as per the findings of a
Botswana study reported by Zash et al. (2017) The study revealed that even when there was high rate of use of ART during pregnancy and postpartum, Botswanan women with HIV were five times more likely to die than those who were non-HIV in the 24 months postpartum. On the other hand, in South Africa, the recent reduction in HIV-related MMR (although still high) was traced to increased availability of ART from the data compiled and analysed by Mnyani et al. (2017). In South Africa, 4,823 women (aged 15–49 years) tested positive for HIV, among them, 156 were pregnant (4.7%) in 2008. In 2012, there were 8,253 HIV-detected women with 240 (4.5%) of them pregnant (Eaton, et al., 2014).