Volume 4, Issue 5, May– 2019 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

Challenging the Challenger on Equity, Maternal and

Child Healthcare Promotion: A Clinical - Based
Description Study in the North Kivu Division of the
Health System, Democratic Republic of Congo
Lévis Kahandukya Nyavanda , Jane Mumma , Kambale Karafuli Leopold , Jean-Bosco Kahindo Mbeva

Abstract:-  Conclusion
Since reproductive health services are limited and
 Background reproductive maternal epidemiology problems are
In many circumstances mothers have confront increasingly complex in nutritional crisis periods, thus the
healthcare difficulties during delivery and these have led North Kivu division system needs an urgent integration of
to mortality. In North health division, about 104 children community-based services linkage to hospital services
and 68 women died from a direct complication related to that can contribute the process of providing maternity
pregnancy out of 100000Live Births, 15 women have a education to community members. It has been noticed
disability due to childbirth out of 100000 Live Births that children births skills that influence infant’s lives and
during that particular time of the survey. mothers are ready reviewed but still in the North Kivu
Division of the health system these information have not
 Objectives yet impacted on the clinicians experiences.
To describe analysis of RDC-DHS 2014 that are
related to maternal and child health promotion by the Keywords:- DR Congo, Clinic-Based Description, Nutrition
North Kivu Division of the health System in DR Congo; Crisis, Maternal-Child Deaths Prevention, Equity In Health,
identify the profiles and level of interventions that have Health Well-Being, Maternity Healthcare Services, Four
been made to prevent maternal-child death and equity Lacks, SMART Methodology, Socio-Demographic Survey.
promotion during nutritional crisis influenced by socio-
political instabilities. I. INTRODUCTION

 Design North health division, about 104 children and 68

This is a clinical-based description cross-sectional women died from a direct complication related to pregnancy
study on data analysis (DHS2014) on maternal health out of 100000Live Births, 15 women have a disability due to
service utilisation in the Health division system of North childbirth out of 100000Live Births, that, there is lack of
Kivu Province, DR Congo. accurate information, reliable data because of lack of a
specific surveillance system that can manage maternal issues
 Results in the processes of promoting maternal health services in
Chart 2. Of the study shows that maternal deaths both health facilities and households settings (DRC-DHS
occurred during neonatal period influenced by of 2011)( HIS 2014) (Nyavanda 2014)[1][2][3][34][64][41]
nutrition crisis are caused directly by sexual violence [65][66][67] [2] [3] [4]. However, maternal death and
(31%), followed by haemorrhage (27%), and disability can be prevented with appropriate health
hypertension (18%). And that child deaths of aged 0-59 interventions. It has been known that also during pregnancy
months is caused by malaria (15), followed by pneumonia nutrition crisis some of the direct medical causes of maternal
(14%) and Diarrhea (14%). In terms of coverage mortality include hemorrhage or bleeding, infection, unsafe
interventions for reproductive health, the contraceptive abortion, hypertensive disorders, and obstructed labor
prevalence rate is 27%. Concerning preventing deaths influence intrapartum death. Other causes include ectopic
and promoting equity during gestation, intrapartum and pregnancy, embolism, and anesthesia related risks[4][5][6].
postpartum health interventions. Is that only a half of Conditions such as anemia, diabetes, malaria, sexually
women had at least four antenatal care visits (50%), most transmitted infections (STIs), and others can also increase a
of women were assisted by skilled birth attendants (75%) woman’s risk for complications during pregnancy and
and only less than half women (49%) received early childbirth, and, thus, are indirect causes of maternal mortality
initiation for breast feeding. and morbidity (Sen, Govender & Cottingham, 2007)
[7][8][9].

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Volume 4, Issue 5, May– 2019 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
 Description de l’analyse logique des défis sur la santé (Nyavanda, 2014) [29][30][31] [32][33][8][29][34]
maternelle et infantile [38][35][41][48].
From different studies on the causes of maternal
mortality, several facts are significant: there is a great  Défis général
variability by region. If postpartum hemorrhage comes to Computer models as "REDUCE", developed by the
mind as cause of death worldwide, is in third position in program "Safe Motherhood" in Mouritania, Ethiopia,
developed countries or she is responsible for 13% of deaths. Uganda, Senegal and Burkina Faso have enabled to gather
This figure rises to more than 30% for Africa and Asia, and concrete and local data on the determinants of morbidity and
more than 20% for Latin America. Of the 42 million mortality maternal and neonatal. This model allows an
abortions worldwide per year according to who estimates, 22 assessment of the demographic, economic and financial harm
million are at risk, and take place in majority 21.6 million in that the country will suffer if appropriate actions are not
developing countries (WHO, 2015) [10][11][12] taken, and the benefits that the country will have when it has
[53][54][50][49]. Clandestine abortion is responsible for 12% taken appropriate and effective actions in response to the
of all maternal deaths in Latin America and the Caribbean questions raised ( WHO/AFRO, 2002,2010)
who have already reached 30% in some countries against [21][35][36][37][38] [43][44][45][46][47]. By this method, it
3.9% in Africa and 8.2% in developed countries (Khan et has been estimated the loss of productivity due to morbidity
al,2006). The risk of maternal death in the developing and maternal mortality according to Maternal-newboborn-ill
countries is 1 in 220 abortions in poor conditions not Health (MNIH) annually in Ethiopia $ 95 million and $ 51
equipped (WHO, 2015) [13][14][15][16][17][5]. Clandestine million in Senegal in this country, the loss due to mortality
abortion is a very young population in the cities, more and infant is known. Specifically, severe anemia after
more unmarried teenage girls to have recourse to abortion, hemorrhage postpartum trained an average loss of
that in some urban centres, most of the requests come from productivity is estimated 40% for an average duration of two
this category (WHO, 2010). In Africa, about 60 percent of years and a half, and obstetric fistula on dystocia a loss of
abortions are in the Group of less than 25 years (WHO, 2004) 70% for seventeen years (Kamrul Islam, 2006 ; WHO, 2014)
[18][19][20][21] [72][73] [74][75][76]. Family planning [39][31][40][41][42] [49][13][27][50].
could be one of the answers to this problem which is also
complex, because many elements are involved as the factor In the field of maternal health, there is some but slow
social, cultural, acceptance of the proposed methods, progress. The multitude of programs entitle "Maternity
legalization, access to services of health, quality of these. without risk" would have created some confusion in
successive under constantly different names, and would thus
 La morbidité maternelle slow down the implementation of effective strategies. Much
On mortality and maternal morbidity would certainly be remains to be done, and it is essential for safe motherhood
even more revealing of the inequality of women in the visibility at high level (AbouZahr, 2001). Faced with this
developing countries vis - a-vis to those of developed complex and multifactorial problem, policy support is
countries. Unfortunately, data on morbidity include few, essential to ensure the sustainability of the actions, train a
incomplete, and unreliable because a lack of internationally lasting change, and make real access to universal care, with
accepted definitions (Ronsmans, 2009) [26][27][28] financial protection mechanisms. Civil society, and above all
[22][23][24][25]. Only rough estimates based on studies of the associations for the defense of women, should keep up
relatively small scale are available. In almost seven cities of the pressure on decision makers and have a role to play in all
West Africa or 20 326 pregnant women were followed, these processes (OMS, 2015)
serious maternal morbidity was 6.17 (5.8 - 6.5) cases for [51][32][52][57][50][58][59][60][61][62][63]. Our fight
every 100 women, is thirty times more common than against the problem of maternal health is to insist because the
mortality (Prual et al., 2000) ( Dujardin,2014). Australia, health maternal and child cannot be completely and correctly
New South Wales, the study of 500 000 births showed an supported if out of its context cultural, family, and
incidence of severe morbidity of 12.5% and a ration community, if problems related to quality and to management
morbidity or maternal death of 283 (Roberts et al., 2009). In services or providers are not identified and taken into
a way contrasted, a review of maternal morbidity acute account, or even if the necessary political support is not
severe in Europe including the Finland, United Kingdom, available. All these aspects must form a coherent whole in
Netherlands and in North America it is to say the United order to ensure a reduction in continuous and long-term
States and Canada revealed affect ten times lower than in mortality. There is no miracle solution to reduce maternal,
West Africa who between 3.8 (95% CI 3.3 - 4.4) and 12 neonatal and infant mortality. The vast majority of research
(95% IC 11.2 - 13.2) per 1,000 births (Van Roosmalen et in the field of maternal health are intended to produce the
Zwart, 2009). The morbidity Ratio or either maternal deaths evidence on treatments or specific strategies. This evidence
ranged from 50 to 110. Other authors speak of 100 cases or cannot be obtained more often than in trial. Without
more maternal morbidity for 1 death (Okong et al., 2010). underestimating the importance of this evidence report, we
Worldwide, about 3000 million women suffering diseases or must recognize that most cruelly missing from decision-
preventable sequelae due to pregnancy or childbirth makers, what are knowledge about the conditions to be

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Volume 4, Issue 5, May– 2019 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
implemented to realize the potential of the defined strategies. [68][69][70] [50]. The health financing architecture in DR
Action research, research on the systems of health and on Congo is not favorable for a PHC strategy to health service
improving the quality of care and services occupy places of delivery, with minimal contributions from governments, high
choice in the field of maternal health, the promotion of equity Out-of-Pocket (OOP) contributions, and vertically
and forensic medicine are also priority. programmed donor projects[69][71][57][14]. The structural
adjustment programs reduced instead of increasing the fiscal
In the DR Congo, according the WHO that said: “using space for sustained improvements in health systems [5]”.
the health systems framework, the study provides a synthesis
of the experiences of implementing of certain interventions in II. METHODS
the province, including, achievements made, weaknesses and
challenges met. Current opportunities are explored and The study methodology procedures is in form of critical
proposals are made of interventions that would facilitate interpretation of quantitative data analysis to mixed analysis
reform of health systems in DR Congo in line with the and interpretation. The survey was carried out on the inputs
maternal child healthcare ideals for the attainment of the and outcomes that can explain the 68 maternal deaths and
Sustainable Development Goals (SDGs) [4] . The analysis of 104 child deaths in North Kivu Province during the survey
health systems in the DR Congo shows that over the last 30 time period. The description was comparing the assumption
years of implementing the PHC strategy there have been a synthesis and from a deductive perspective point of view,
number of achievements[34][55][56]. Some provinces such conclusion and necessary applicable recommendations were
as in the capital city, Kinshasa, through health division have generated from the both comparison of the synthesis and
largely embraced their stewardship roles, including grounded theoretical interpretation data. The study is
developing national policies and strategic plans that highlight retrospective because it is concerned with data review of
universal access to essential services, interpectoral DHS-DRC 2014 on identifying the influences factors that are
collaboration and community involvement in health. associated to maternal and child deaths and hinder strategies
Increased availability of information for planning and in promoting equity and health promotion during nutrition
decision-making has facilitated the stewardship role. But a crisis in North Kivu Province, DR Congo.
good number of other provinces have managed to
substantially increase public funding for the delivery of  Data collection
health services. In the provinces of the district health workers Data of the Demographic and Health Survey conducted
are being trained across a range of cadres, and efforts are by the DR Congo Ministry of Planning, the Ministry of
being made to ensure appropriate orientation and versatility Public Health, ICF international in collaboration with
of health personnel in the context of PHC”. UNICEF and other international donors in 2014. The
objective of the DHS is to produce representative results at
In addition to that WHO from passed experiences said: the national and provincial as well as urban and rural levels.
“The above achievements have led to some improvements in The use of these two-stage for selection probabilistic sample
health systems objectives over the last 3 decades? There have technic is to select clusters that is community settings and
been improvements in health status as demonstrated by the health facility settings (DRC-Ministère du Plan et al, 2014).
decline of under-five mortality rates from 188 to 165 per
1000 live births between 1970 and 2005. Deaths of children  Data analysis
from vaccine preventable illnesses have markedly declined The empirical analysis starts from the fact that
and in a few provinces the spread of HIV/AIDS has been investment in health well-being is an important input in child
reversed. However the trend of improvements in health status growing health within a household and the two phenomena
is unlikely to lead to attainment of most of the SDGs for the are correlated. On the other hand child life is interdependent
DR Congo. It is possible though for the East Region to on mother health status. Mean child life is correlated to
achieve many if not all of the SDGs if specific actions are mother life too. Thus healthcare services provided to
taken by the different stakeholders. There have been many pregnant woman at health facility are for purpose to
challenges in implementing PHC since Alma Ata. The lack promoting both mother and child health well-being. In
of common understanding of the PHC strategy and the reproductive maternal health epidemiology, mother-child
advocacy of different models by partners has been a major well-being are simultaneously determined and can be
hindrance for its translation into appropriate policies and evaluated in a particular context. This calls for an estimation
plans. A second challenge has been to implement the notion approach that takes into account the endogeneity
of multi-sectoral determination of health at various levels (Wooldridge, 2008). The estimation system to be used is
since the need for a multi-sectoral approach is easy to calculated in the equations as follows:
appreciate but its implementation is not. A major challenge
for appropriate implementation of the PHC strategy has been 𝑤 = 𝜎𝑤𝑥 + 𝜑 + 𝜀1 (1)
the very low levels of health funding and especially public 𝑤 = 𝜎ℎ𝑥 + 𝑦𝑤ℎ + 𝜀2 (2)
health funding in the DR Congo because less budget located
to health sector (less than 3% of the national budget)

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Volume 4, Issue 5, May– 2019 International Journal of Innovative Science and Research Technology
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Where , w is the maternal healthcare services towards perfectly. This contrasts with theory derived deductively
well-being and h is the inputs to influence maternal-child from grand theory, without the help of data, and which could
health positively or negatively; the reproductive maternal and therefore turn out to fit no data at all”. The researcher
child well-being is endogenous in the mother-child health followed all the steps mainly (1) open coding to find
care services provision as a health production function. The categories, (2) axial coding to find link between the themes
maternal-child health well-being is captured by the indicator or categories, (3) selective coding to find the core themes or
constructed from maternal health care services provided from categories (Strauss and Corbin, 1998).
conception up to postpartum and from newborn up to five
years. In the context of this study our dependent variable is IV. RESULTS
maternal-child health status during nutrition crisis time
period. If the mother and the expected newborn are not fed,  Demographic influences of nutrition crisis that affect
means that the demographic and health measured indicator maternal and child health
underweight is susceptible to be determined and being The North Kivu province in the East of the DR Congo
associated with an interpretation of malnourished health country, it’s length boundaries is about 59631Km2 (Division
status, thus predictable variable that influence maternal and of plan 2017, DSRP) with the Republic of Uganda and
child deaths and the socio-demographic and health inputs are Rwanda at the East; at the North-west with Ituri province,
represented our independents variables: ANC, PNC and FP, and South-west with Maniema province and South Kivu
etc. province at the south part. The Province length’s boundaries
is about 2.5% of the surface of the entire country. The
III. DATA INTERPRETATION population is surrounded by an exaggerated ecosystem that it
natured by Semuliki and Rutshuru valley. The ecosystem
 Quantitative data provided ombrophyte mountainy forests. At hydrological
Mother-child health is measured by the interpretation of point of view, we have also a number of lakes such as
underweight or malnourished that is due to nutrition crisis. Edouerd, Kivu and Mukoto and 9 rivers: Rutshuru, Rwindi,
Therefore x is a vector of socio-demographic and health Semuliki, Osso, Tuha and Lowa. The average of population
factor that is associated with the situation of crisis to life expectancy is 49 formen and 54 for females. The
determine the well-being. This implies that maternal population is composed by four main sub-group population
healthcare services (W) are supposed to influence the (Tab N0…):
mother-child health well-being (h); z is a vector of  The children under five years (0 to 4years);
instrumental variables that influence the outcomes without  The youths (5 to 24 years);
varying the status. Mean reproductive maternal healthcare  The adults ( 25 to 64 years);
services can be influenced without influencing the mother-  The elders (65 years old and above).
child health status, thus the health status interpret the well-
being positively or negatively. 𝜎, 𝜑, 𝑎𝑛𝑑 y are parameters to Population by Sex Rates by age groupPyramid Graph
be estimated and, 𝜀1, 𝜀2 are the errors terms. Given that (1)
Age group M F Total M%0 F%0 M F
and (2) are simultaneously determined, and the error terms of
these two equations are correlated and this leads to less bias 0 - 1 Month 999049 997889 1996938 109.57 109.44 109.57 109.44
and inconsistency in estimates. Therefore, the equations (1), 2 - 10 Months 988028 986973 1975001 108.36 108.24 108.36 108.24
(2) are estimated in a system in which the first step is to find 11 -12 Months 841011 889772 1730783 92.24 97.58 92.24 97.58
valid instruments for the observable variables that affect on 1 - 4 years 657035 460811 1117846 72.06 50.54 18.01 12.63
health well-being and health services (w) without affecting 5 - 14 years 351322 461201 812523 38.53 50.58 3.85 5.06
mother and child health status. This is shown with percentage
15 - 24 years 292403 180010 472413 32.07 19.74 3.21 1.97
that is higher positively meaningful and this means health
care services impacted positively. Whereas percentage is 25 - 34 years 112855 114872 227727 12.38 12.60 1.24 1.26
lower negatively meaningful, that means health services 35 - 44 years 45867 65866 111733 5.03 7.22 0.50 0.72
impacted negatively on mother and child health status in a 45 - 54 years 187393 188686 376079 20.55 20.69 2.06 2.07
negative way. The interpretation was interested in 55 - 64 years 85296 77542 162838 9.35 8.50 0.94 0.85
reanalyzing information in a systematic way in order to come 65 - 74 years 51241 57524 108765 5.62 6.31 0.56 0.63
up with useful conclusions and applicable recommendations. 75 - 84 years 5333 9523 14856 0.58 1.04 0.06 0.10
 Qualitative analysis 85 - 94 years 3089 3342 6431 0.34 0.37 0.03 0.04
Qualitative data analysis was not derived from 94 and above 1822 2341 4163 0.20 0.26 0.02 0.03
computer package, but data was analysed manually following Total 4621744 4496352 9118096 506.88 493.12 50.69 49.31
all the steps of the grounded theory. Borgati S. (sd):” the Table 1:- Demographic representation of North Kivu
phrase grounded theory, refers to an ideology that is Province, (From our survey in January 2017).
developing inductively from a corpus of data. If done well,
this means that the resulting theory at least fits one dataset

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Volume 4, Issue 5, May– 2019 International Journal of Innovative Science and Research Technology
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North Kivu province from the above statistics, we because of repetitive war and other natural disasters such
realise that they have been a big improvement in saving epidemics, famine, economic crises, mass migrations, etc.
children lives against infant mortality comparing to the 1990s because of its population size and severity of the health
up 2010 (DRC-DHS, 2014). However the effects of repetitive situation, North Kivu represents an enormous concentration
wars and epidemic disasters, the infant mortality rate has not of morbidity, mortality, migration and wars as human made
sensitively reduced. Because during our survey we realized disasters. It remains one of the most populous province in the
that children interrupt the vaccine dose because looking for country. The repetition of wars has accentuated disparities,
secured places. This implies that population insecurity in although most of the population is affected the poor health
their respective places influence abandon of immunasation state. Household survey data on child death and malnutrition
services thus persistence of infant morbidity and mortality. show that the western part of the country, not directly
The statistics show that the represent a development process affected by the wars. Generally has better outcomes than the
where at given stage death rate is control for 0 Months to rest of the country. Similarly health indicators are better in
1years. The slope is not enlarged, but is large. The pyramid urban areas than in rural areas. Nevertheless, even these
graph represent the second type of population pyramids better –off areas experienced declines since the health budget
(International Dictionary of Population Studies, IDPS 1964). is centralised and is low than 2% of national budget and it
should be noted that their health and nutrition situation is
poor compared to overall average in other countries. For
example, estimated under-five mortality rate in 2007 in urban
areas was 316 per 1000, which is comparable to estimates for
Ethiopia or Kenya as a whole, and exceeds the overall rate of
Kenya and Tanzania. The poor experience higher
malnutrition and death. From community and household of
survey data, it is estimated that under-five death among the
poorest quintile of households was 512 per 1000 in 2017-
2014, compared to 256 per 1000 among the highest quintile.

 Socio-economic influences of nutrition crisis that affect

maternal and child health

Fig. 1:- Illustration of the North Kivu population trends, by

Nyavanda, 2018.

According to the slop, the ascendant and descendant

way, the pyramid reflect the situation of the following
demographic characteristics: (i) Population that is transitional
types of phases; (ii) Health conditions being controlled and
eradicated; (iii) Population social behaviour being addressed;
(iv) Health education on hygiene and proper sanitation is
being addressed; (v) External movement is reduced for the
moving population. A part from the war and other sudden
catastrophe, North Kivu population is among the DR Congo
that practice business, agriculture, animal keeping activities
therefore it needs to stay without any migration. The
population is sedentary rather than being nomadic. North Graphe1. Quintile of economic well-being in North Kivu,
Kivu is one of the 26 operational provinces of the DR Congo 2014.
and Goma city is the provincial capital city. North Kivu
province has 33 Health Zones whereby Karisimbi Health The very low (23.3%) quintile is half of the fourth
Zone is one of them. North Kivu health division was one of quintile (26.9%) gradually. This implies that the majority of
the 11 divisions of the country before 2015. Today is one of people would have fulfill the requirement of basic health
the 26 health divisions that did not get change in terms needs at certain level.
restructuring according to health principles of the
decentralization process. This implies that the former system Important household-level determinants of health and
that was implemented in DR Congo still inculcated in this nutrition outcomes are mothers’ education, and behaviors
region as far as services providers are concerned. In general such as breastfeeding, sexual practices and contraceptive use.
the system is one of the fragile ones in sub-Saharan region Expect for fever incidence and prevalence which largely

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Volume 4, Issue 5, May– 2019 International Journal of Innovative Science and Research Technology
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depends on the epidemiological pattern of malaria, most of  Evidence study analysis
the various multivariate models of the determinants of a The contextual and factor, conflicts among
number of health outcomes such as child mortality, communities since 1997 up to date has caused severe
malnutrition, diarrhea and respiratory infection, show that increases in death and deterioration in other health and
children of mothers with any education are at lower risk, nutrition outcomes. Data show that most deaths were not
even after controlling for socio-economic status. This explain directly due to violence but related to the disruption of the
that better-educated mothers having better knowledge for economy and society and deterioration of household coping
preventive health practices and being more likely to take a mechanisms. The direct and indirect effects of the conflict on
sick child to a trained health provider. In north kivu, a health and nutrition worked through many mechanisms,
majority of mothers (75%) have received at least some including its impact on household resources, on the health
education, but the proportion is considerably lower in rural system, on other sectors, and on government action and
areas (65%) than in urban areas (94%). finances including the health system. Empirical evidence for
the effects of the wars on nutrition or food insecurity and
 Child breastfeeding health outcomes can be readily seen in time trends and
Exclusive breastfeed is a crucial determinant of infant geographic patterns at both national and regional levels. A
and child health and nutrition as well as child development. regression model found that, controlling for a variety of other
While almost all children are breastfed to an extent, only factors including socio-economic status, children in the
around a quarter are exclusively breastfed during their first centre and of east of DR Congo were far more likely to be
six months of life, and this rate has been decreasing overtime. chronically malnourished than children in the western
Among other practices with an important impact on health provinces (DRC-DHS, 2007). Surveys among particular wars
are modern contraceptive use, which is low 5.4%, and risky affected populations revealed sometimes extreme levels of
sexual behaviour. death, while a regression model indicates that other important
factors held equal, the risk of child death from 2007-2014
 Poverty impact was significantly greater in the centre and east than in the
Poverty, affecting the mass of the population, clearly west. A retrospective study on mortality showed increased
undermines health and nutrition outcomes analyzed expect death coinciding with the most intense periods of the conflict,
fever incidence, there are clear and large differences between with the largest increases concentrated in the centre and
the poorest and the best-off. The various regression models eastern parts of the country, most directly affected by the
show socio-economic status as a consistent determinants of repetitive wars and epidemics.
health outcomes. For example, controlling for a variety of
other factors, children from households in the highest quintile  Evidence illustration point of view
are around 1.4 times less likely to have diseases such as Evidence is that conflict has decreased the importance
respiratory infections or diarrhea. However, such associations to health in terms of socio-economic impact factors. But for
are not as evident. Over the lower ranges of household good illustration is that education and household economic
economic status, indicating that the mass of the population, is status, increased that the importance of access to health
at a similar level of poverty and suffers similarly from poor services. A regression model of child death information
health and nutrition. However, it is evident that increasing analysis from household study in 2010 indicate that
inequality is a large risk as the country’s economy grows in prospective effectives of mothers education and household
the coming years that will not be affected by wars. economic status lessened overtime suggesting that the
conflict affected wide swathes of the population regardless of
Empirical analysis has shown of evidence that explain their socio-economic status . However, the analyses suggest
the challenges in terms of mother and child health promotion. that the positive effects of access to health services may been
These analysis are based on the following areas as our accentuated overtime, particularly in the regions most
research is concern. The illustration of the DR Congo affected by the respective was. This is motivating evidence
situation in general and North Kivu in particular (DRC-DHS, that health services make a difference in such situation.
2010-2014); the main indicators are: nutrition and health
indicators, numbers of people affected annually in DRC as  Health service utilisation and SMART analysis
whole, application of the Standardised Monitoring and At the household level, utilisation of basic child and
Assessment of Relief and Transitions (SMART) mother health services is low overall. In general, utilisation
methodology in estimating nutrition status of children under- of preventive health interventions for mother and child is
five years and mortality rate of the specific population, the low. Only around 45% of mother and children received
innovation of news strategies and interventions for health vaccination during pregnancy and infancy period. To get
equity. more analysis on this the SMART methodology emphasises
on the issue. The Standardised Monitoring and Assessment of
Relief and Transitions is usually applied in conflict and post-
conflict monitoring, food insecurity interventions impact
evaluation, emergency and natural disaster assessments, and

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Volume 4, Issue 5, May– 2019 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
during socio-economic crisis. SMART analysis is an The analysis show that sexual violence (31%),
interagency initiative launched in 2002 by a network of haemorrhage (27%), and hypertension account for more than
organisations and humanitarian practitioners. The half of maternal deaths during neonatal period.
methodology is “an improved survey method for the
assessment of severity of a humanitarian crisis based on the  Analysis of the coverage of interventions
two most vital public health indicators mainly nutrition status The coverage interventions analysis varies across the
of children under-five, and mortality rate of specific continuum of care. The reproductive and pre-pregnancy
population. health remain an issue during interventions implementation.
The following results have been shown by the maternal
 Causes of maternal and child deaths during nutrition clinical surveys.
crisis
The health problem are complex according to their
causes malnutrition influence occurrence of other diseases
like anemia, loss of weight and fixed growing especially for
children. This in short and run or long terms lead to deaths
during delivery or neonatal period.

Graph 4. Reproductive and Pre-pregnancy health.

The graph. 3. Shows that the coverage interventions

still very low whereby women and men lack access to
Chart2. Deaths occurred during the neonatal period: under essential types of contraceptive (45%) that is why the
nutrition causes of child aged 0 to 59 months, 2014. contraceptive prevalence rate is 27%. However women and
men who lack information about FP (10%) were also found.
According to the findings child deaths show that In important number of the population (18%) refuse to use
malaria (15%), diarrhea and Pneumonia (28%) remain at the FP. This is a challenge for community health providers.
second range among the highest causes of child deaths, Maternal deaths can be reduced and prevented by as much as
together accounting for 117 out of 1000 of deaths. More than 68 women for 100000LB, by limiting the number of
11.7% of child deaths occur in the neonatal. pregnancies and increasing birth intervals. However,
women’s access to modern contraceptives is compromised by
social and political factors. As such, the contraceptive
prevalence rate for modern methods among currently married
women is just 27%, a quarter of desirable level while only
one out two women of reproductive age (15-49) use modern
methods of contraceptive methods in North Kivu. Comparing
to individual use in 2015, more than half (70%) where 65%
were women and only 5% were men. And in 2016
contraceptive among the entire population were (75%),
women (60%) and men (15%). In 2017, according the study
survey, contraceptive intervention among population who are
satisfied with the service were 78%, where men (18%) and
women were (60%). It implies that family planning program
is progressing gradually with effectiveness.
Chart 3.Maternal deaths occurred during neonatal period,
2014

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 Pregnancy (Gestation), birth (intrapartum) and postnatal sedation anaesthesia and only ketamine was available. The
(postpartum) health interventions majority lack midazolam, propofol, etc. The major issue was
Coverage estimates for service delivery contacts such the lack of anesthesiologist in all the visited hospitals.
as antenatal care, skilled and appropriate maternity healthcare Because of the above issues, the study shows that the period
giver at birth and postnatal visits for the mother. The surrounding birth accounts for a high proportion of deaths.
interventions during gestation, birth and postnatal do not According to analysis of information provided in the DHS,
increase. This translates that Congolese women still 2014. Analysis has estimated that maternal, stillbirths and
vulnerable during their reproductive cycle. Official estimates neonatal deaths have a number of important causes.
reveal that vast majority of maternal deaths can be prevented
by having skilled care givers, appropriate medicines and
providing care at the right time, right place, and right
information about antenatal healthcare to the needed woman.

Graph 6. Period surrounding birth accounts of specific

maternal and child deaths.

The crucial period when mothers die while giving life is

at intrapartum (55%) followed by stillbirths (22%) means
Graph 5. From pregnancy to postpartum health interventions maternal death should prevented before labour, and delivery
continuum. at that moment all care givers have to be involved in
management of the pregnancy.
At gestation women who were assisted for at least four
antenatal care visits (50%), followed by 75% of assistance by V. DISCUSSION
skilled birth attendants during birth assistance period, and
49% of women where assisted for early initiation breast  Effluences of nutrition crisis on maternal and child deaths
feeding at postnatal care period. A challenge for clinicians. According to EDS-DRC 2014 that said: “Health,
The care during pregnancy seems to be higher than the care nutrition, and population outcomes, including the main
provided during delivery and after delivery. This explain the sector-related MDG indicators, are extremely poor in DRC
complexity circumstance that end up with complications and have deteriorated over the past decade. DRC is emerging
during the two last phases of pregnancy management. from a long and destructive conflict, which followed years of
Pregnancy active management recommend intensive care economic crisis, so that it is among the poorest countries in
whereby specialist on the matter should be permanent and the world. Over one third of under-five children are
assist the needed woman. But we noticed that on 1% of chronically malnourished (stunting), and 16% suffer from
gynaecologist assisted during delivery and 25% visits after acute malnutrition (wasting), reflecting wide vulnerability to
delivery. Why this happen in such way? short-term crises. Retrospective mortality surveys have
revealed extreme levels of mortality among conflict-affected
 Quality and equity in health care services populations, so that it is estimated that 3.8 million deaths can
Quality care emerge because it remains a problem in be attributed to the war since 1997 up to date. Under-five
our health facilities. Cohort observational study on obstetric mortality, estimated from the 2002 Multiple Indicator Cluster
practices in hospitals had revealed that current practices in Survey (MICS2, EDS 2014), is in the range of 104 to 220 per
most of health facilities were still not aligned with best 1,000 or greater, one of the highest in the world. Maternal
practice standards. The majority (85%) of hospitals were mortality is similarly among the highest anywhere, estimated
lacking oxytocin to control haemorrhage. For anaesthesia at 1,289 per 100,000 live births. The total fertility rate
none of the hospital visited uses regional, spinal, and remains very high at 7.1[77][78][79][80]”. From the
inhalational general anaesthesia. Most of the hospital uses perceptive of PRONUT (2015) and others nutritionist and

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dietitians the North Kivu health Division have suggested that centre of health as dystocia well taken care in hospital can
efforts to reduce maternal mortality and morbidity must also have a very positive influence. On the other hand, the failure
address societal and cultural factors that impact women’s of management to the hospital it is - to - death of a newborn
health and their access to services (EDS-DRC, 2014). for example can have a negative impact on confidence.
Women’s low status in society, lack of access to and control Furthermore, if all pregnant women from the neighborhood
over resources, limited educational opportunities, poor who were referees at the hospital were giving birth without
nutrition, and lack of decision-making power contribute problems, there is little of each patient is convinced of the
significantly to adverse pregnancy outcomes. Laws and merits of a current reference. The influence of older women
policies, such as those that require a woman to first obtain can also discredit the services of health not traditional
permission from her husband or parents, may also discourage compared to traditional services.
women and girls from seeking needed health care services.
Particularly if they are of a sensitive nature, sensitization of  Profiles of the pregnancy and expected newborns indexes
population in many reproductive activities and programs such It's a certain intensity of perception - to-say recognition
as family planning, abortion services, or treatment of STIs of the gravity of the situation is necessary for it to be
may aware individuals to have self-responsibilities to motivating. As we experienced, the intensity of this
promote mother-child health and prevent death in perception can vary depending on local cultures, this is the
communities during nutrition crisis[81][82][83][84] . case for the bleeding including. The perception of problems
of health does not necessarily lead a motivation of patients.
 The daily lives of the parturient in health facilities. In a survey in the area of health of Karisimbi, in the city of
In the same perceptive of Dujardin and other authors, it Goma, North Kivu, on 450 women living 11 peri-urban
is very necessary to say that the behavior of the providers neighborhoods filled d health centres, 69% complained of
according to Olivier de Sardan (2004) reveal the parturients gynecological problems, but only 5% had used the integrated
violence, and more generally, all of dysfunctions of the yet easy health services may be available for some (PNSR,
services of health also affects the behavior of newborns in the 2012) (UNFPA, 2015). In some cases, there may be a sense
future life. Women whose pregnancy is normal priority will of shame or even cultural prohibitions. As we have seen in an
be more sensitized to attend the prenatal consultation area of health urban in Goma, adolescent girls in rural areas,
according to the reputation of the services, the quality of care came to study in the city, will feel completely lost in the
given and if these services are available from a financial and event of unwanted pregnancy. They are in a desperate
geographical point of view. As a general rule, the level of situation that can lead them to a suicide attempt, because they
confidence depends primarily on personal experience. Many are afraid of losing the support of their families, who may
other authors like Akin et al, 1985, have already confirmed reject them; indeed, they have become a subject of shame for
that past experience determines the future use. If the woman their parents. As well, these teenage girls do not know where
is satisfied of the service uses previously whether traditional to turn and especially due to the lack of correct information,
or non-traditional, she'll use it again in the future, and vice fear of the home and lack of confidence in the staff of health
versa. This level of satisfaction mainly depends on the care facilities.
quality and efficiency of care, but also the acceptability of the
services of health it is to say the quality of hospitality, for  Weaknesses of mobile resources
example, and the quality of information and explanations The direct and indirect costs related to the use of
received. In many maternity urban but also rural, the modern health care are still very high for the poorest in most
parturients are returned as long as the expansion is not very cases even these treatments are not available or accessible in
advanced, this decreases the footprint of services and some health facilities. Even when treatment is free, the costs
particularly the workload, but is probably not the best associated with moving can be prohibitive for people living
decision for improve the quality of the relationship between with less than $1 per day per capita, population who
patients and midwives. According to experience, many of sometimes represents more than 50% of the total population
such cases of maternal deaths and stillbirths have already of the province and 10% of the country Hence the importance
occurred in most of the hospitals in the Provincial Division of of the transparency of pricing, price display, of the removal
the health system in North Kivu in the Democratic Republic of informal payments, supply of obstetric care ambulance.
of the Congo. etc[85][17][86][79].

 The experience of the members of the family of the The current study has introduced the top four barriers to
parturient accessing maternal delivery services which are:
Experience can also have an influence on the individual 1) Lacking appropriate maternity information,
confidence, especially when the patient has not itself 2) Lacking money for delivery;
sufficient experience especially if she is primigravida. The 3) Lacking appropriate mean for transportation to the health
experience of others will be even more convincing that the facility;
bond is between two people and improving the State of 4) Lacking the appropriate person to assist to go to the health
health is compelling. In this sense, a critical incident at the facility.

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(sometimes expressed per 1,000 women). It is the frequency
The first lack is concerning limited access to get health to which women are exposed to the risk, each year during
personnel that can provide or deliver to people the right and their period of fertility. Ratio or report of maternal death:
save reproductive maternity information. This number of maternal deaths per 100,000 live births. It reflects
communication provided by the appropriate health personnel the risk of maternal death when a woman is pregnant. Risk of
can lead the woman or a man to get a responsible behaviour maternal death on the life adult (Lifetime risk): it takes into
towards maternal and child health prevention. The second account the probability of pregnancy and death as a result of
lack is explained by not having access to the money due to this pregnancy, accumulated during the breeding period (35
the possession ownership, the decision to utilize the money. years by convention). ). The proportion of maternal deaths
This is especially to women are married. The low income of among deaths of women of reproductive age: this flag is used
the woman or lack to the value of the money in cash needed. by who pour estimating maternal mortality in countries that
The third lack is explained in the sense that a woman may use specific surveys (method of the sisters).
use public transport mean which can’t help her up to the
health facility[87][17][88] . These means are such as the During nutrition crisis due socio-political influences in
bike, motorcycle that are not appropriate because they North Kivu province in particular and DR Congo in general,
increase pregnancy complication risks during labour. The obstetric complications has been associated with all
fourth lack that concern the first person to assist. A pregnant pregnancy historical indexes and this has regenerate
woman can’t go alone at the health facility for delivery. This unmanaged consequences of mother, couples, and families at
process of selecting, waiting, taking the decision about whom community and health facilities levels. This is because there
to take the pregnant woman to the maternity healthcare has are a complex factors that stringed health services such as
been a problem and this is concerned as lack of appropriate limited resources, rigid and fragile health policies in terms of
person to look after the pregnant women during and after implementation and follow up. Most of qualified health
labour for many families. personnel are concentrated in hospital infrastructures and
especially in urban areas, whereas some specific clinical
According to Dujardin, the above factors oriented services are needed outside the infrastructures such as
WHO to classify maternal deaths and provides some specific reproductive maternity education and counselling and family
definitions [6] : planning. This implies that some specific maternity services
are community –based provision. Therefore there is a
1) Maternal death, fortuitous or accidental: are deaths during pressing need to integrate community birth attendants,
pregnancy or postpartum but whose causes have nothing midwives and gynaecologists in the DR Congo health system
to do with it; to provide care from the community basis. Although
2) Pregnancy-related maternal deaths: are deaths during Community Health Workers work for some of these services,
pregnancy or within 42 days after its termination, but with limited knowledge. Our hypothesis is that
regardless of the cause of death; community linked to hospital specific maternity services can
3) Late maternal deaths: are deaths resulting from direct or contribute on preventing both home and clinic maternal and
indirect obstetric causes more than 42 days but which was child deaths in North Kivu province, DR Congo.
aggravated by the physiologic effects of pregnancy;
4) Deaths from indirect obstetric cause: are deaths resulting VI. CONCLUSION
from a pre-existing disease or condition occurred during
pregnancy unless it is due to direct obstetric causes, but Since most maternal and stillbirths deaths occur due to
which was aggravated by the physiological effects a number of determinants packed in the degree of service
pregnancy; rendered, this determinant is closely bound to the
5) Deaths from direct obstetric cause: are deaths resulting development of countries and communities and the ability of
from obstetric complications (pregnancy, childbirth and the health services to be accessible to the lowest cost. In
postpartum), interventions, omissions, incorrect treatment some situations, we can provide a survey followed health
or a chain of events resulting from one of factors known socio of an observation of a cohort of the parturient in semi-
to be driving death. directed interview or in-depth, focus groups to better
understand a possible lack of confidence. This is for instance
According to WHO, maternal death can be expressed in the the case when the usage rate does not improve despite a
form of different indicators that Duffy has summarized as better functioning of the services and the refusal of the
follows [6] : reference continue to occur despite the improvement of
exchanges between providers and patients. These services are
Maternal mortality rate: strictly speaking, should be often particularly limited in community and hospital settings.
considered for the calculation of this rate the number of To integrate community health focal services such mobile
maternal deaths per 100 000 pregnancies. However, usage maternity health by community birth attendants, midwives,
today defines the maternal mortality rate as the number of gynaecologists and other community health providers and
maternal deaths per 100,000 women of reproductive age

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these being affiliated to certain referrals , then maternal and this through systematic programs. An important step for
child deaths will be prevented at all levels. health promotion, in order to prevent negative maternal
health outcomes, is to have the Ministry of Health supply
RECOMMENDATIONS adequate educational materials regarding safe practices.

In short - medium and long term, as the most vulnerable  Increase access to reproductive health, sexual health,
determinant is the degree of satisfaction of the use of the and family planning services sensitisation. Due to the
service in particular in the previous appeal, the track is the lack of access to care and reproductive maternity
logical strategy that will improve the quality of care and also education in health community and clinical services,
the quality communication between patients and health maternal and child death rates are higher at the same level
personnel. The other major factor is the ability of women and in rural areas as well as in urban areas. In addition, many
their families to finance direct and indirect costs and the men and women in rural as well as urban areas lack
intangible costs. This strategy should be considered by the access to information and services related reproductive
North Kivu Health Division System in order to prevent health epidemiology especially mobilisation motive
maternal and stillbirths deaths and promote all Maternal and related to HIV/AIDS and other STIs.
neonatal community and clinical based activities.
 Strengthen reproductive health and family planning
 Maternal and child food security promotion activities policies and improve planning and resource allocation
and collective projects that can provide raw staff items. and deployment. While the Community Health Focal
Pregnant women need to take appropriate diet before Person scores demonstrate that Karisimbi health zone
conception, during gestation, during and labour. This facilities having strong maternal health activists,
secures the newborn health during his/her infancies. A implementation of the strategy activities may be
balanced diet during pregnancy is very crucial for the inadequate. Often, available resources are not used in
mother and child live ‘sake. Therefore activities, and North Kivu Province, if recruitment and integration of
projects to generate sources of food provision should be appropriate resources is done then health services impact
initiated in families and communities with the community can realised. In North Kivu volunteerism has worsen
health personnel assistance. perfection in services deliveries because of LNGOs but
we hope for preventing maternal and child death,
 Increase access to high quality antenatal care and advocacy can strengthen activities, policies and increase
promote health equity. At some extent pregnant women the amount of resources devoted to reproductive health
need a given special care during reproductive life span. and family planning. In other cases, operational policy
This because of the complexity of pregnancy outcomes barriers. Barriers to implementation and full financing of
and the wellbeing of the expected newborn. At this reproductive maternal health and family planning policies
particular time when the service is needed, right of mother must be removed such as paying ANC services.
and baby should the priority in terms of maternity care
services.  Increase access to and education about family Planning,
equity and reproductive maternity education. Another
 Provide prompt postpartum care, counseling, and access feature that relates closely to preventing maternal and
to family planning. It is important to detect and child deaths is the provision of family planning
immediately manage problems that may occur after counseling to individuals, couples, family members, and
delivery, such as hemorrhage, which is responsible for community members.
about 25 percent of maternal deaths worldwide. Individual/Family/couple/community planning helps
Postpartum care and counseling will help ensure the women prevent unintended pregnancies and space the
proper care and health of the newborn. Counseling should births of their children. It thus reduces their exposure to
include information on breastfeeding, immunization, and risks of pregnancy, abortion, and childbirth within the
family planning. community. Reliable provision of a range of contraceptive
methods can help prevent maternal deaths associated with
 Avoid adolescent pregnancies and improve post abortion unwanted pregnancies. Community health personnel
care. About 13 percent of maternal deaths worldwide are should be recruited, trained, and integrated in order to
due to unsafe abortion especially for adolescent. Women reach service to the needy as far as is community based
who have complications resulting from abortion need provision.
access to prompt and high quality treatment for infection,
hemorrhage, and injuries to the cervix and uterus.  Increase access to skilled delivery care and appropriate
maternal services at the right time, by the right health
 Strengthen health promotion activities. Mass media personnel and at the right place. Delivery is a critical
should be used to educate the public about pregnancy and time in which decisions about unexpected, serious
delivery, and community-level organizations should assist complications must be made. Community and clinical

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skilled birth attendants, midwives and gynaecologists are [11]. E. M. Mafuta et al., “Social accountability for maternal
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