Pregnancy And Madagascar: Safe Or Not?

Madagascar is a large island off the southeast coast of Africa. It is a popular tourist destination, but there are some concerns about the safety of travelling there, especially for pregnant women.

The country has a high maternal mortality rate, with 426 deaths per 100,000 live births. This is mostly due to delays or a lack of maternal healthcare services. There are also high levels of poverty, and most primary healthcare facilities are not easily accessible.

In addition, there is a high risk of malaria, which is particularly dangerous for pregnant women and children. While the Malagasy government recommends that pregnant women sleep under insecticide-treated nets and receive intermittent preventive treatment, uptake of these interventions is low.

Other health risks include the presence of traditional healers, who may provide incorrect or harmful advice or treatment. While some traditional midwives are reported to have positive relationships with biomedical health workers, others may encourage pregnant women to delay seeking medical care, e.g. by recommending harmful practices such as avoiding bananas during pregnancy or administering hot water douches immediately after birth.

Therefore, while it may be possible to have a safe pregnancy in Madagascar with proper precautions, there are significant risks that should be carefully considered before travelling there while pregnant.

Pregnancy and childbirth in Madagascar

Barriers to Healthcare Access

One of the main barriers is the distance to healthcare facilities. About 25.8% of the population lives more than 10 km from a healthcare facility, and even when facilities are within reach, there are often financial barriers to accessing services. In 2018, only 8% of the population had health insurance, and there is a high poverty rate of 70.5%. Additionally, there is a shortage of healthcare staff, with 50.3% of primary healthcare facilities lacking a doctor, and 53.5% of facilities not being accessible year-round.

Another challenge is the preference for traditional healers and home care over biomedical care. Traditional birth attendants, called "reninjaza", who do not receive any medical training, are often consulted instead of skilled birth attendants. This is partly due to the influence of family members, particularly grandmothers, partners, and mothers-in-law, who may pressure pregnant women to conform to traditional practices. There is also a belief that traditional healers can address issues related to jealousy from others, which is thought to affect pregnant women.

Furthermore, there are cultural taboos and beliefs that can impact healthcare-seeking behaviours. For example, it is considered inappropriate to talk about or refer to a pregnancy before it becomes visible. Additionally, there are food restrictions during pregnancy, such as avoiding bananas, as they are believed to give the baby too much strength and make delivery difficult.

Malaria

Malaria is also a significant concern during pregnancy in Madagascar, as it can lead to anaemia, low birth weight, stillbirth, and maternal death. While the World Health Organization (WHO) recommends insecticide-treated nets and intermittent preventive treatment during pregnancy, the uptake of these interventions is sub-optimal in the country. The entire population of Madagascar is at risk of malaria, and efforts to improve malaria prevention and control are ongoing.

Improving Maternal Healthcare

To address these challenges, organisations like Doctors for Madagascar and SEED Madagascar are working to improve care for pregnant women and newborns, particularly in rural areas. They provide free transportation to healthcare facilities, special courses for pregnant women to recognise early warning signs and improve nutrition, and mobile clinics with portable ultrasound machines. Additionally, they collaborate with traditional care providers and include key familial decision-makers in education sessions to encourage behavioural changes and improve maternal and child health outcomes.

Antenatal care in Madagascar

Barriers to Antenatal Care:

• Socioeconomic Factors: Poverty, lack of health insurance, and geographical distance to healthcare facilities pose significant challenges. About 70% of the population lives below the poverty line, and only 8% had health insurance in 2018. Additionally, 25.8% of people live more than 10 km from healthcare facilities, and many struggle with transportation costs.
• Cultural and Traditional Beliefs: Traditional beliefs and practices play a crucial role in antenatal care. Some women prefer traditional caregivers, such as "reninjaza" (traditional birth attendants), who provide care and advice during pregnancy, delivery, and the postpartum period. These practitioners often have close relationships with pregnant women and are considered more experienced than biomedical caregivers. However, their lack of formal medical training can lead to delays in seeking biomedical care, potentially impacting the health of both mother and child.
• Healthcare System Deficiencies: The public health system in Madagascar faces challenges such as understaffing, lack of equipment, and frequent stockouts of medicine and supplies. These issues contribute to the preference for alternative care options, including traditional healers and self-medication.
• Lack of Awareness and Knowledge: Insufficient knowledge about antenatal care and safe pregnancy practices is prevalent among pregnant women and their families. This lack of awareness contributes to delays in seeking biomedical care, especially in rural areas.

Facilitators and Interventions:

• Community Health Projects: Organisations like SEED Madagascar are working to improve maternal health outcomes by providing education and promoting behavioural changes. They collaborate with local health centres and the Ministry of Health to increase access to antenatal services and raise awareness about safe pregnancy practices.
• Improving Healthcare Accessibility: Initiatives such as Doctors for Madagascar aim to improve antenatal care by providing free transportation to healthcare facilities, offering special courses on pregnancy and early warning signs, and conducting mobile clinics with portable ultrasound machines to monitor high-risk pregnancies.
• Collaboration with Traditional Caregivers: Recognising the importance of traditional caregivers, some biomedical health facilities have authorised rituals to be performed in clinical spaces and have assigned assistant roles to traditional midwives. This collaborative approach aims to reduce delays in seeking biomedical care and improve maternal health outcomes.
• Skilled Birth Attendants: The World Health Organization (WHO) and the Ministry of Health in Madagascar recommend skilled birth attendants during pregnancy and delivery to prevent and manage complications. However, the utilisation of these services is still low, with only 49% of births assisted by skilled birth attendants in 2018.
• Malaria Prevention: Malaria during pregnancy is a serious concern in Madagascar, increasing the risk of adverse outcomes for both mother and infant. The WHO recommends insecticide-treated nets (ITNs), intermittent preventive treatment (IPTp), and prompt case management. However, uptake of these interventions remains sub-optimal, and efforts are needed to improve access and coordination.

Risks and complications

Madagascar has a high maternal mortality rate of 426 deaths per 100,000 live births, with most deaths occurring due to delays in seeking medical care in cases of obstetric complications. The country also has a high incidence of malaria, with the entire population at risk. This poses a significant threat to pregnant women, who are recommended to sleep under insecticide-treated nets and receive intermittent preventive treatment. However, the uptake of these measures is sub-optimal.

Pregnant women in Madagascar face challenges in accessing adequate healthcare due to poverty, lack of health insurance, and geographical distance from health facilities. Additionally, traditional beliefs and taboos influence health-seeking behaviours, with many women preferring to consult traditional healers or "reninjaza" over biomedical care. Delayed access to biomedical care during obstetric emergencies contributes to the high maternal mortality rate.

Travel within Madagascar, especially in rural areas, can be difficult due to poor road conditions and long distances. This may pose risks for pregnant women, particularly those in advanced stages of pregnancy, as highlighted by a TripAdvisor user who cautioned against long journeys on rough roads.

Malaria is a concern for pregnant women visiting Madagascar, and it is recommended to consult a doctor for advice on malaria prophylaxis. Additionally, there are strict laws and cultural taboos in Madagascar that pregnant women should be aware of, such as the prohibition of wearing hats and eating eels.

Overall, while Madagascar offers unique experiences, pregnant women should carefully consider the potential risks and complications before planning a trip to the country. It is essential to consult with a healthcare professional and follow their advice regarding travel to Madagascar during pregnancy.

Traditional medicine and healers

Traditional healers, often referred to as 'reninjaza', are particularly important in remote areas, where they are highly regarded and considered pillars of their communities. They are often the first port of call for those who fall sick, as they are more accessible than doctors, who can be few and far between.

Reninjaza are trained in massage, which they use to treat a range of ailments, from fatigue and back pain to repositioning a fetus in the womb. They also provide herbal remedies and spiritual guidance, and are often called upon to lift curses or provide protection against witchcraft.

While some traditional healer remedies have been found to be effective, there are also risks associated with traditional healers, including the use of poor-quality products, unqualified practitioners, and incorrect diagnoses. Despite these risks, traditional healers are often integral members of their communities and local culture and heritage.

There have been calls for greater collaboration between traditional healers and the medical profession, with some health professionals expressing a desire to work with "established, good traditional healers". However, regulation and standardisation of traditional healing practices pose a challenge.

Travel and transport

Madagascar is a large island, and travel between destinations can be time-consuming and uncomfortable. The roads are often in poor condition, and long-distance travel is usually done in 4x4 vehicles. Travel by air is possible, but internal flights are expensive.

For example, to get to the Tsingy (Bemaraha National Park) from Morondava is a nine-hour drive over rough roads. Morondava itself is either a 12-hour drive or an internal flight away.

If you are pregnant, it is important to consider the potential risks of long-distance travel over rough roads. It is recommended that you consult your doctor for advice before planning any long journeys.

In rural areas of southern Madagascar, medical care is particularly difficult to access. Most women in these areas have never seen a doctor during their pregnancy, and basic medical facilities and staff are often insufficient. Doctors for Madagascar is a charity working to improve care for pregnant women and newborns in the south of the island. They provide free transportation for pregnant women from a Centre de Santé de Base (CSB) in an ambulance stationed in either Fotadrevo or Manambaro. These ambulances can be called via a free hotline.

Mobile clinics, carried out by a travelling midwife or doctor with a portable ultrasound machine, are another important service for pregnant women in remote areas. Every day, they visit different villages to monitor and consult high-risk pregnancies and take urgent cases directly to hospital.

Frequently asked questions