Comparative evidence of years lived with reproductive age morbidity in sub-Saharan Africa (2010-2018)

doi:10.21203/rs.3.rs-1593301/v1

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Comparative evidence of years lived with reproductive age morbidity in sub-Saharan Africa (2010-2018)

https://doi.org/10.21203/rs.3.rs-1593301/v1

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Background

Despite remarkable progress in reducing maternal mortality over the past three decades, maternal morbidities remain high, particularly in sub-Saharan Africa (SSA). However, the number of years women spend with maternal morbidities, and how much each maternal complication contributes to unhealthy remaining years in reproductive ages is unknown. We estimate the number of life years that women of reproductive ages spend in poor health due to indirect maternal health morbidities.

Methods

We use Demographic and Health Survey data from 23 SSA countries to estimate age-specific mortality prevalence in reproductive age women, and construct life tables to estimate the survival function and reproductive age life expectancy (RALE) with and without HIV and anemia using the Sullivan method.

Results

There is a high prevalence of HIV (4.9%) and anemia (34.3%) among SSA women. There is also heterogeneity in prevalence across regions, with higher prevalence of anemia in East (27.9%), Central (36.5%) and West Africa (47.8%), and HIV in Southern Africa (13.0%). These conditions compromise women’s health by an average of 14.3 years [CI 95%, 14.3-14.4], approximately 42% of RALE life years. On average, SSA women spend 11.6 years [11.6-11.7] with anemia, 1.7 years [1.7-1.8] with HIV, and 1.1 years [1.1-1.2] with both conditions.

Conclusions

The high burden of life years with reproductive age morbidities among SSA women highlights that to achieve healthy lives for women and children as part of Sustainable Development Goal 3, morbidity prevention and management measures among women will need to be enhanced over the entire reproductive age span.

Maternal morbidities

life expectancy

reproductive age

sub-Saharan Africa

Globally, about 295,000 maternal deaths were observed in 2017 (1). While remarkable progress has been made in reducing maternal mortality over the past three decades, marked regional disparities persist. Ninety four percent of all maternal deaths occur in Lower and Middle Income Countries (LMICs), and sub-Saharan Africa (SSA) alone accounted for roughly two thirds of these deaths in 2017, with a maternal mortality ratio (MMR) of 462 compared to 11 per 100,000 live births in high-income countries (2). Being a rare event, maternal deaths account for a small fraction of the overall burden of poor maternal health and they do not represent a comprehensive measure to monitor progress in improving maternal health outcomes (2). However, maternal morbidities are still high. The World Health Organization (WHO) recommends including morbidity in the monitoring of maternal health as the years that women spend with illness and suffering compromise their healthy life years (3). Maternal morbidity results in detrimental effects on women’s health which may disrupt the achievement of Sustainable Development Goal (SDG) 3.1 (of reducing the global maternal mortality ratio to less than 70 per 100,000 live births)(4) and yet it has been neglected in the reproductive health agenda (5).

When a pregnant woman has indirect maternal morbidities such as HIV, malaria and anemia, they are also more likely to suffer from direct causes of mortality such as sepsis. HIV infected women have over five times higher risk of direct maternal mortality, and are more likely to die from underlying causes than HIV negative women (6). A study in Mozambique showed that malaria, HIV and, anemia were found in more than 40% of maternal deaths due to abortion, ectopic pregnancy and sepsis (7). Further, the risk of still births is doubled among HIV infected women and fetal anemia is increased among infants born to HIV positive women (8). Hemorrhage is the leading cause of maternal mortality (1) and anemia is one of the leading global causes of hemorrhage and disability (9), and therefore should be treated as one of the most serious global public health problems.

While women in LMICs have higher life expectancy than men, they spend most of their life with diseases due to reproductive age maternal morbidities (10). Evidence shows that infants born to women with obstetric complications are 3.7 times more likely to die than those without complications (11). Economically, women spend 11% more than men in similar age groups on reproductive age morbidity treatment expenditures, 24% have difficulty in resuming household work (12), and socially, some women are neglected by their husbands due to reproductive age morbidities such as fistula, (13). The high levels of intimate partner violence among pregnant women may also exacerbate maternal morbidities (14).

Global evidence shows that for every maternal death, 30–40 women end up having maternal morbidities that undermine their normal functioning, including physical, mental or sexual health issues that also lead to other socioeconomic repercussions (5,15). Globally, about 27 million annual morbid episodes were estimated to have occurred in 2015 from the five main direct obstetric causes of maternal mortality (16). SSA has high rates of reproductive age morbidity, including haemorrhage, eclampsia, abortions, and prolonged labour, indirect morbidities including HIV, malaria, and anemia (2,15), as well as the novel COVID-19 pandemic (17). These estimates are mainly based on health facility data. The overall estimate of morbidity is not known as most countries’ maternal incidence and disease burden data are not available or comparable – many SSA countries do not have strong health systems for routine monitoring and the definitions of morbidities may vary between countries. The data available in health facilities has limitations since some women do not use health facilities for deliveries, and hospitals tend to attract complicated cases which may not be representative of the actual morbidity prevalence (18,19).

Unlike mortality, the demographic impact of morbidity in pregnancy and in the postpartum period has rarely been examined, and yet many women face morbidities in almost every pregnancy and child birth (5). In SSA, studies of maternal health impact have estimated the life years lost for reproductive age women as a result of maternal mortality (20–22) and healthy life expectancy for the entire population (23). However, little is known about how long reproductive age women spend with maternal morbidities, which may have an impact on their lifestyle and reproductive health choices as well as affect their infants’ health (12). There is limited research measuring the demographic impact of maternal morbidities on the health of women. Since the reproductive age period is limited to 15–50 years, eliminating morbidities would allow women to have successful pregnancies, healthy children and support them to live longer and healthier lives even beyond the reproductive ages (24).

This study estimates the number of life years that women of reproductive ages spend in poor health due to reproductive age morbidities. This is the first study in SSA, to the best of our knowledge, to quantify the estimated life years women of reproductive ages live with maternal morbidities during their reproductive life and measure how much each morbidity compromises their reproductive age life expectancy, using common WHO maternal morbidity definitions and a representative sample.

We used Demographic and Health Survey (DHS) data for SSA countries that measured both HIV and anemia prevalence between 2010 and 2018 to determine the prevalence of maternal morbidities (HIV and anemia) among women of reproductive ages (15–50) in 23 countries (25) (See additional Table A1 for countries included, survey years and sample sizes). We used HIV and anemia prevalence to estimate number of years lived by reproductive women with the two diseases (7,26). SSA countries were excluded from the analysis if they only had one disease (either HIV or anemia) for women or if they only measured infant and not maternal anemia. The DHS is a representative, cross-sectional survey with information on a country’s demographic and health status which are comparable in many common indicators across countries (25).

Analysis

DHS age-specific death and population counts were used to construct country-specific life tables and estimate the survival function and reproductive age life expectancy (RALE) (22). RALE refers to the average number of years expected to be lived by a woman aged 15 during her reproductive age period (15–50), based on observed age-specific death rates and is calculated as:$RALE\left(t\right)=\frac{T\left(15,t\right)-T(50,t)}{\mathcal{l}(15,t)}$, where $T(x,t)$ and $\mathcal{l}(15,t)$ correspond to the life table measures for the person-years above age x and the number of survivors at age 15 at time t, respectively. In summary, RALE is a life expectancy where the life table starts at age 15 and is completed at age 50. Since the reproductive age range is 15 to 50, the total number of years for RALE are 35 years if no woman dies. In addition, healthy and unhealthy RALE were calculated using the prevalence rates of HIV and anemia of women in reproductive ages (the respective International Classification of Diseases 10th revision codes are HIV B20-B24 and anemia D60-D64) (27).

We defined reproductive age morbidities (HIV and anemia) as morbidities which women have experienced due to indirect causes during their reproductive age period. These were the only morbidities captured in the DHS across SSA between 2010 and 2018. However, HIV and anemia have been associated with most indirect maternal deaths, including those from direct causes as they predispose a woman to direct causes of maternal deaths, such as postpartum haemorrhage leading to death (6,7). It is common to find HIV and anemia as the contributing causes of death among women who die from direct maternal mortality causes (7). The prevalence of HIV and anemia are used to calculate the average number of years a woman will spend with HIV and anemia in their reproductive age life expectancy. This prevalence of morbidity can be interpreted as the number of reproductive years with HIV and anemia which women aged 15–50 would experience if current age specific rates of mortality and morbidity prevailed throughout the reproductive age period.

The Sullivan method is usually used for separating life expectancy into disabled and disability-free life years (28,29). We used the Sullivan method to calculate the reproductive years spent with and without HIV and anemia. It uses the life table person-years combined with the age-specific prevalence of a disease to derive age-specific unhealthy person-years from a particular disease. After that, unhealthy total person-years between ages 15 and 50 and unhealthy reproductive age life expectancy are derived (29).

The resultant reproductive age life expectancy (RALE) is then the addition of healthy life expectancy (HLE), and unhealthy life years due to HIV (UHIV), anemia (UA), and comorbidity of HIV and anemia (UHA):

$$RALE\left(t\right)=HLE\left(t\right)+UHIV\left(t\right)+UA\left(t\right)+UHA\left(t\right)$$

We calculated RALE with and without morbidities for each country in SSA, as well as an aggregate for the entire region (as the average of the age-specific death rates and assuming that the obtained information between 2010 and 2018 did not differ much from year to year). Confidence intervals of 95% for all healthy and unhealthy life expectancies were calculated by bootstrapping (details in additional data A1) (30). All calculations were conducted in the R statistical programming language (31).

Morbidity burden is high among the SSA countries. Anemia is higher in almost all countries followed by HIV and the comorbidity of the two morbidities (Fig. 1, detailed values in additional Table A2). There is also heterogeneity in disease prevalence across SSA regions. There is generally a higher prevalence of anemia in East, Central and West Africa (having the highest prevalence) and a very low HIV prevalence as compared to Southern Africa that has high prevalence of HIV, anemia, and comorbidity. Anemia prevalence is high at both younger and older reproductive ages compared to HIV, which is higher in middle and older reproductive ages. There is a higher comorbidity in countries that have high HIV prevalence than those with anemia and the age pattern is similar to that of HIV.

Source: authors’ calculations based on DHS data (25)

As an example of the calculation of healthy and unhealthy RALE for SSA countries, Fig. 2 shows the life table survival function of Zambian women from age 0 to 100 and depicts morbidity of women in reproductive ages (15–50) in 2018 (32). The overall survival for females aged 0-100 is represented by the outer curve. The area under the curve between ages 15 and 50 shows the RALE for Zambian women of 34.3 years [95% CI 34.3–34.4] and it is divided by its healthy and unhealthy life years by each disease and comorbidity. Zambian women have a high number of morbidities due to anemia (8.1 years [8.0-8.2]), HIV (3.0 years [3.0-3.1]), and comorbidity of the two diseases (2.4 years [2.4–2.5]). This is equivalent to a total of 39.4% of years of RALE lived unhealthy (anemia 23.6%, HIV 8.7%, and comorbidity 7.0%).

Source: authors’ calculations based on DHS data (25) and 2019 Life Table data from UN World Population Prospects (32) Note: the entire age 0-100 life table survival function is presented to clearly visualize the corresponding RALE.

Figure 3 shows the unhealthy life years spent with HIV and Anemia for SSA countries, 2010–2018. There is a higher number of years spent with anemia than HIV for all countries except Lesotho which has more HIV years. Many women spend more years with HIV than the comorbidity of HIV and anemia, except for countries which are mainly in west Africa where there are lower years spent with HIV than most parts of SSA.

The healthy and unhealthy RALE of SSA women between ages 15–50 and the years that they spend in reproductive ages with each disease are shown in Table 1. For the entire SSA region, on average women will spend 14.3 years [14.3–14.4] unhealthy of their RALE with morbidities, equivalent to 42.2% of total RALE: 11.6 years [11.6–11.7] with anemia (34.3%), 1.7 unhealthy years [1.7–1.8] with HIV (4.9%), and 1.1 unhealthy years [1.1–1.2] with the combination of HIV and anemia (3.1%). Most of the countries in SSA have similar RALE except Gambia, Ghana, Guinea, and Lesotho that have lower RALE. Rwanda has the highest RALE at age 15 (34.7 years [34.7–34.8]) while Guinea has the lowest (29.4 years [29.0–30.0]). Similarly, Rwanda has the lowest number of years of women with morbidities (8.3 years [8.3–8.4]) as compared to Gambia which has highest (21.4 years [21.4–21.5]). South Africa (11.8%) and Lesotho (11.2%) have the highest comorbidities as well as the highest HIV rates in SSA (Additional Figures A1-5 for maps of these and other results).

Source: authors’ calculations based on DHS data (25)

Table 1

Healthy and Unhealthy Reproductive Age Life Expectancy (RALE) by Morbidity for SSA Countries, 2010–2018.
			Unhealthy life years [95% CI]
Country	Year	RALE [95% CI]	HIV	Anemia	HIV & Anemia	Total Unhealthy	Healthy Life years
Burundi	2016-17	34.4 [34.4–34.5]	0.4 [0.4–0.5]	12.9 [12.8–13.0]	0.2 [0.2–0.2]	13.5	20.9
Burkina Faso	2010	34.3 [34.3–34.4]	0.2 [0.2–0.2]	16.3 [16.2–16.4]	0.3 [0.3–0.3]	16.8	17.5
Cameroon	2018	34.2 [34.2–34.3]	1.6 [1.6–1.7]	13.3 [13.3–13.4]	0.0 [0.0]	14.9	19.3
lvory Coast	2011-12	34.1 [34.0-34.2]	0.6 [0.2–0.2]	16.6 [16.2–16.4]	1.2 [0.2-.03]	18.4	15.7
Chad	2014-15	34.2 [34.2–34.3]	4.0 [3.9–4.1]	4.9 [4.9-5.0]	0.0 [0.0]	8.9	25.3
DRC	2013-14	34.0 [34.0-34.1]	0.3 [0.2–0.3]	13.3 [13.2–13.4]	0.3 [0.3–0.3]	13.9	20.1
Ethiopia	2016	34.4 [34.4–34.5]	0.5 [0.5–0.6]	9.1 [9.0-9.2]	0.3 [0.3–0.3]	9.9	24.5
Gabon	2012	34.3 [34.3–34.4]	0.7 [0.6–0.7]	18.4 [18.2–18.5]	1.5 [1.5–1.6]	20.6	13.7
Gambia	2013	33.9 [33.7–34.0]	0.3 [0.2–0.3]	20.4 [20.1–20.7]	0.7 [0.6–0.8]	21.4	12.5
Ghana	2014	33.5 [33.4–33.6]	0.4 [0.4–0.4]	13.4 [13.3–13.6]	0.5 [0.4–0.5]	14.3	19.2
Guinea	2018	29.4 [29.0-29.7]	0.3 [0.2–0.3]	12.9 [12.6–13.2]	0.3 [0.2–0.3]	13.5	15.9
Lesotho	2014	33.8 [33.7–33.9]	7.1 [7.0-7.3]	4.9 [4.8–50]	3.8 [3.7–3.9]	15.8	18.0
Malawi	2015-16	34.2 [34.2–34.3]	2.3 [2.3–2.4]	9.5 [9.4–9.5]	2.2 [2.2–2.3]	14.0	20.2
Mali	2012-13	34.5 [34.5–34.6]	0.2 [0.1–0.2]	17.7 [17.5–17.9]	0.3 [0.3–0.3]	18.2	16.3
Namibia	2013	34.3 [34.2–34.4	4.2 [4.1–4.3]	5.2 [5.1–5.2]	2.2 [2.2–2.3]	11.6	22.7
Niger	2012	34.2 [34.1–34.3	0.1 [0.1–0.1]	15.2 [15.1–15.3]	0.1 [0.1–0.1]	15.4	18.8
Rwanda	2014-15	34.7 [34.6–34.7]	1.5 [1.4–1.6]	6.8 [6.7-7.0]	0.0 [0.0]	8.30	26.4
Senegal	2017-18	34.2 [34.1–34.3]	0.1 [0.0-0.1]	18.1 [17.9–18.2]	0.2 [0.2–0.3]	18.4	15.8
Sierra Leone	2019	34.2 [34.1–34.3]	0.3 [0.3–0.3]	15.5 [15.3–15.6]	0.4 [0.4–0.5]	16.2	18.0
South Africa	2016	34.2 [34.1–34.3]	6.0 [5.3–5.8]	6.7 [6.1–6.8]	4.0 [3.6–3.9]	16.7	17.5
Togo	2013-14	34.2 [34.2–34.3]	0.4 [0.3–0.4]	14.9 [14.7–15.0]	0.6 [0.6–0.7]	15.9	18.3
Zambia	2018	34.3 [34.3–34.3]	3.0 [2.7-3.0]	8.1 [7.6–8.1]	2.4 [2.2–2.4]	13.5	20.8
Zimbabwe	2015	34.1 [34.1–34.2]	3.9 [3.8-4.0]	6.5 [6.4–6.6]	3.0 [2.9–3.1]	13.4	20.7
SSA	2010–2018	34.0 [34.0-34.1]	1.7 (4.9%)	11.6 (34.3%)	1.1 (3.1%)	14.3 (42.2%)	19.6 (57.8%)
Source: authors’ calculations based on DHS data (25)

To our knowledge, this is the first study to examine reproductive age life expectancy and partition it into healthy and unhealthy life years for anemia and HIV in SSA between 2010 and 2018. Results show that a 15-year-old woman in SSA is expected to live 34.0 more years [33.0-34.1] in her reproductive life. Maternal mortality reduced SSA RALE by one year despite being a rare event (22,33). However, an extensive proportion of women’s reproductive age life expectancy is spent with morbidities (over one third of their reproductive years). On average, the total number of years spent with reproductive health morbidities for women in SSA is 14.3 years [14.3–14.4]. Of these, 11.6 years [11.6–11.7] will be spent with anaemia, 1.7 years [1.7–1.8] with HIV, and 1.1 years [1.1–1.2] with both anemia and HIV. These diseases affect women’s daily life functions and compromise their reproductive health life and that of their infants (12). This study also shows a high comorbidity of anemia and HIV for countries that have high HIV rates in Southern Africa, such as South Africa and Lesotho as HIV has been found to increase vulnerability to other diseases (18).

Previous studies have shown the disease burden (18) and demonstrated the effect of maternal mortality on life expectancy but have not shown the impact of morbidity on RALE (22,33). Our study highlights the demographic impact of reproductive age morbidities on the health of women by showing the number of life years that are affected by morbidities and how each morbidity contributes to women’s poor health in their reproductive ages. While for reproductive health policy makers, a decline in the maternal mortality ratio is a major milestone, unfortunately less attention has focused on how morbidities affect women’s health after survival. Most of the women who survive continue to be affected by the morbidities that they suffered from their reproductive life years, especially if the morbidities were severe, some of which have long term consequences and also affect their infants’ health (6,13,34).

The finding that SSA women spend extensive periods of their reproductive years with morbidities is concerning. Studies have shown that despite women having longer life expectancy, they spend most of their older lives with morbidities (35). Although maternal morbidity measures vary, our results are similar to previous studies that show that maternal morbidities vary across regions and countries, and that west Africa has higher disease prevalence. About a quarter of morbidities were attributed to indirect maternal causes, and older ages have higher morbidities which only applies to HIV and not anemia for this study (18,24). COVID-19 has added to this burden of maternal morbidities being faced by women from 2019 onwards. Global maternal and fetal outcomes have worsened during the COVID-19 pandemic, with an increase in maternal depression, still births and raptured ectopic pregnancies as well as maternal deaths (17). These outcomes are likely to be worse in LMIC regions (SSA inclusive) with already high burden of morbidity prevalence (17). Women are known to run and take care of homes even though their level of autonomy is low in many countries (36). Being affected by these morbidities means that they will not operate optimally and their contribution to household duties and running of the home, workforce and society will be compromised. These diseases also affect infants, causing ripple effects for the future generation’s health and growth (37).

The present study has limitations. The Sullivan method assumes that women with and without morbidities (based on cross-sectional morbidity prevalence) have the same age-specific mortality rates. As such, our results correspond to an underestimate of the mortality seen by women experiencing comorbidities. Further, maternal morbidities are comprised of both direct and indirect causes. We do not have information on the prevalence of direct maternal morbidities in the DHS, such as hemorrhage, which leads to an underestimation of the total effect of reproductive age morbidities on RALE. However, our study presents comparative results of the morbidity burden (anemia and HIV) among SSA women between 2010 and 2018 using nationally representative samples, which provides an important estimate of morbidity prevalence among reproductive age women and informs programming and policy across the region, particularly as morbidity definitions and measurements vary across the region (18). Finally, mortality and morbidity data of SSA countries is incomplete, and our results should be taken as an approximation to the burden carried by women in the region. We have tried to compensate for this shortcoming by including confidence intervals in our estimates.

This study demonstrates the excess disease burden on the healthy lives of women due to reproductive age morbidities. Many of these morbidities are preventable(20) or can be managed with low cost measures (38–40). The measures used could be used to track maternal morbidity and mortality progress among reproductive age women in SSA and will be valuable for population health scholars and analytically relevant for research on inequality, mortality trends, morbidity, and population dynamics. If successful management of women and children’s health as well as SDG 3 is to be achieved, morbidity prevention and management measures and promotion, and women education and autonomy (36) will need to be enhanced from pregnancy to the postpartum period.

SSA

Sub Saharan Africa

RALE

Reproductive Age Life Expectancy

HIV

Human Immunodeficiency Virus

SDGs

Sustainable Development Goals

LMICs

Lower and Middle Income Countries

MMR

Maternal Mortality Ratio

WHO

World Health Organisation

DHS

Demographic and Health Survey

HLE

Healthy Life Expectancy

UHIV

Unhealthy Life Years due to HIV

Unhealthy Life Years due to Anemia

UHA

Unhealthy Life Years due to Comorbidity.

Ethics approval and consent to participate: This study involved secondary data analysis of public sources, which did not have any individual identifiers. As such, ethical approval for human subject research from the Institutional Review Board of the respective institutions was exempted.

Consent for publication: Not Applicable

Availability of data and materials: The datasets used and/or analysed during the current study are available in a public, open access repository. Data are available on the website (https://dhsprogram.com/data/available-datasets.cfm)

Competing interests: None declared

Funding: None

Authors’ contributions: VCR conceived the study and together with AK and BH planned its implementation. AK conducted the analysis with guidance from BH and VCR. AK wrote the first and subsequent drafts with guidance and advice from BH and VCR.

Acknowledgements: Authors acknowledge the support from MEASURE DHS for providing the datasets.

Additional data

Additional data are available at BMC online.

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Comparative evidence of years lived with reproductive age morbidity in sub-Saharan Africa (2010-2018)

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