Obiang-Obounou and Fuh Maternal and Infant Mortality in Chad ORIGINAL RESEARCH ARTICLE The State of Maternal and Infant Health and Mortality in Chad DOI: 10.29063/ajrh2020/v24i1.4 Brice Wilfried Obiang-Obounou1* and Manka Eunice Fuh2 Department of Food Science and Nutrition, Keimyung University, Daegu, South Korea1; Department of Public 2 Policy and Administration, Yeungnam University, Daegu, Korea *For Correspondence: Email: [email protected]; Phone: +82-53-580-5870 Abstract The level of Chad‘s government expenditure on health is a predictor of the general health of the population and, consequently, life expectancy. We used data from the World Bank‘s World Development Indicators and publications from the World Health Organization to assess the state of maternal and infant health and mortality. The primary objective of this research was to investigate whether Chad had reduced the risk of maternal and infant mortality after signing the Abuja Declaration in 2001. We hypothesised that increased general government health expenditure was associated with improved health mediated by increased numbers of skill health workers and minimum out-of-pocket health expenditure. Our secondary objective was to assess effective implementations of health policies in line with the Millennium Development Goals that Chad has agreed to achieve by 2015. We observed that, as of 2015, the government health expenditure was only 6.28% and the population out-of-pocket spending was over 56%. Furthermore, only 20% of women give birth in a hospital. These results led to three major policies recommendations in order to improve maternal and infant health in Chad: skilled birth attendants training, enhanced social status of nurses, and the development of a supplemental nutrition care program for women. (Afr J Reprod Health 2020; 24[1]:26-34). Keywords: sub-Saharan Africa, maternal mortality, infant mortality, poverty, Abuja Declaration, Chad Résumé Le niveau des dépenses publiques concernant la santé au Tchad est un indicateur de la santé générale de la population et, par conséquent, de l‘espérance de vie. Nous avons utilisé les données des indicateurs du développement dans le monde de la Banque mondiale et les publications de l‘Organisation mondiale de la santé pour évaluer l‘état de santé et de mortalité maternelle et infantile. L'objectif principal de cette recherche était de déterminer si le Tchad avait réduit le risque de mortalité maternelle et infantile après la signature de la Déclaration d'Abuja en 2001. Nous avons émis l'hypothèse qu'une augmentation des dépenses publiques de santé générale était associée à une amélioration de la santé grâce à un nombre accru d'agents de santé qualifiés et des dépenses de santé remboursables minimales. Notre objectif secondaire était d'évaluer la mise en œuvre efficace des politiques de santé conformément aux objectifs du Millénaire pour le développement que le Tchad a convenu d'atteindre d'ici jusqu‘à 2015. Nous avons observé qu'en 2015, les dépenses publiques de santé n'étaient que de 6,28% et la population hors les dépenses de poche dépassaient 56%. De plus, seulement 20% des femmes accouchent à l'hôpital. Ces résultats ont conduit à trois recommandations sur les politiques majeures afin d'améliorer la santé maternelle et infantile au Tchad: la formation d'accoucheuses qualifiées, l'amélioration du statut social des infirmières et l‘élaboration d'un programme complémentaire de soins nutritionnels pour les femmes. (Afr J Reprod Health 2020; 24[1]: 26-34). Mots-clés: Afrique subsaharienne, mortalité maternelle, mortalité infantile, pauvreté, Déclaration d'Abuja, Tchad Introduction six-member countries of the Central African Economic and Monetary Community (CEMAC), The Republic of Chad (Chad) is a landlocked including Cameroon, the Republic of Congo, country sharing borders with Libya to the north, Gabon, Equatorial Guinea, and the Central African Sudan to the east, Niger to the west, the Central Republic. The country is the fifth largest country African Republic to the south, and with Cameroon in Africa in terms of area (1,284,000 square and Nigeria to the southwest. Chad is one of the kilometers). Yet, only 1 out of 5 women give birth African Journal of Reproductive Health March 2020; 24 (1): 26 Obiang-Obounou and Fuh Maternal and Infant Mortality in Chad in hospitals and most infant deaths in the country important predictor of malnutrition and poor are preventable. This is mostly due to over 45% of health. its population living at or below the national The primary objective of this research was poverty line according to the World Bank1. to investigate whether Chad has reduced the risk The poverty line is defined as the amount of of maternal and infant mortality after 15 years income needed to afford the necessities of life, through the adoption of the Abuja Declaration in such as food, water, and shelter2. The Human which African leaders decided to allocate 15% of Development Index (HDI) is a summary measure their government expenditure on health. We of average achievement in key dimensions of hypothesised that increased general government human development: a long and healthy life, being health expenditures are associated with improved knowledgeable, and having a decent standard of health that are mediated by increased numbers of living3. While Chad‘s population grew from 5.96 skilled health workers and a minimum out-of- million in 1990 to 14 million in 2015 (Table 1), pocket health expenditure. A secondary objective HDI results, which considers life expectancy as a of this study was to propose effective health key element of human development, was 0.396, policies in line with the Millennium Development ranking Chad 186 out of 188 countries4. Goals that Chad agreed to achieve by 2015. These Chad has potential for economic goals include eradicating extreme poverty and development, especially since it started oil improving maternal and infant health. It is hoped exploration in 2003. Oil rents (i.e., the profit that this initiative will help prevent children and difference between the cost of crude oil production maternal mortality in Chad. and its selling price) have doubled current In this study, we first present Chad‘s government revenues. However, the population general socio-demographic and health status. Next, remains poor with those first being affected we analyze Chad‘s maternal and infant nutrition negatively being women living in a lower and health status. We then examine the country‘s socioeconomic status and children under 5 years healthcare system. The final section discusses old. If the health of the mother and her child are possible nutrition and health policies for Chad‘s determinants of the country‘s overall health most vulnerable populations: children and their situation, factors such as low Gross Domestic mothers. Product (GDP)5, poor socioeconomic status (SES)6, and malnutrition will adversely affect their Methods health, increase maternal and infant mortality, and Our data are mainly from the World Bank‘s World consequently decrease life expectancy at birth (life Development Indicators (WDI) database and expectancy). We had previously shown the publications from for the World Health relationship between socioeconomic status, dietary Organization (WHO). In September 2000 189 intake, food insecurity (malnutrition), and health7. countries signed the Millennium Declaration with SES is commonly conceptualized as the social the goal of improving the socioeconomic status of standing or class of an individual or group. It is the poorest countries around the world by 2015. often measured as a combination of occupation, The following year, African Union countries income, and education. A mother‘s ability to buy pledged to spend 15% of their annual budget to or consume enough safe and nutritious food to improve the health of their populations. Thus, the meet their dietary needs and food preferences for a data of this study cover the period 2000 to 2015. healthy and active life appears to determine their For missing data, we employed the imputation dietary practices and socioeconomic status. method using the most frequent value. Therefore, a low socioeconomic status is often Furthermore, through process tracing methods, we linked with malnutrition, poor health, and examined the impact of the Chadian governments‘ consequently a higher mortality rate. health expenditure in relation to its impact of the The socioeconomic level of the mother is an population out-of-pocket health expenditures from African Journal of Reproductive Health March 2020; 24 (1): 27 Obiang-Obounou and Fuh Maternal and Infant Mortality in Chad 2000 to 2015. The results are then compared with micronutrient deficiencies are estimated to Botswana. underlie nearly 3.1 million child deaths annually9. Malnutrition has two components resulting in diet Results and Discussion and health related problems: over nutrition and under nutrition. Over nutrition is due to excess of Socio-demographic and health status some nutrients. In Chad, maternal and infant malnutrition is associated with the absence or In 1990, Chad‘s population was approximately insufficient amounts of some nutrients (i.e., under 5.96 million and has since grown by an average nutrition). Consequences associated with annual rate of 3% or 2 million every 5 years malnutrition in Chad are problems of anemia, (Table 1). Despite its low life expectancy (52.58 absence of exclusive breastfeeding, and child years in 2015) and high death rate (13.22 per 1000 wasting (i.e., a lower than average weight for people), Chad‘s population is relatively young. one‘s height). The country is still among the 34 Approximately 47.58% of the population was 14 countries with the highest burden of malnutrition years old or younger in 2015, with only 2.46% and accounts for 90% of the global burden of over the age of 65 (Table 1). malnutrition9. A younger population should in theory be Anemia is a decrease in the total amount a predictor of economic development, a healthy of red blood cells or hemoglobin in the blood.