Choice of focal countries
The four focal countries - Burkina, Benin, Mali and Morocco - were chosen on the basis of facing challenges in maternal heath, having recently The average rate of skilled attendance at delivery for all developing countries was 42% in 1990, rising to 52% in 2000. However, the average for sub-Saharan Africa was 40% in 1990, rising to just 43% in 2000 (WHO 2006b). This is reflected in the high maternal mortality situation of the countries included in this study, particularly Burkina Faso, Mali and Benin. Their slow progress is related to the lack of financial and human resources that these countries have. Burkina Faso, Mali and Benin rank 177, 178 and 161 in the Human Development Index (out of a list of 182 countries); Morocco is 130th. Recent analyses show that they also attract less bilateral and multilateral assistance than Anglophone countries. Mali and Burkina are amongst the 30 countries contributing to largest amount of ill health worldwide (Ravishankar et al. 2009). However, they rank below 30 with respect to donor assistance for health. Francophone countries appear to have therefore an important unmet need for technical and financial assistance from the international community to improve health including reducing maternal mortality.
WHO has estimated that the maternal mortality ratio in Burkina Faso was 1,000 per 100,000 live births in 2000. While it is worth noting that official estimates are much lower than this (307/100000 for 2008), the authorities have given priority to the reduction of maternal mortality. However, despite efforts to promote antenatal care and improve access to emergency obstetric care, the use of health services remains low (54%, MICS 2006), in part because of growing household poverty and the financial barriers associated with user fees in health facilities. In March 2006, the government made the bold decision of introducing a “subsidy policy” to the cost of delivery and obstetric and neonatal emergency care for women and their babies.
The level of maternal mortality in Benin has reduced from 498 maternal deaths per 100,000 live births in 1996 to 397 maternal deaths per 100 000 live births in 2006 (DHS 1996, DHS 2006). Benin also has some of the highest levels of skilled birth attendance (76% nationwide in 2006) and antenatal care utilisation levels in Africa. However, Benin is not on track to meet its MMR target by 2015. A number of bottlenecks have been identified, in particular related to inequities in the use of skilled birth attendants and access to EmOC, which vary according to wealth quintiles and geographical areas. There are also problems of poor quality of care provided in hospital maternity units which have been documented by several studies (Saizonou et al. 2006; Edson et al. 2007; Stanton et al. 2009).
Health care is prohibitively expensive for the majority of the Malian population, particularly women and children. According to the latest report of the national health accounts (2004), 51 % of health expenditure is supported by households, compared with 22% by the state. Mali has a very high MMR (464/100,000) and low skilled birth attendance (45%) (DHS 2006).
The maternal mortality rate in Morocco is also relatively high (227 maternal deaths/100 000 live births). Low financial accessibility was pointed out as the first barrier to access to care in 74% of pregnant women (PAPFAM 2003-04).