The Untold Story: Drivers of High Maternal Mortality Rates in The Gambia

TABLE OF CONTENTS

LISTS OF ABBREVIATIONS

ABSTRACT

ACKNOWLEDGEMENTS

DEDICATION

CHAPTER ONE: INTRODUCTION
1.1 Introduction
1.2 Problem statement
1.3 Research questions
1.4 Justification for the study
1.5 Outline of structure

CHAPTER TWO: LITERATURE REVIEW
2.1 Introduction
2.2 Maternal Mortality
2.2.1 Definition and causes
2.2.2 Epidemiology and burden of maternal mortality
2.2.3 Health system factors
2.2.4 Socio-cultural and economic factors

CHAPTER THREE: CONCEPTUAL FRAMEWORK
3.1 Three Delays Model as conceptual approaches to studying Maternal Mortality
3.1.1 First delay model
3.1.2 Second delay model
3.1.3 Third delay model

CHAPTER FOUR: RESEARCH METHODOLOGY
4.1 Introduction
4.2 Research aims and questions
4.3 Research Design
4.4 Data collection method
4.5 Limitations of the study

CHAPTER FIVE: RESULTS AND DISCUSSION
5.1 Results
5.1.1 Drivers of high maternal mortality in The Gambia.
5.1.1.1 Socio-economic factors
5.1.1.2 Socio-cultural factors
5.1.1.3 Health service factors
5.1.1.3.1 Experience with the healthcare system
5.1.1.3.2 Facility infrastructure and uneven distribution
5.1.1.3.3 Staff shortage
5.1.1.3.4 Shortage of equipment and drugs
5.1.1.3.5 Shortage of blood supplies
5.1.1.3.6 Inadequate management
5.1.2 Steps undertaken to reduce maternal mortality in The Gambia
5.2 Discussions
5.2.1 Socio-economic and cultural factors
5.2.2 Health service factors

CHAPTER SIX: CONCLUSION & RECOMMENDATIONS
6. Conclusions

References

ABBREVIATIONS

Abbildung in dieser Leseprobe nicht enthalten

ABSTRACT

Introduction:

The maternal mortality in The Gambia is currently at an unpleasant rate of 289 per 100,000 live births, well above the Sustainable Development Goals (SDGs) target of 70 per 100,000 live births.

Objectives:

This dissertation aims to explore the drivers of this high maternal mortality in The Gambia through exploration of the roles of socio-economic and cultural practices, health system factors and actions undertaken by the government.

Methodology:

The study is based on secondary literature review of relevant published literatures and grey literatures.

Results:

The causes of maternal mortality in The Gambia are multifaceted and intertwined. Rural-urban inequality in health, education and income are evident

Recommendations:

More political commitment needed to give priority to maternal and child health care, including maternal mortality.

ACKNOWLEDGEMENT

I am thankful to my supervisor, Dr. Edward Ampratwum, for his support and guidance during the writing of this thesis. I am also thankful to my academic supervisor, Dr. Seth Schindler, for his support and encouragement during the period of my studies.

I am very thankful to my mother for her continued prayers.

Finally, I am indebted to my beloved wife, Mrs Fatou L Bah Keita, for her unflinching love, support and encouragement throughout the period of my studies. Much love to our son, Ibrahim, for consistently taking away my pens to try to write on my papers.

DEDICATION

This thesis is dedicated to all girls and women who lost their lives through pregnancy and childbirth in The Gambia, and around Africa and to those who dedicate their time and effort to improve maternal health outcomes.

CHAPTER ONE: INTRODUCTION

1.1 Introduction

The adaptation of the Millennium Development Goals (MDGs) in 2000 by the international community committed countries to MDG 5 to reduce maternal mortality by three quarters between 1990 and 2015. Statistics have shown a global decrease of 45% in maternal mortality since 1990 (Idoko et al. 2017). Available data indicates global maternal deaths of 295,000 in 2017 with low-income countries accounting for 94% of the deaths (WHO 2019). Out of the 295,000 global maternal deaths in 2017, Sub-Saharan Africa and Southern Asia accounted for 254,000 (86%) and Sub-Saharan Africa alone accounted for two-thirds (196,000) and Southern Asia accounted for one-fifth (58,000) (WHO 2019). The uneven high numbers of maternal deaths in some parts of the globe uncovers unfairness and inequality in access to healthcare services and also characterises the gap between rich and poor (Idoko et al 2017). Despite this gloomy picture, from 2000 to 2017 Southern Asia has shown 60% (from 384 to 157) reduction in maternal mortality rate whilst Sub-Saharan Africa registered a reduction of 40%, showing an overall reduction of just under 50% (WHO 2019). The Gambia, with a population of about two million inhabitants, is relatively one of the smallest and densely populated low-income countries in West Africa with a rank of the highest maternal mortality among the African countries (Lowe et al. 2016). According to the World Health Organisation (2018) The Gambia has also registered a remarkable improvement in reducing maternal mortality rate from 932 per 100,000 live births in 2000 to 597 per 100,000 live births in 2017 and recently to 289 per 100,000 live births in 2020 (GBOS 2021). Out of 55,969 annual births in The Gambia, only over 5,000 (9%) occurred in the only main referral tertiary hospital in the country and this hospital accounts for more than 30% of 340 annual maternal deaths in the country (Idoko et al. 2017).

Provision of health care is one of the key integrals of development by the government and the health systems framework relies upon financial commitment. To supplement its health budget, the government introduced user fees in public healthcare services through the cost recovery programme (CRP), Bamako Initiative (BMI) and drug revolving fund (DRF). However, these programmes/initiatives have not led to the realisation of universal access to healthcare and the government’s annual budget spending on health (13.9%) is still less than the percentage of Abuja Declaration for African Union countries to spend their annual budget on health (Cham 2003, Cham 2003; Sundby 2014). The burden of out of pocket or the opportunity costs expenditure for healthcare services is as high as up to 85% as there are no social health insurances in The Gambia (Sundby 2014). The Gambia has a good coverage of access to healthcare facilities with over 85% of the population having access/living within 3 kilometres to primary health care and over 97% having access /living within 5 kilometres to outreach healthcare post (Cham 2003). The department of health’s maternal health care policy is based upon different levels of care with a referral system network where high risk pregnant mothers are being referred to tertiary hospitals for further management to reduce maternal mortality (Cham et al 2003). However, not much progress is made in maternal care services because there are only five tertiary hospitals in the country ( 3 in urban areas and 2 in rural areas) that give emergency obstetric care with some interruptions due to power cuts, lack of blood or essential medications (Sundby 2014). The Gambia’s maternal mortality rate is still unacceptable high at 289/100,000 live births exceeding the 2015 Millennium Development Goal’s (MDG) target of 263/100,000 live births and now the Sustainable Development Goals (SDGs) aim at reducing maternal mortality by 2030 to less than 70 per 100,000 live births with no country having maternal mortality rate of more than twice the global average (GBOS 2021; Lowe, Chen & Huang 2016). It is quite troubling to know that maternal mortality is also one of the leading causes of deaths among inpatients in The Gambia (WHO, 2018).

1.2 Problem Statement

The Gambia, with a population of about 2 million and the most densely populated country in West Africa, has been overstrained with maternal ill-health problems and is among the countries in Africa with the highest levels of maternal mortality, currently at unacceptable rate of 289 per 100,000 live births (Lowe, Chen & Huang 2016; GBoS 2021). The current maternal mortality rate is well above the Millennium Development Goal 5 target of 263 per 100,000 live births and Sustainable Development Goals (SDGs) 3.1 target of 70 per 100,000 live births (Lowe et al 2016). Despite progress in the increase of the use of antenatal care and physical access to health care facilities in The Gambia, Lowe, Chen & Huang (2016) and Jammeh, Sundby & Vangen (2011) both highlighted that still majority of women in The Gambia delivered at home under the supervision of a traditional birth attendant and or a family member, below the United Nations’ target of 90 percent of births to be attended by skilled birth attendants. The provision of emergency obstetric care is considerably the main catalyst for preventing maternal deaths (Cham, 2003) however, Jammeh, Sundby & Vangen (2011) highlighted that the number of basic emergency obstetric care facilities in The Gambia is far below the United Nations recommended level, resulting to considerably lack of meeting the needs for obstetric emergency care, with only 1 in 5 women with obstetric emergencies report to a medical facility for assistance (Lowe, Chen & Huand 2016). Maternal mortality continues to be one of the leading causes of deaths among in-patients in healthcare facilities in The Gambia (WHO 2018) and a woman in The Gambia is reported to have 1 in 23 lifetime risk of dying from maternal related causes with more than 50% maternal deaths occurring among women under 35 years (Lowe, Chen & Huang 2016). However, as argued in many literature, these problems are compounded by weak health system resulting to inadequate financial and logistic support, appalling shortage of skilled human resources for health and lack of full functional referral systems (Adjiwanou and Legrand 2013; Jammeh, Sundy & Vangen 2011; Cham 2013)

In an effort to dig out the puzzle behind the high maternal mortality rates in The Gambia, I will use the following research questions to find possible answers.

1.3 Research questions

1. Identifying the drivers of high maternal mortality in The Gambia?

a. To examine the socio-cultural and economic factors influencing persistently high maternal mortality rate.

b. To identify health service factors associated with high maternal deaths rate

2. What actions have been undertaken to reduce maternal mortality in The Gambia?

1.4 Justification for the study

Firstly, Like many Sub-Saharan African countries, The Gambia’s recent maternal mortality rate remains unacceptable at 289 per 100,000 live births, compared with 230 deaths per 100,000 live births in low/middle countries in 2013 (GBoS 2021; Oh et al. 2019). The government is unable to meet its own target of reducing maternal mortality from 750 per live births to 150 per 100,000 live births by 2015 as stipulated in its National Health Policy 2012 - “Health is Wealth”. The maternal mortality rate is also higher than both target goals of Millennium Development Goals (MDGs) and the Sustainable Development Goals (SDGs). As a result, this has become a great concern to The Gambia government and its development partners, the civil societies and the women in particular.

The increasing number of women dying from pregnancy and childbirth in public healthcare facilities has resulted in the formation of a civil right group called “Gambia Womens’ Lives Matter '' organising protests to register their concerns to the government about the levels of maternal deaths in healthcare facilities.

Thus, the unacceptable high maternal mortality rate in the country coupled with the government’s failure to meet the Millennium Development Goals (MDGs) 5, Sustainable Development Goals (SDGs) 3.1 and its own national health policy target makes it crucial to choose The Gambia for my dissertation.

Secondly, there is much literature on maternal mortality, however much of the research on maternal morbidity and mortality is conducted within a biomedical perspective with little or no notice of how political and socio-cultural factors play a role in maternal morbidity and mortality (Lori and Starke 2012). Similarly, many of the studies on maternal mortality conducted in The Gambia have been devoted to the measurable obstetric causes of maternal mortality rather than the roles played by socio-economic, cultural practices and health systems in persistently high maternal mortality.

Therefore, this dissertation will attempt to explore the drivers of high maternal mortality rates in The Gambia through exploration of the role of the socio-economic, cultural practices and healthcare systems using the conceptual framework of Thaddeus and Maine 1994 “Three Delays Model” associated with maternal mortality.

Finally, but not the least, my training and experience in the field of health as a Registered General Nurse (RGN) and a trained State Certified Midwife (SCM) have motivated me to choose such an important topic for my dissertation to increase my awareness and knowledge and also to contribute to the literature.

1.5 Outline of Structure

This dissertation comprises six chapters. The first chapter is an introduction to the research topic which explains the situation of the research topic in the country selected and efforts being made to tackle the problem of maternal mortality. This chapter also has the problem statement, research questions and justification for selecting both the topic and country. Chapter two is about the literature review in which there will be thorough review of literature on maternal mortality in the context of both global and Sub-Saharan Africa and The Gambia. In chapter three you will read about the conceptual framework/approach - Three Delays Model - adopted by Thaddeus and Maine in 1994 to study maternal mortality. Chapter four is about research methodology which will explain research aims and questions, research design and data collection method. Chapter five focuses on analysis of results of key points and discussion of key points. Chapter six will be the conclusion chapter where reflections on the key findings will be made together with some recommendations.

CHAPTER TWO: LITERATURE REVIEW

2.1 Introduction

Pregnancy and childbirth should be a joy for every family and it is every parent's desire to see their child grow up. However, in certain parts of the world this phenomenon is opposite to many marginalised women and families who are vulnerable as a result of where they live or who they are (Graham et al , 2016).

The death of a woman quite often leaves the family behind devastated and usually pushes the family into poverty because of the expenditure on healthcare for the deceased mother that came either too late or the treatment was ineffective (WHO, 2005).

Maternal mortality is a global issue and maternal health remains a key international development goal as it is estimated that around 210 million women get pregnant each year with 140 million newborn babies being delivered each year (Graham et al 2016). The high maternal deaths in some parts of the world highlights inequality in access to healthcare services and the gap between developed and developing countries (Idoko et al 2017). Ravindram and Berer (1999) argued that the sensitive nature of maternal mortality as a symbol of inequality has made both the World Health Organization(WHO) and United Nations International Children’s Emergency Fund(UNICEF) to call it a litmus test of status of women and their access to healthcare services. Most of the pregnancy related deaths among women in the world do occur in developing countries and Rosenfield & Maine (1985) argued that this has been neglected by the medical, obstetric and public health communities in developing countries in their article “Where’s the M in MCH?” in 1985 where they criticised that the standard maternal and child health (MCH) programs were focusing more on the health of infants and young children than women’s health.

This criticism received more attention resulting in the formal launch of the Safe Motherhood Initiative (SMI) in Nairobi, Kenya in 1987.

The Safe Motherhood Initiative concentrates on preventing the death of pregnant women through the four main basic principles: Family Planning, Prenatal Care, Clear and Safe Delivery, and Emergency Obstetric Care (OEC) (Cham 2003).

The slow progress in achieving the main goals of the Safe Motherhood Initiative may contributed to the inclusion of health agenda in Millennium Development Goals (MDGs) which indicated that ill health contributes to poverty and improving health of the population is a condition for poverty alleviation, reduction in inequality and development (WHO, 2005). The main goal of Millennium Development Goal 5 is to reduce maternal mortality by three quarters between 1990 and 2015 (Idoko et al 2017). However, there has been patchy progress in achieving Millennium Development Goal 5 resulting to a shift from MDGs to Sustainable Development Goals (SDGs) to transform a new agenda for maternal health towards ending preventable maternal mortality by reducing it to less than 70 per 100,000 live births and no country should have maternal mortality rate greater than 140 per 100,000 live births by 2030 (WHO 2015).

Maternal mortality and morbidity is not only a development issue, but also a matter of human rights. The Universal Declaration of Human Rights states that “Motherhood and Childhood are entitled to special care and assistance” (WHO 2015, p.5). Human rights are universal and for women, human rights include “access to services that will ensure safe pregnancy and childbirth” (Gruskin et al 2008, p589).

The literature review will examine/focus on definition and causes of maternal mortality; epidemiology and burden of maternal mortality; socio-cultural and economic factors, the healthcare systems factors associated with maternal mortality.

2.2 Maternal Mortality

2.2.1. Definition and Causes

Maternal mortality simply means the death of a woman during pregnancy or childbirth. In 2005, the World Health Organisation (WHO) defined maternal mortality as “the death of a woman while pregnant or within 42 days of termination of pregnancy or delivery from any cause irrespective of the duration and site of the pregnancy, or its management but not from a complication that is accidental or incidental” (WHO, 2005, p169). The International Statistical Classification of Diseases and Related Health Problems (ICD-10) further introduced a new category, called late maternal death, defined as “the death of a woman from direct or indirect obstetric causes more than 42 days but less than one year after termination of pregnancy” and also because of lack of association of definition of maternal deaths with accidental deaths, the ICD-10 introduced the term pregnancy-related death, defined as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death” ( WHO 1992, cited in Jamison 2006:1). The Centre for Maternal and Child Enquiries (CMACE) in the United Kingdom has adopted the definition of maternal mortality from WHO, however it classifies the causes of maternal deaths into four main areas, namely, during pregnancy and within 42 days after birth, direct causes, indirect causes and coincidental late deaths (Okwan & Kovacs 2019).

Literature review has shown that traditionally maternal deaths were classified into two main groups: (1) Associated deaths caused from incidental illness during pregnancy or the lying in period and (2) puerperal deaths, divided into two main groups - Puerperal fever or puerperal sepsis described in the eighteenth and nineteenth centuries as “metria” or “puerperal pyaemia” (Loudon 1986:1). Associated deaths and Puerperal deaths are now known as indirect and direct obstetric deaths (Loudon 1986). Loudon (1986) argued that indirect/associated deaths were included in most maternal deaths accounts before death registration in 1838.

The causes of Maternal deaths are either direct obstetric complications from pregnancy, maternal death during pregnancy, delivery or postpartum, incorrect treatments or complications from any intervention omission and examples are haemorrhage/bleeding, infections, unsafe abortions and obstructed labour with bleeding). Indirect obstetric causes of maternal deaths arise from an existing disease developed before pregnancy or during pregnancy and not specific to direct pregnancy such as Anaemia, Malaria, Tuberculosis and Heart diseases (Okwan & Kovacs 2019, p17). According to statistics, eighty percent (80%) of all maternal mortality in the world are due to direct obstetric causes whilst twenty percent (20%) are due to indirect causes (Cham 2003). According to Ghebrechiwot (2004) about 60 percent of maternal deaths occur during childbirth and the immediate postpartum period, with 50 percent (50%) of these deaths happening within the first 24 hours (cited in Khama et al, 2006). Maternal deaths during the postpartum period accounts for between 50% and 71%. Postpartum haemorrhage/bleeding (PPH) continues to be the main immediate direct obstetric cause for maternal deaths in both developed and developing countries . According to history, Taj Mahal in India was built by a grief-stricken emperor as a memorial to his wife who died of postpartum haemorrhage nearly four hundred years ago (Owen, Cassidy & Weeks 2021). Maternal mortality is widely considered a public health problem, however, its reduction entirely depends on treatment rather than prevention as women at risk can be identified but difficult to identify who will develop complications (Cham, 2003). However, despite advances in maternity care, postpartum haemorrhage globally accounts for 70,000 maternal deaths equal to one woman dying from it every eight minutes. Statistics have shown that 60% of global maternal deaths are due to Postpartum haemorrhage, Pueperal sepsis, Pre-eclampsia, Eclampsia, Obstructed or prolong labour and complications of unsafe abortion and of which 80% cases are in Africa (Knight & Kennedy 2013). Indirect obstetric causes account for about 20 to 25 percent of maternal deaths, attributed to illnesses worsened by pregnancy such as anaemia; malaria; HIV/AIDS; heart diseases; lung; liver; kidneys and ectopic pregnancies (WHO, 2005). According to WHO, between 88 - 98% of the maternal deaths are preventable with appropriate medical interventions such as access to timely emergency obstetric interventions (Knight, et al 2013).

2.2.2. Epidemiology and Burden of Maternal Mortality

Maternal mortality is both a devastating medical problem in many societies and also a concern for international development agencies and acts as a health indicator signifying the large gap between developed and developing countries. Statistics have shown that globally there has been progress in reducing maternal mortality, however, this progress has been patchy and uneven between regions and countries with the most burden on governments in developing countries. Globally in the past 25 years maternal mortality rate fell by almost 44% to 216 maternal deaths per 100, 000 live births in 2015 and the global lifetime risk of maternal death fell enormously from 1 in 73 to 1 in 180 (WHO 2015). However, between 2000 and 2017, the maternal mortality ratio has fallen only by about 38% and globally 810 women die every day of preventable causes of pregnancy and childbirth complications (WHO 2019).

Low and lower middle-income countries continue to account for a disproportionately high percentage of 94 percent of the global maternal deaths, unacceptably high at around 295,000 per 100,000 live births in 2017 (WHO 2019). WHO (2019) statistics have shown that Sub-Saharan Africa and Asia accounted for about 86% (254 000) of the global maternal deaths in 2017, with Sub-Saharan Africa accounting for approximately two-thirds (196 000) and Southern Asia accounting for about one-fifth (58 000). As of 2015, the two regions with the highest maternal mortality are Sub-Saharan Africa and Oceania (WHO 2015). According to WHO, India had maternal deaths of 4500 during 2015 and became the second largest number of maternal deaths after Nigeria and they (India and Nigeria) alone account for one-third of global maternal deaths (SK et al 2019).

In 1838, the first Registrar General of England and Wales (Thomas Henry Lister) commented on maternal death as “A deep, dark continuous stream of mortality” and asked “how long is this sacrifice of lives to continue?” (Graham et al 2016, p1; Loudon 1986, p2). Although some countries have successfully reduced their maternal mortality rate quite considerably, replicating these successes to all other countries and regions by 2030 as enshrined in MDG 5a is the major challenge.

It is estimated that 303,000 maternal deaths occurred worldwide in 2015 (equates to about 830 women dying each day - about one woman per two minutes) of which 99% occurred in low-income countries, particularly in South Asia and Sub-Saharan Africa (Mohammed et al 2020). In 2015, there were 201,000 maternal deaths in Sub-Saharan Africa and a woman in this region has 36 times more lifetime risk of maternal death ( 1 in 16) compared to 1 in 4900 in rich countries (Graham et al., 2016). The high-income countries have an overall maternal mortality rate of 12/100,000 live births which is 46 times lower than the highest figure in Sub-Saharan Africa of 546/100,000 live births (Graham et al 2016). Statistics have shown that in 2015 Sub-Saharan Africa accounted for 66% (201,000) – 42% in 1990 - of global death, seconded by Asia 22% (66,000) and this shows that 5% of the world’s countries account for more than half of the maternal deaths(Graham et al 2016). However, despite this gloomy picture of global maternal mortality, there has been some progress in reducing maternal mortality. According to WHO(2019) between 2000 and 2017, there has been a reduction of sixty percent (from 384 down to 157) of maternal deaths in Southern Asia with also a forty percent in Sub-Saharan Africa. In addition, four other sub-regions - Central Asia, Eastern Asia, Europe and Northern Africa- have almost halved their maternal mortality ratios, which overall bring to just under fifty percent (50%) of maternal mortality in developing countries in 2017 (WHO 2019). Despite progress in reduction of maternal mortality in developing countries, there is still tangible evidence of inequalities in accessing quality health services, disgracefully highlighting the gap between the rich and the poor.

However, Karanja et al (2018) highlighted that such inequalities do not only happen between high and low and middle income countries, but also within countries evidenced by differences in maternal and child mortality rates by geographic location as well as social position and ownership or control of resources. WHO (2019) estimated that the maternal mortality ratio in low income countries in 2017 is 462 per 100 000 live births compared to 11 per 100,000 live births in high income countries. A woman in low income countries has more lifetime risk of dying from pregnancy and childbirth related complications than a woman in high income countries which is 1 in 45 compared to 1 in 5400 in high income countries (WHO 2019). The evidence of epidemiology and burden of maternal mortality is quite evident on countries' burden with it, particularly developing countries. Due to the failure of attaining the Millennium Development Goal five to reduce global maternal mortality rate to 263 per 100,000 live births by 2015, the new global goals of Sustainable Development Goals have committed countries to reduce their maternal mortality to 70 per 100,000 live births by 2030. The new goals also commit countries to ensure increased universal access to Family planning services and promote gender equality, including ending girl-child marriage. However, the greatest obstacle in archiving these goals is the funding gap from the donors.

2.2.3. The healthcare systems factors

Many health theorist, for instance Shiffman, argued that early interventions in maternal care, safe and legal abortion, trained medical attendants at delivery and provision of emergency obstetric care are importance in reducing maternal mortality (Osemwengie and Shaibu 2020). Shiffman (2000) argued that good interventions with priorities and policies in maternal health can make a great positive impact in reducing maternal mortality and not only changes in socio-economic status of women. Thus, it has been argued that maternal mortality is a by-product of poor healthcare systems that are not capable of dealing with pregnancy and childbirth complications and lack of availability of enough skilled health care providers can lead to the increase in maternal mortality rate (Green and Pearson 2006; cited in Osemwengie and Shaibu 2020). It has been argued that healthcare systems in most developing countries deter women from using it for maternal care services due to misconceptions about the availability and provision of services at the healthcare facility coupled with the perceived quality of care provided (Karanja et al 2018). A study conducted in Kenya by Karanja et al (2018) highlighted that some women avoid giving birth in the healthcare facilities due to the high number of women undergoing caesarean section which they believe are not necessary.

Many African countries do not have a strong policy on staff management and also policy on patient protection/rights of patients in their healthcare systems and as a result staffs’ unacceptable behaviour deter women from using the services. The fear of disrespect and verbal abuse (shouting or rudeness) and physical abuse (pinching during examinations) by health care providers are common study findings in many African countries as narrated in one study: “all the women would be delivering at hospital, it’s the issue of knowing who is the attendant at the hospital, may be Mr.(name) is the attendant and people know him as a rude person, so people opt elsewhere” (Karanja et al 2018, p7).

“There was another one who said that the reason why she doesn’t like going to delivery in the hospital is because there was a day when she was giving birth and a nurse pinched her with a pair of scissor so that she can push the baby, that was very painful to her and that discouraged her from delivery at the hospital (Karanja et al 2018, p7).

The physical location of healthcare facilities in many developing countries is one of the major problems in accessing maternal health care. Atuoye et al (2015) highlighted that, in developing countries, women living in rural settings find it extremely difficult to access specialised maternal health care services due to poor road networks and lack of regular means of appropriate transport, resulting in significant adverse effect on maternal and child health outcomes. Adde et al (2020) pointed out that many of these facilities are far from the rural population, often in urban areas and access to them is even more difficult as roads from rural areas are often in bad conditions and the high cost of transportation fares to the urban areas are not always affordable by many rural women and in some instances, women resort to the use of donkey/horse carts, bicycles or motorcycles. Maternal services are sometimes not available at night in these facilities and consequently, any woman that goes into labour during night will undoubtedly use the service of a traditional birth attendants (Karanja et al 2018). This problem can be noted in the disparities between rural and urban healthcare facility deliveries (Adde et al 2020) As asserted by Atuoye et al (2015) the availability of transport to move women from home to healthcare facility and subsequently to the referral centre for specialised care is one of the crucial and important determinants of maternal and child health outcome as it encourages women to go back to traditional medicine or deliver at home with patronage of traditional birth attendant services. Karanja et al (2018) highlighted that lack of essential drugs and supplies coupled with the negative attitudes of staff are hindrance to health facility delivery.

The causes of maternal mortality and morbidity as explained by Gerein et al (2006) are due to the healthcare systems inability to effectively deal with complications related to pregnancy and childbirth, particularly during or shortly after childbirth, which could be due to availability of skilled health providers. Sub-Saharan Africa is burdened with workforce crisis and maternal ill health and it is estimated that SSA needs about 1 to 1.4 million nurses, midwives and doctors to provide essential care (Gerein et al 2006). This workforce crisis in the health system can be attributed to HIV/AIDS and high migration of nurses, midwives and doctors to developed countries in search of greener pasture and evidence in literature has shown that the more qualified national staff are the more likely they will look for international employment due to poor wages (Gerein et al 2006). A study conducted by Malawi Obstetric Quality of Care Assessment found that 60 percent (60%) of health workers in Malawi are unsatisfied with their salaries (Seljeskog et al 2006).

According to reports, a large number of health workers (18-41%) are living with HIV/AIDS in Sub-Saharan African countries causing more absenteeism which results in more burnout due to workload (Gerein et al 2006). The distribution of healthcare providers between geographical areas and healthcare facilities are usually associated with understaffing in rural poor locations as a high number of health professionals only work in urban and richer areas in developing countries (Gerein et al 2006). The movement of health professionals from public to private facilities aggravated the workforce crisis in SSA and according to Gerein et al (2006) one would wonder about the quality of services available for women for delivery in South Africa since 75 percent of their specialists work in the private sector. A regression analysis of data from 117 countries have found that maternal mortality is correlated to staffing level (Gerein et al 2006). Due to workforce crisis in SSA, Staff are sometimes ask to do substitution tasks as an emergency measure to tackle staff shortage which can undermine the health system and reduce the quality of care at the detriment of women’s health or life: for example midwives and nurses providing basic emergency obstetric care in remote rural areas where there are no doctors and there are even reports of untrained staff having to deliver babies (Gerein et al 2006).

2.2.4. Socio-cultural and economic factors

The use of skilled birth attendants at the healthcare facilities is one of the major catalysts in reducing maternal mortality, however the decision to use this service can be determined by socio-cultural and economic factors in developing countries. Cultural factors are quite important for health care seeking behaviour in all communities (Seljeskog et al 2006) and Serizwa (2014) argued that social and cultural influences are determinants in shaping health behaviours and perception of health. As pointed out by Serizawa et al (2014) rural women in developing countries are unlikely to use maternal services as they view this service as more of curative than preventive measures which is further compounded by their belief that pregnancy is a natural phenomenon and manageable without the involvement of healthcare professionals. Women's autonomy in decision-making largely depends upon their bargaining power within the household which helps them to access and control over material and social resources, such as knowledge and power, within the family and community (Ogu et al 2016). The views on pregnancy and motherhood by most traditions in developing countries are crucial in decision making. In many societies in developing countries, women cannot make decisions regarding their own health and they also do not have decision-making power to decide to seek delivery in a healthcare facility (Ogu et al 2016). Decisions are usually made by older women, family members such as mothers, grandmothers, mothers-in-law, who are perceived as knowledgeable, or from husbands. However, in many societies, the most important person in decision making is the husband who is responsible to provide money to pay for transportation and hospital fees (Karanja et al 2018; Ogu et al 2016; Seljeskog et al 2006). Ogu et al (2016) asserted that some of these actors in decision making may have different interests to the delivery location which leads to delay in decision making to seek maternal care and sometimes prevents the woman from healthcare facility delivery as the decisions are mostly made when the woman is already in labour. Metwally (2013) has stated that WHO 2010 country health profile of Pakistan shows that 43 percent of all cases of where the baby should be delivered are made by the husband. In most communities in developing countries pregnancy and delivery are regarded as natural occurrences and do not require intervention unless something went wrong and it is also a taboo to discuss any birth plans.

Consequently, decisions on place of birth are often made at the onset of labour which is likely to be at home as delivery at healthcare facilities are deemed as unnecessary (Karanja et al 2018). This concept is supported by the belief that being attended by traditional birth attendants (TBAs) at home is equivalent to hospital delivery as they are seen as trained health personnel since most of them are trained by government health workers as part of primary health care (PHC) component.

In some traditional cultures in developing countries, such as in Malawi, the family need to be present to observe the labour process and according to Seljeskog et al (2006, p72) the baby might be rejected by the family if the family did not witness the delivery : “If a woman delivers at hospital, the husband says:- that’s not my baby”. the traditional views place on delivery and motherhood prevents women from using the healthcare facilities to be attended by skilled birth attendants for fear of having operation as caesarean sections are commonly regarded as negative because “a woman is born to delivery vagianlly” and anything other than this is considered being dangerous and being lazy for having operation (Seljeskog et al 2006, p72). In addition, operations are considered a threat to culture. Culture and religion also play an important role in women’s maternal health seeking behaviour of using health care facilities. The gender of the healthcare provider plays a role in influencing the location of birth as some women are not comfortable being attended by a male nurse as described in this conversation between FGD and chiefs in a study conducted in a rural Maasai community in Kenya by Karanja et al (2018, p7):

“When you turn to social factors, sometimes women don’t want to go to hospital because the attendant isn’t a woman, and don’t want to be attended by a male, because she may not want everybody to see her private part”. It has also been argued that some women prefer home delivery to healthcare facility delivery due to unfamiliar birthing positions they are being subjected to by skilled birth attendants (Karanja et al 2018).

A study conducted in four African countries by Adjiwanon and LeGrand (2014) demonstrated the negative impacts of constrictive sociocultural and gender norms on the use of maternal health services by women. For example the study reported that women who live in communities where violence against women are relatively acceptable are less likely to use skilled birth attendants; communities where modern contraceptive are less used their women are less likely to use skilled birth attendants for their last delivery and the use of skilled birth attendants are less likey with women with low decision-making authorities.

Religious belief and practices can have great influence in women’s and their actors in decision making in utilisation of maternal services in many developing countries. For example, Serizawa et al (2014) reported that Muslim women in Sudan believe that God is responsible for the outcome of any health-related matters. Ganle (2015) highlighted that the duty of Muslim women to maintain the sanctity of their body by preserving their physical body from the opposite sex who they bear no relationship has impeded their ability to access maternal care services and increase their risk of pregnancy and birth related complications. Thus, muslim women are less likely to use any maternal services that involve opposite sex skilled health worker as narrated here by a lactating mother in Northern Ghana:

“When I was pregnant with my first child, one day I went to the clinic for antenatal care. The midwife told me to go into the room so that she can examine me. When I went into the room, there were two other nurses in there..one was a man. But the midwife asked me to remove my dress and lie down. But the man was there, so I said no I’d wait until the man goes out, because as a Muslim, it is improper for a man who is not my husband to see my nakedness. The nurse was angry and started speaking abusive words….me too I became very annoyed and walked out of the room. I never went back there again till I delivered, and I will never go there if I get pregnant again” (Ganle, 2015, p10).

Serizawa et al (2014) stated that witchcraft is widely believed among women in Sub-Saharan African and reported that a study in Sudan showed all participating mothers saying that the mother and her newborn baby must stay at home for forty days after delivery as they are vulnerable to witchcraft during this period.

In many African societies, there is general religious belief that pregnancy and childbirth increase the risk of attacks by witches and other satanic forces and pregnant women need spiritual care, thus, having care and delivery in faith based healthcare facilities are regarded as a safe haven (Ogu et al 2016). Ogu et al(2016) reported that a study conducted by Adaniki et al shows that the majority of women interviewed in the study believe that hospital delivery would be greatest if there is collaboration between their religious leaders and healthcare workers, indicating women’s use of maternal care services can be improved with faith tolerated hospitals.

Gender inequality and social disempowerment of women have perpetuated harmful traditional and cultural practices in many developing countries, leading to high maternal deaths in these countries due to limited control over decision making to use maternal care services (Ogu et al 2016). In some cultures, pregnant women are denied of eating certain foods that in fact are nutritious and help development of pregnancy, example, pregnant women are not allow to eat eggs to prevent the unborn child from stealing or prevent the unborn baby to be too big that can cause the need for caesarean section (Ogu et al 2016).

Social cultural factors have been stumbling blocks in using modern contraceptive methods in some parts of Sub-Saharan African countries (Ogu et al 2016). There are many women around the world that are still undecided if to get married or not.

It is estimated that, in developing countries, around 218 million women and girls, aged 15-49 who are not willing to get pregnant but not using modern contraceptive methods due to lack of access to the service, religious idealogy or their partners and communities disapproved the use of modern contraceptives, resulting to unintended pregnancy, unsafe abortion or unplanned birth (Sully, et al 2019). It is estimated that 35 million unsafe abortions do occur annually in low and middle-income countries (Sully, 2019) and according to WHO (2019) complications in pregancy and chidlbirth and unsafe abortion were the biggest killers globally among aged 15-19. It is estimated that up to 13 percent of maternal deaths each year are attributed to unsafe abortions (WHO 2019).

The traditional and cultural practices of Female Genital Mutilation/cutting has had a great negative impact on women’s maternal health. Statistics have shown that globally almost an estimated more than 140 million women and girls have been subjected to some form of FGM with yearly 3 million girls being subjected to or at risk of being subjected to FGM (Kaplan et al 2013, Tiilikainen & Johansson 2008). Decision making regarding FGM is quite complex and usually base upon traditional and cultural idealogy. WHO (2010) conducted a study on FGM in Gambia and Senegal which asserted that decision-making about FGM usually involve many family members within a context marked by extensive social pressure to comply with the traditional practice of FGM. The consequential long term effect of this harmful traditional practice on women’s maternal health cannot be overemphasized because the long term risks include development of keloids (overgrowth of scar around the external genital areas) that can cause obstetric complications during childbirth, such as prolonged and obstructed labour and haemorrhage, leading to maternal death if not managed properly (Edouard et al 2013 & Matanda et al 2018).

Child marriage is a harmful practice which can be attributed to both cultural practice and socio-economic factors. Member states of United Nations have signed a resolution to end child marriage but the practice is still going on for over the years due to poverty (Ogu et al 2016). WHO (2019) reported that 7.3 million babies are born to mothers under age of 18 each year, and 9 in 10 births are girls who are married, with 18 of the 20 highest countries with child marriage found in Africa, a continet with the higest rate of maternal deaths. In many African societies, girls from poor family background are more vulnerable to child marriage than their conterpart from rich family. According to recent data, 1 in 3 women aged 20-24 in developing countries married before the age of 18 and an estimated 15 million girls under 18 marry each year (Petronic et al 2017). In recent literatures, it has been emphasised that child marriage is not confined to any geographic region or defined by any culture or religion but it takes place as far as Bangladesh, Burkinafaso, Brazil, Niger, Nicaragua and Nepal (Petronic et al 2017). According to Petronic et al (2017) South Asia consumes the largest child brides and majority of the countries in the world with highest prevalence of child marriage are in Sub-Saharan Africa.

Ogu et al (2016) argued that poverty can put young women into transactional sexual relationship and betrothal of girls before age 18, in which they lack power to negotiate the use of condom as most of the sexual encounters are in exchanged for money or material benefit which consequently put these young girls to high risk of unwanted pregnancy. As lamented by Petronic et al (2017) child marriage is a violation of the girl’s basic human rights; increases risk of early pregnancy (as they are expected to prove their fertility early in the marriage) and sexually transmissible infections (STIs) such as HIV and AIDS due to their limited knowledge about these infections and their inability to negotiate condom use with their perpetrated partners. Studies have shown that girls who married under 18 are less likely to seek medical care during pregnancy and consequently more at risk from pregnancy and childbirth related complications, the leading cause of maternal death worldwide for girls age 15-19 (Jouhki and Stark 2017).

Child marriage is a manifestation of gender-based violence and subjects these child brides to abusive sexual relationships, physical violence and deprivation, increasing their chances of delivery without skilled birth attendant (Ogu, et al 2016). Studies have also shown that the use of maternal care services is influenced by the age of the woman - young women are more less likely to use maternal care services than elder women with more power in making decisions and also their experience with the service (Jacobs et al 2017). As pointed out by Ogu et al (2016) maternal deaths are high among child married women due to lack of being attended by skilled birth attendants during delivery and prolonged obstructed labour due to undeveloped pelvis.

Sully et al (2019) pointed out that if women in low and middle-income countries (LMICs) wanting to avoid pregnancy were to use modern contraceptives and all preganant women receive proper care, the unintended pregnacy, unsafe abortion and maternal death would be dropped by two-thirds.

Literature has shown that inadequate means of livelihood and poverty of a woman plays an important role in maternal health care seeking behaviours (Ogu et al., 2016). Adde et al (2020) reported that financial constraints have prevented many people, particularly the poor, from accessing and utilising healthcare services in many Sub-Saharan African countries. Ogu et al (2016) reported that a systematic analysis of data in Nigeria’s demographic health survey has shown correlation between wealth quintile and delivery at healthcare facility where only 8 percent (8%) of women from poorest 20 percent (20%) of family delivered in a healthcare facility compared with 86 percent (86%) of women from the richest 20 percent (20%) of families. In development literature, it is argued that road networks and transportation are regarded as determinants of poverty (Atuoye et al 2015).

Jacobs et al (2017) highlighted that women living in poor rural community settings had lower use of maternal care services and were less likely to use skilled birth attendants. In many African countries, road networks are poor, especially in rural areas, coupled with high cost of transportation. Therefore, a pregnant woman with low incomes from a rural setting may be challenged with availability and high cost of transportation when seeking maternal health care as evidenced in a study in rural Ghana : “We barely can feed ourselves.Even sometimes the transport cost during emergencies is too high and we are unable to afford[it]. When you ask the vehicle owners why they charged such fares, they tell you the roads are bad so it is not their fault” (Atuoye et al 2015, p5). Sustainable Development Goal 1.1 targets to end extreme poverty as it is claimed to be a major determinant of maternal mortality as it deters women from seeking maternal care and the ability to rest and eat a balanced diet (Ogu et al., 2016). Eating a balanced diet can prevent women from malnourishment and anaemia which increases her chance of pregnancy complications and maternal death as anaemia can trigger bleeding during delivery. Socio-cultural and economic status of women has a huge impact on their education which has an overall effect on their maternal health seeking behaviour. Education has been described as a catalyst to the realisation of the SDGs and despite a global increase in literacy rate (91%), literacy rates remain unacceptably low in Sub-Saharan Africa (Ogu et al., 2016). Educated women are more likely to make decisions where to seek treatment and it has been argued that educated women are less likely to acknowledge that pregnancy and childbirth related complications are inevitable acts that have been destined to happen by God (Ogu et al., 2016). Manyeh et al (2017) reported that a study in Ghana has shown that women with primary education were 61 percent (61%) more likely to have a skilled birth attendant at a delivery than those who had no education. Similar study conducted in Nigeria by Adewuyi et al (2017) associated home delivery with lack of paternal education (48%) and paternal primary education (25%). Education gives the power of knowledge to women to demand and seek proper health care and it has been claimed that maternal mortality tends to be higher in countries where female literacy rate is lower than the male literacy rate (McAlister and Baskett 2006). A recent WHO global survey on maternal and perinatal health has shown that maternal death was three times more likely in women with no education than women with tertiary level education (Ogu et al 2016). A literature review has shown that educated women tend to marry and bear children later than the less educated ones, therefore making childbearing safer for them (Ogu et al., 2016). Studies have shown that there is a strong correlation between Gross Domestic Product (GDP), “measure of the economic output of a nation” and maternal mortality rate, as the assessment of maternal mortality in 181 countries found that higher GDP correlates well with low rates of maternal mortality rate (Ogu et al., 2016). A study conducted out by Buor and Bream (2004; cited in Osemwengie and Shaibu 2020) demonstrated correlation between skilled healthcare personnel and life expectancy at birth with maternal mortality, in which they suggested that gross national product (GNP) per capital and health expenditure per capita strongly are correlated with maternal mortality. Consequently, developing countries are urged to allocate a minimum of 3 percent (3%) of their GDP to their total health expenditure and to allocate 25 percent (25%) to reproductive health (Ogu et al., 2016).

CHAPTER THREE: CONCEPTUAL FRAMEWORK

3.1 The Three Delays Model

There are many contributing factors that influence pregnant women’s delay in access to and use of healthcare facilities and treatments in The Gambia and thus, no single conceptual framework will be enough to fully explain in detail all the contributing factors that delay pregnant women’s access to maternal healthcare services in The Gambia. This research will be based upon qualitative methods to explain how socio-cultural, economic and health systems contribute to the high maternal mortality in The Gambia by using the conceptual framework of the “Three Delays Model” to help better explain the relationship between the contributing factors and the high maternal mortality in The Gambia. The Three Delays Model has been developed by Thaddeus and Maine (1994) based upon the concept that majority (75%) of maternal deaths are due to direct obstetric causes and majority of these deaths are preventable with timely medical intervention, thus, highlighting delay as the main contributing factor to maternal deaths in developing countries. The three delays model has been widely used in many previous studies to examine the barriers to seeking maternal healthcare services through investigating what, why and how maternal deaths happened (SK et al., 2019).

As argued by Thaddeus and Maine (1994), pregnant women are most of the time simply blamed by care providers for the delay, however, they highlighted that the Three phases of Delay Model helps to depict the barriers and potential intervention points the pregnant woman encounters during her journey from home to the healthcare facility (Chavane et al., 2018). The three delays model has three phases described as: Phase 1 delay - delay in deciding to seek care; phase 2 delay - delay in reaching an adequate/appropriate healthcare facility and phase 3 delay - delay in receiving adequate care at the healthcare facility. The research will now explain these three phases of the delay model within the contextuality of The Gambia.

3.1.1 Phase 1 delay - delay in deciding to seek care

This phase is influenced by contributing factors that delay pregnant women to recognise danger signs and make decisions to seek care for pregnancy and birth related complications (Jammeh, Sundby and Vangen 2011). Pregnant women in The Gambia, like many in developing countries, decision making to seek care is sometimes not under their control - it is usually influenced by many factors such as nature of the illness; socio-cultural factors; socio-economic factors and experience with the healthcare system (Thaddeus and Maine 1994; Mgawadere et al., 2017).

3.1.2 Phase 2 delay - delay in identifying and reaching healthcare facility

Accessibility of maternal healthcare services can influence women’s decision and determine time spent in reaching the health facility (Thaddeus and Maine 1994). The reasons for this delay can be subcategorized: transportation and travel distances; and seeking care at more than one facility.

3.1.3 Phase 3 delay model - delay in receiving adequate and appropriate treatment

Chavane (2018) highlighted that this phase is one of the critical causes of preventable maternal deaths in developing countries. Thaddeus and Maine (1994) argued that delays in the delivery of care are a symbol of inadequate care that results from staff shortage, shortages of essential equipment and drugs and blood as well as inadequate management.

CHAPTER FOUR: RESEARCH METHODOLOGY

4.1 Introduction

It is well known that research methodology dictates what method and procedures to be used to design, collect and analyse data. There are different methodologies that can be used in research, however, in this research, a qualitative method is being used together with Thaddeus and Maine’s model ( three phases of delay) as a conceptual framework to try to find out and analyse answers to the research questions.

This chapter will involve the followings: research aims and questions, research design, data collection method and limitation of the research study.

4.2 Research aims and questions

The overall aim of this research is to identify how socio-economic factors, cultural practices and health systems contribute to maternal mortality rates in The Gambia with a view to broadening understanding and knowledge in the subject area and also to contribute to the development of the literature.

The research questions are:

1. Identify the drivers of high maternal mortality in The Gambia?

a. To examine the socio-cultural and economic factors influencing persistently high maternal mortality rate

b. To identify health service factors associated with high maternal mortality rate

2. What actions have been taken to reduce maternal mortality in The Gambia?

4.3 Research Design

The research design is based on a qualitative method to interpret the factors contributing to maternal mortality in The Gambia. The researcher uses The Three Delays Model adopted by Thaddeus and Maine in 1994 to investigate the preventable causes of maternal mortality based on three phases of delay: delay in deciding to seek care; delay in reaching an adequate/appropriate healthcare facility and delay in receiving adequate care at the healthcare facility

4.4 Data collection method

The data collection for this study is based on a secondary literature review of relevant published documents about the factors contributing to maternal and mortality in The Gambia using collective data from the most recent Demographic and Health Surveys in The Gambia and SSA. Relevant information and databases were reviewed and analysed together with searching of the reference lists of the articles, reports and books retrieved to access the original sources. The research also involved internet search by using Google Scholar search engines to get access to Department of Health’s of The Gambia relevant data, Gambia Bureau of Statistics, World Health Organization, UNFPA, UN, African Development Bank and World Bank websites. The researcher reviews relevant documents and makes selections by reading abstracts, executive summary and conclusions. Grey literature is also used including media reports, newspapers, social media such as Facebook and Messenger to retrieve relevant information. Keywords used to search for literature were: The Gambia, maternal mortality, EmOC, MCH, developing countries, SSA, health service utilisation, Family planning, Socio-cultural, Socio-economic and human rights. Although ethical issues are quite important in any research work, however, this study does not need any as it is based upon secondary research by reviewing relevant literature.

4.5 Limitation of the study

This study has its limitations as it is squarely based upon literature review using some documents based on grey literature (Thesis and social media report) due to limited access to data in The Gambia coupled with limited published literature on the research topic on Gambia. Research studies on maternal mortality in The Gambia are very few and mostly biomedically conducted in rural areas in The Gambia. The researcher is both a trained nurse and trained midwife with keen interest in maternal mortality in The Gambia.

CHAPTER FIVE: RESULTS AND DISCUSSION

5.1 Results

Based upon the literature review, the high maternal mortality in The Gambia can be attributed to delay in deciding to seek care, delay in identifying and reaching healthcare facilities and delay in receiving adequate and appropriate treatment at the healthcare facility coupled with the actions taken by the government to reduce maternal mortality. However, in an attempt to answer research questions the analysis of these results are presented this format:

5.1.1 Drivers of high maternal mortality in The Gambia

5.1.1.1 Socio-economic factors

The Gambia, like many Sub-Saharan African countries, economic constraints have deterred many women from accessing and utilising healthcare services (Adde et al., 2020). Lowe, Chen and Huang (2016) argued that women in The Gambia ponderously foot most of the healthcare expenses, however their lack of cash incomes and savings have limited their control and utilisation of land to do some income generating activities to enable them to raise some money for their maternal healthcare needs, resulting to limited intra-household bargaining power by becoming entirely dependant on their husbands or family members for financial support which consequently reduce their decision making power to seek maternal healthcare services on time. Although maternal healthcare service is free in The Gambia, the lack of finance can be an impediment in reaching this service. The financial cost involved in receiving free maternal healthcare services, such as cost of medication, bed fees for extended stay, transportation cost and other associated opportunity costs has been a burden and barrier to Gambian women to seek free maternal healthcare services (Jammeh, Sundby and Vangen, 2011).

A study conducted by Jammeh, Sundby and Vangen (2011) on barriers to EmOC services in perinatal deaths in rural Gambia, reported that in some instances, family members have to borrow money or sell their assets to meet some of these costs as explained by a 20-year old woman with severe pre-eclampsia/haemorrhage:

“He (her husband)gave us the little money he had on him….to raise more money he initially sold his goat and latter his sheep….We are farmers so we barely have enough for the family upkeep not to mention about(sic)emergency funds” (Jammeh, Sundby and Vangen, 2011, p5).

5.1.1.2 Socio-cultural factors

Literature review has shown that women in The Gambia are facing many challenges in accessing maternal health care during the entire period of pregnancy due to socio-cultural factors (Lowe, Chen and Huang 2016). In The Gambia pregnancy and childbirth are often within a woman's entity and many cultures consider it as a natural phenomenon and as a result, decisions to seek care are often influenced by the traditional “wait and see” approach in which actions are taken only when complications occur (SK et al., 2019; Seljeskay et al 2006). Mostly when these complications occur, older women/mother-in-laws in their menopause are usually contacted for advice and decision making as they are regarded as experts on pregnancy and childbirth and are hardly disputed (Cham, Sundby and Vangen, 2005). It has been argued by Thaddeus and Maine (1994) that pregnant women’s health seeking behaviour is greatly influenced by the nature of their illness and the ability to recognise that abnormality exists to seek specialist treatment.

A recent survey conducted in six regions of Senegal has shown that women in these regions did not know the basic signs and symptoms of obstetric complications with some recognising fever, dizziness and pallor as signs of a normal pregnancy (Thaddeus and Maine 1994). A similar study conducted in The Gambia by Cham, Sundby and Vangen (2005) highlighted that actions taken by women are influenced by their previous uncomplicated pregnancies which lead to delays in decision making process from two hours to five days. Women with an uneventful previous history of home delivery usually consider seeing a healthcare facility prior to delivery as unworthy and therefore, less likely to seek a decision to use maternal healthcare services (Karanja et al., 2018). In The Gambia, most pregnant women do not disclose their pregnancy during the first trimester for fear of miscarriage/harm from the bad people (witches and enemies) through spiritual manipulation and therefore, use ANC lately (Laing et al. 2017). As highlighted by Cham, Sundby and Vangen (2005) some women and family members in The Gambia use previous pregnancies as a risk-prediction tool. Like many women in African countries, most women in The Gambia regard delivery outside home as shameful and being attended by a male care provider, particularly during labour and childbirth, as culturally and religiously immoral and unacceptable and thus, they prefer to deliver at home by a TBA or a relative (Cham, Sundby and Vangen, 2005). Although there has been progress in the number of women using antenatal care and access to healthcare facilities, the vast majority of women in The Gambia delivered at home by TBAs with no formal training in recognising obstetric complications and only one in five women with obstetric emergencies report to a healthcare facility for assistance (Lowe et al., 2016). A study conducted in Kassal, eastern Sudan, to examine the knowledge and practice of TBAs has given support to this statement where the results had shown only ten percent (10%) of TBAs aware of danger signs in pregnancy and with less than twenty-five percent (25%) referred a woman to health facilities with obstetric complications (Ali and Siddig, 2012).

According to Lowe, Cheng and Huang ( 2016) socio-cultural beliefs have limited the empowerment of Gambian women’s maternal healthcare seeking decision making and created unequal distribution of household works for them, resulting in an increase in their physical and emotional work burden with little rest throughout the duration of pregnancy. This unequal distribution of household works is due to the lack of a household head’s understanding of women’s problems as women feel ashamed to discuss any issue related to pregnancy and sexuality due to socio-cultural beliefs (Lowe, Chen and Huang, 2016). The traditional beliefs associated with pregnancy and delivery has also limited men’s involvement in maternal health to provide the required support women needed during pregnancy and delivery as explained here by a husband:

“We think that pregnant women should be taken to the health facility by their fellow women especially during delivery. It is better to leave it that way since pregnancy and delivery is not our (husbands) responsibility” (Lowe 2017, p3).

Men are seldom involved with household chores due to social stigma attached to it which increases household work burden on women and consequently limit their already limited available time to access and use healthcare service for delivery and pregnancy related complications (Lowe, Cheng and Huang, 2016). Like many SSA countries, Gambia has a patriarchal marriage system which affects women intra-household decision making power and consequently, decision to visit a healthcare facility for delivery is usually made by older family members or mother-in-laws who are negative of using the skilled birth attendants (Jammeh, Sundby and Vangen, 2011). A study conducted in The Gambia by Cham, Sundby and Vangen (2005) highlighted instances where mother-in-law prepared traditional herbs for her daughter-in-law with obstructed labour to make delivery quick and painless and advised her not to go to hospital too early and to wait after three hours (the next Muslim prayer time) before seeking medical attention. This problem is further compounded by the woman’s limited ability to go out (even to attend maternal healthcare clinics), without the consent of her husband or mother -in-law which consequently impedes the woman’s effort to seek immediate care as required (Thaddeus and Maine 1994). It is a common practice in The Gambia for family members to seek spiritual help when a woman is in labour or has certain conditions that are viewed as spiritual rather than physical such as eclampsia, which may delay care seeking and increases the woman’s chance of dying from pregnancy and childbirth related complications (Ogu et al 2016). Vast majority (90%) of the The Gambian population are Muslims (Kaplan et al., 2013) and many women prioritise fulfilling their marital responsibilities of meeting the needs of their partners/husbands over their own health of seeking early care when required under the banner of culture and religion (Lowe, Chen and Huang, 2016). It is a common practice in The Gambia for men leaving their older wives for younger ones within the sphere of polygamy which results to creating a cycle of intimate partner violence (Chant and Touray, 2012). A study conducted in The Gambia among antenatal clinic attendees has shown (61.8%) prevalence of intimate partner violence resulting in 12% requiring medical care and 3% prevented from seeking healthcare (Idoko et al., 2015). Studies have shown that women in polygamlous relationships are more prone to mental disorders coupled with family and financial problems than those in monogamous marriages (Al-krenawi, Graham and Izzeldin,2001). Although the legal age for marriage has been increased to 18 years in 2016 in The Gambia, early marriage is still a common practice in The Gambia. According to Jouhki and Stark (2017) statistics have shown that there are still high rates of early marriage (36%) in The Gambia and 16% of women (age 20 - 49) had married by age of 15, and 41% by age of 18 (GBOS 2014) and 19% gave birth to a child at the age of 18 (UNICEF 2010). Gambia has a fertility rate of 4.4 per woman with only 17% among married women using modern methods of contraception(GBOS 2020). coupled with unmet need for family planning of 24% of currently married and 45% of sexually active unmarried (GBOS 2020). As children are seen as valued assets in Gambian culture, any infertlie woman is likely to be divorced or her husband married a co-wife to bear children (Jouhki and Stark, 2017). As a result, this group of young girls are more likely to get pregnant early and get more children to show their fertility with consequential high risk of pregnancy and childbirth related complications (Jouhki and Stark, 2017). Due to cultural and religious beliefs, most women in The Gambia do not have formal education and a recent demographic and health survey revealed a staggering illiteracy rate of 39% among females and in which 33% live in urban areas and 53% live in rural areas (GBOS, 2020) which can have a negative effect on their maternal healthcare seeking behaviour. Ogu et al (2016) argued that the global survey on maternal and perinatal health by WHO highlighted that maternal death was three times more likely in women with no education than women with education as education affects the health seeking behaviour of women. Literature has shown that skilled birth attendance prevents maternal deaths, therefore pregnant women’s lack of using these services due to lack of education can lead to more maternal deaths (De Allegri et al., 2011).

Due to limited access to modern contraceptives with unmet need for family planning of 45% of sexually active unmarried (GBOS 2020) teenage pregnancy becomes unavoidable in The Gambia. In The Gambia, unwanted pregnancy (pregnaancy outside marriage) is often received with shame and sanction by the family and the society and as a result, they tend to conceal the preganancy and resort to illegal and unsafe abortion or completely disengage themselves with maternal healthcare services which increases risk of complication during pregancy and childbirth (Laing et al. 2017).

The cultural practice of female genital mutilation (FGM) is quite common in The Gambia with prevalence rate of 73% in women age 15-49 (GBOS 2020) which increases their risk of obstetric complications during delivery (Edouard et al. 2013; Matanda et al. 2018). A recent study on the impact of FGM in The Gambia found that one out of three girls and women suffer injuries as result of FGM and women with FGM are four times more likely to suffer complications during childbirth (Kaplan et al. 2013).

5.1.1.3 Health service factors

As argued by Chavane (2018) this phase is one of the main causes of preventable maternal mortality in developing countries and it is related to the health system. Thus, based on literature review, this section will explain in detail below how the health service factors are associated with high maternal deaths rate in The Gambia:

5.1.1.3.1 Experience with the healthcare system

Women’s previous experience with the healthcare system plays a crucial role in their maternal healthcare seeking behaviour. The quality of care provided in previous visits are used as a litmus paper for women in making decisions to seek care at the same healthcare facility. This perception is highlighted in a study in Guatemalan highlands where health facilities are conveniently located but the utilisation is low due to perceived poor quality care (Thaddeus and Maine 1994). A similar study conducted in the urban areas of The Gambia found that 40% of public workers and 15% of informal workers do not use nearest public healthcare facilities due to perceived poor quality services (Harpham, 1996). The behaviour of skilled healthcare providers and their lack of understanding towards women coupled with the fear of harassment and punishment by healthcare providers has deterred many women from seeking care from healthcare facilities in The Gambia (Cham, Sundby & Vangen 2005). A study conducted by Cham, Sundby and Vangen (2005 : p4) on maternal mortality in the rural Gambia has highlighted a case where a sick pregnant woman refused to go to a health centre to seek treatment because she feared the nurses would be rude to her for not having an antenatal card. In addition, the increasing number of male midwives and younger qualified midwives and nurses are also contributing factors to non-utilization of health services by women during labour and delivery (Cham, Sundby and Vangen, 2005).

A recent study conducted in The Gambia by Ferguson et al.(2020) pointed out that some women would prefer to die at home during childbirth than to be attended by a male care provider at the healthcare facility. Although there has been progress in access to a primary health facility, there is still high percentage of women delivering at home which could be due to structural factors in provision of maternal healthcare services on antenatal clinic days during weekdays only which gives wrong impression to women that maternal healthcare services are only available on clinic days (Cham, Sundby and Vangen , 2005 ).

5.1.1.3.2. Facility infrastructure and Uneven distribution

The Gambia has poor facility infrastructures that have ramifications of quality service. The shortage of electricity power and water supply are quite common in The Gambia with no exception to healthcare facilities which can delay treatment in emergency situations with possible fatal results. The healthcare system in The Gambia has made it difficult to reach the appropriate facility for care due to distance and unavailability of certain healthcare services within the healthcare facility. At times women had to travel long distances under poor road conditions using unsuitable transportation systems (donkey/horse cart or bicycle) with high chance of dying on the way and only to find that the service is not available after reaching the healthcare facility (Jammeh, Sundby & Vangen 2011). Thaddeus and Maine(1994) argued that reaching the health facility does not mean the end of healthcare seeking journey as the nearest healthcare facility might be a peripheral one with no basic equipment to treat the condition or even to offer basic essential first aid and by time the woman is transferred to a suitable /adequate healthcare facility, her risk of dying during the journey will increase. Cham, Sundby & Vangen (2011) highlighted that this predicament is not unfamiliar in The Gambia where some healthcare facilities cannot provide basic obstetric emergency care and have no ambulance (to transfer women to the nearest hospital) or even they do have, it usually serves multiple purposes and may not be available at times or lack fuel. This statement has been substantiated by a midwife who explained how a patient came to the health centre at around 4:00pm but could not managed her and needed to transfer her to hospital for possible caesarean section but their ambulance had a breakdown a week ago and there was no transport through out the night until the following morning around 11:00am when they got transport from agricultural department to transport the woman to hospital (Cham, Sundby & Vangen 2005, p4). In a recent study, Cham, Vangen & Sundby (2007) reported that 25% of the 42 maternal deaths that occurred at their study areas were related to delays in reaching a medical facility and in receiving care at the facility.

The uneven distribution/location of public healthcare facilities (more concentrated in urban areas) in the country coupled with limited basic obstetric emergency care facilities resulted to pregnant women being transfer from one healthcare facility to another one resulting to delays in access to appropriate treatment with high risk of death as explained by a husband of a deceased:

“We took her to the health centre in the village….she was examined by the nurse who later transferred her to another health centre [44 km away]. There she spent the night and the following morning she was again transferred to the hospital [36 km away]. On our way to the hospital we had to cross the river at two different crossing points. Immediately after we arrived at the hospital she died” (Cham, Sundby & Vangen 2005, p5 ).

Thaddeus and Maine (1994) argued that studies have shown that people living in urban areas have better access to healthcare facilities than do rural inhabitants.

5.1.1.3.3. Staff Shortage

In The Gambia, like many developing countries , there is shortage of trained and qualified healthcare personnel at all levels of the healthcare delivery system with rate of 0.107 physicians and 1.618 nursing & midwifery per thousand population which has a negative impact on the quality of maternal healthcare services (WHO 2018) as it leads to delays in receiving the care they need (Thaddeus and Maine 1994). According to WHO (2018) 84% of health workers in the country are in the public sector with a maldistribution of health workforce of an urban bias of 66% of them working within the main urban region causing unnecessary shortage of staff in the rural areas. The shortage of staff can be attributed to high attrition rate of trained health workers where more than 50% have been lost in the last ten years to private institutions (WHO 2018). The main teaching hospital in The Gambia lost 57 Registered Nurses from 1998 - 2003, creating a vacancy rate of 33% with a quarter of its graduate staff leaving the country (Gerein, Green & Pearson 2006). It has been reported that many basic health facilities do not even have a midwife resulting in increased workload in tertiary hospital (Gerein, Green & Pearson 2006, p44).

The loss of a high number of health professionals can make it difficult for any manager to maintain adequate staffing and good quality of care (Gerein, Green & Pearson 2006). The poor working and living conditions of staff, such as housing , salaries and condition of the healthcare facilities are major factors contributing to high attrition of staff to private sectors and emigration (Chigudu et al. 2018). The shortage of trained and qualified healthcare personnel has led to the limitation of providing essential obstetric surgery. For example , study in Central and Upper River Divisions has shown a caesarean section rate of only 0.6% (far below recommended rate of 5-15%) and also obstetric labour cases spent on average 4 days before any intervention of which five of them underwent caesarean sections on the fourth day and died shortly (Cham, Vangen and Sundby 2007).

5.1.1.3.4 Shortage of equipment and drugs

The material and technical resources pose a major problem in the health system. There is inadequate supply and distribution of drugs and equipment in the healthcare facilities such as surgical equipment and vacuum aspirators and basic gloves, giving sets and blood bags (Cham, Sundby & Vangen 2009). Most of the equipment and drugs are acquired through donor support and many of the equipment are poorly maintained or no longer working (Chigudu et al. 2018). Private funding is respponsbile for 60% of Gambia’s total expenditure on health which highlighted the intermittent shortage of essential drugs in public healthcare facilities, increasing opportunity costs on women using the service (Cham, Sundby and Vangen, 2009).

5.1.1.3.5 Shortage of blood supplies

Blood transfusion is one of the key life-saving interventions that should be available in the first level referral healthcare facilities providing emergency obstetrics care for reduction of maternal deaths (Jammeh, Sundby & Vangen 2011), however shortage of blood supplies in the healthcare facilities, particularly the major referral hospitals have been a concern to citizens and civil societies.

Shortage of blood causes delay in receiving appropriate care. Studies have shown that one of the district hospitals in the country (Farafenni General Hospital) had more than 15 maternal deaths due to lack of blood and malfunction of the blood transfusion services such as lack of blood bags, electricity and commercialised of blood donation (Cham, Vangen & Sundby 2007).

5.1.1.3.6. Inadequate management

The lack of proper management can contribute to delays in delivery of care through poor management of staff. The maldistribution of staff can cause undue staff shortage in other areas. For example in one hospital three doctors were given annual leave on one occasion leading to one doctor in the whole maternity unit to do ward rounds, perform operations and run an out-patient clinic (Cham, Sundby & Vangen 2005). There are instances where there are no duty rosters for doctors and after working hours, it becomes difficult to look for them when there is an emergency (Cham, Sundby & Vangen 2005). Lack of adequate management to put appropriate policies in place can also lead to poor working practice leading to maternal death such as this case in a hospital where a patient was received from a health centre on the 13th around 9:00am and seen by doctor and diagnosed hand-presentation and asked midwives to observe her. No action was taken by the doctor until late in the evening on 15th and took her to theatre and performed a caesarean section and the patient was wheeled death from the theatre (Cham, Sundby & Vangen 2005, p5). Sometimes political factors create barriers to proper management whereby the government officials at national level interfere with policy work at regional and local levels with the purpose of making their presence felt in the rural areas to gain political support (Chigudu et al. 2018)

5.1.2 Steps undertaken to reduce maternal mortality in The Gambia

Over years there have been many strategies and interventions implemented by the The Gambia government to reduce maternal mortality. One of the early strategies taken by the government was the introduction of a primary health care (PHC) program in 1998 with the aim to make healthcare more accessible and affordable to the majority of the citizens. However, Jammeh, Sundby & Vangen (2011) highlighted that physical access to healthcare services remains a problem in The Gambia. To make the public healthcare facilities more effective and efficient, The Gambia government through its line ministry in 1993 replaced and increased the three regional health teams (RHT) in the country to six divisional health teams (DHT) responsible for the day to day administration, management and supervision of the primary and secondary levels healthcare facilities within each respective division. However, the management and provision of care at the healthcare facilities within these regions have been hampered by severe inadequate human resources, poor facility structures coupled with power tussle between RHT leaders and the national government and the interference of government officials with regional policy work to gain political support at rural areas (Chigudu 2018). In 2001, the Ministry of Health introduced a new health policy called “Changing for Good' ' incorporating socio-economic and health development challenges with the sole aim of providing accessible quality healthcare to all Gambians that would be a model within the African region by the year 2020 (WHO 2006). In 2012, a new policy called “Health is Wealth” was introduced as part of national development plan, vision 2020 - replacing the 2001 policy - “Changing for Good” - with the main target of reducing the maternal mortality rate from 730 per 100,000 live births to 150 per 100,000 live births by 2015 (MOH 2012). Unfortunately this target was missed and Gambia is still burdened with high maternal mortality. The government through the Ministry of Health (MOH) also launched a training programme with support from donor partners to train midwives in advanced midwifery who are best known as “at risk midwives'' to provide sufficient and adequate care to obstetric emergencies at district levels/major healthcare centres and this resulted in amelioration of all minor healthcare centres to major healthcare centres with provision of equipment and trained personnel to provide emergency obstetric care (EmOC) (Cham 2003).

With support from WHO country office in 2006, the Ministry of Health trained nurses to become Nurse anaesthetists and Scrub nurses to help in essential surgical operations at district level/major healthcare centres together with comprehensive training of health personnel in emergency surgical interventions to reduce maternal mortality and trauma at district level (WHO 2006). However, both training programmes were stopped due to lack of sustainability as the government depends heavily on donor support for its health budget/expenditures. There still remain big challenges for women to reach the limited facilities providing EmOC services in the country. In 2015, the government initiated a results-based financing intervention to increase uptake of skill delivery which has yielded positive results with significant increase in referral to health facilities for delivery. However, this project benefited only one third of the population and did not last long due to funding (Ferguson & Hassan 2020). The same year in January 2015, TBAs were redesignated as ´Community birth companions´ (CBCs) and their role changed to referring and or escorting women during labour and childbirth with or without complication to health facilities as their inability to provide emergency obstetric care has hindered effects to reduce maternal mortality (Ferguson & Hassan 2020). Government has advised that all deliveries should take place at the health facilities and be attended by skilled personnel (Ferguson & Hassan 2020).

However, this is a big challenge to the government due to staff shortage, poor accessibility to healthcare and poor health system. The government has good comprehensive health policies which may make the national health system look optimistic on paper, however the implementation of these policies is a major challenge. For example the country started training its own medical doctors with more than 6 classes graduated but most of them working in the urban areas and majority of the healthcare services at field level are provided by nurses and expatriate doctors (Sundby 2014). Although, government has declared free maternal healthcare services, the burden of out-of-pocket expenditure for services is reported to be as high as 80% due to the government's lack of adequate expenditure on health - less than Abuja-recommended 15% target of the national budget on health (Sundby 2014). The present government promised to make MCH as their first priority and to make the health system free from political interference (Green 2017), however this promise is yet to be seen and there has been reports of almost daily occurrence of maternal deaths, - on August 11, 2021 Gambia Women's Lives Matter reported 3 maternal deaths on the same day from caseration section in a main teaching hospital. The current government has been downplaying the levels of maternal mortality in the country, and have not made any tangible effort to reduce the levels of high maternal mortality in the Gambia.

5.2 Discussion

This is based on the findings in the previous sub-heading and attempts to address some of the interventions used to overcome each factor.

5.2.1 Socio-economic and cultural factors

Decisions to seek care during obstetric emergencies are commonly influenced by socio-economic and socio-cultural factors, nature of illness and distance. The low status of women in Gambian society due to cultural and religious beliefs limit their intra-household bargaining power to make decisions regarding their maternal healthcare needs. The family members that make decisions for them also lack awareness of potential pregnancy and childbirth related complications. The lack of awareness of these complications appear to be high among uneducated women due to their limited accessibility to maternal health related information. This problem is compounded by the high rate of illiteracy among TBAs who are involved in the majority of deliveries in The Gambia, particularly in the rural areas, and lack knowledge and skills in recognising and managing pregnancy and childbirth related complications. Many years ago, there used to be mobile public health education film shows in all parts of the country to increase people's awareness in health related matters and I believe this can be reintroduced again to overcome this problem. A study in Sierra Leone to increase knowledge on preparation and decision making about child births has shown an increase in community´s knowledge and understanding about the importance of healthcare facility delivery and danger signs in pregnancy and childbirth (Herschderfer et al. 2012). There used to be home visits by midwives in The Gambia but this practice has been stopped and I believe reintroducing it can help to reduce maternal mortality. This is evidence in a study in Egypt which reported a half reduction in maternal mortality through home visits-based programs educating communities on pregnancy, delivery and postpartum warning signs (Gipson et al. 2005). A study in Guatemala and Brazil about evaluation of training programs on detection of obstetric complications to TBAs has shown a remarkable increase in the number of cases referred to healthcare facilities by TBAs (Koblinsky et al. 2000). This training can be done in The Gambia to increase TBAs knowledge on obstetric complications. Another strategy that can be taken by The Gambia government to reduce maternal mortality is to try electronic health program as this was piloted in Rwanda to track and monitor pregnant women and the pilot study reported 75% of detecting pregnancies and also identified at risk pregnant women, resulting zero maternal death during the period (UNFP 2012).

5.2.2 Health service factors

The uneven distribution and location of healthcare facilities in The Gambia make it difficult to access maternal health care service in certain areas due to distance and poor roads, particularly during times of obstetric emergencies. Maternity waiting areas (MWAs) have been developed near healthcare facilities for use by high risk pregnant women during the last weeks of their pregnancy to ease access to maternal care (WHO 1996) and an evaluation of this in Ethiopia has shown considerable difference between those admitted directly from home and those from MWAs (Kelly et al. 2010). Gambia could benefit a lot from adapting this program since EmOC care facilities are limited and access to them is difficult.

Economic constraints have deterred many women from accessing health care services in The Gambia (even though maternal healthcare service is free) due to associated opportunity costs coupled with lack of health insurance schemes for many Gambians. A Safe Mother Initiative with a component of community support system to secure emergency funds for transport and obstetric service costs has assisted many to timely access emergency obstetric service in Bangladesh during 1998 - 2001 (Hossain & Ross 2006). A similar project intervention (results-based financing intervention) was initiated by Gambia government in 2015 to increase uptake of skill delivery and results show significant increases in referral to health facilities for delivery, increase in accompaniment to health facilities for delivery and also increase in transportation to health facilities for delivery (Fersuson & Hassan 2020).

Staffing is a key element in providing quality maternal health care services and developed countries like England have increased training of more midwives to increase accessibility to skilled birth attendants (Brouwere et al. 1998). Although, there has been an increase in training midwives and nurses in The Gambia, retaining and motivating them has been the ongoing problem coupled with the changing roles of TBAs to CBCs for referring and or escorting women during labour and childbirth to the health facility. Many women are not utilising facility care due to perceived poor quality of service coupled with staff shortage, staff attitudes and lack of drugs and other medical supplies. Socio-cultural and religious factors can make health facilities unacceptable by women which can impede utilization of healthcare services. Therefore, socio-cultural factors and religious factors need to be recognised and understood by service providers. For example, a facility-based intervention to develop gender sensitive approach in managing obstetric problems with attention to training of staff on communication skills and waiting time and cleanliness of health facilities under Safe Motherhood Initiative was done in Bangladesh with good outcome - facility deliveries increased from 2.4% to 20.5% (Hossan & Ross 2006)

CHAPTER SIX: CONCLUSION & RECOMMENDATIONS

Although the evidence gathered in this study is not enough, it is evidence in this study that the causes of maternal mortality in The Gambia are multifaceted such as socio-cultural and economic factors, health service delivery factors and actions taken by the government. This highlighted that the factors are intertwined and therefore all barriers need to be understood and responded to in order to minimise the risk of maternal mortality. The study has pointed out evidence of rural - urban inequalities in health, education and income. Lack of women empowerment has limited their intra-household power dynamic to make decisions for their healthcare needs which overall put them at high risk of pregnancy and childbirth related complications. The study findings also show how political interference and inadequate management, such as poor staff placement/postings and poor management of staff duty rota in the health system contributes to maternal mortality. It also highlighted the lack of human resources of trained healthcare professionals coupled with lack of drugs and other medical supplies and their negative impact on the health system.

The literature has shown that despite efforts made by The Gambia government, it is still far from achieving the health agendas of SDGs. However, the study has shown some policies, strategies and interventions done by some countries to reduce their maternal mortality. This shows that the Gambia government could do similar cost effective interventions to increase utilization of health services and skill birth attendants to reduce maternal mortality. The literature review of this study has considerably widened my knowledge and intellectual thinking on the topic/subject matter and I am sure it will contribute to the academia.

In view of the literature review and study findings, the following recommendations are made:

1. Give priority to maternal health and maternal mortality and let them be on your agenda to have more political support.
2. Encourage and support more research on maternal health and make maternal audit mandatory and investigate any incident of maternal deaths in health facilities
3. In order to have a significant number of births attended by SBA, the government needs to ensure adequate numbers of midwives trained and deployed appropriately.
4. Promote women empowerment and human rights
5. develop locally acceptable interventions that will increase the chance of effective and long lasting positive changes to increase health care utilization and reduce maternal mortality.
6. Develop policies and guidelines regarding management of women on admission and discharge in maternity wards to minimise confusion

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