**2. Sub-Sharan Africa: the world of poverty and hunger**

In the past decade, the world has experienced significant socioeconomic progress, even though the effects of the COVID-19 pandemic have had negative effects on population wellbeing [5]. In this chapter, the Human Development Index (HDI) is used to show the inequalities across world regions and within region, essentially SSA. The underlying assumption is that poverty and hunger are rampant in countries with low HDI. Furthermore, it is unlike to expect sustainable health, including MCH, if people are not fed properly, and live in extreme poverty. The recent report on HDI shows the following. First, SSA is the least developed region in the world based on HDI. Indeed, HDI in developing regions range from 0.547 in SSA to 0.705 in Arab states. It is clear that the region is still facing a number of challenges, including leadership and governance, women's empowerment, education, and employment among others. Turning to the distribution of HDI at country level, the report clearly shows that most SSA countries are located at the bottom of the ranking. For instance, 31 SSA countries ranked between 157th (Mauritania) and 187th position (Niger). This is a clear indication of poor leadership and governance in the region, adding up armed conflict and wars which are literally impeding sustainable democracies in the countries. Furthermore, the AIDS pandemic is still causing a number of serious damages in SSA countries, leaving behind vulnerable children and increasing the percentage of populations living under the poverty line [6]. Additionally, policymakers paid less attention to nutrition, while SSA is the region of the world where the number of underweight children has stagnated over time as a clear alarm to detrimental effects of malnutrition on children development growth, with all known consequences such as brain development [7–9]. Yet, fully complete nutrition is key to ensure optimal development and to ensure citizens are prepared to build national wealth while fighting hunger and eliminating poverty.

There is evidence of the co-occurrence of poverty and hunger in many regions of the world, including SSA and scholars really wonder if extreme poverty in SSA can be eliminated by 2030 [10, 11]. According to the World Bank, households with a per capita income or expenditure less than \$1.90 per person per day are defined being poor [12]. From the Economic Development Report released recently [13], there is evidence that most SSA countries have made progress in reducing the number of

#### *The Role of Leadership in Sub-Saharan Africa in Promoting Maternal and Child Health DOI: http://dx.doi.org/10.5772/intechopen.105773*

people living below the poverty line. In fact, between 2010 and 2019, the percentage of households living below the poverty line (\$1.9 per person per day) declined from 40 to 34%, in spite of the COVID-19 pandemic. It is common that people living in poverty to be undernourished, which led scholars to question the relationship between poverty and nutrition by adopting the human capital approach: Is it the cause or the consequence? Scholars posit that nutritional status has a profound impact on human capital [14], especially at earlier ages where the brain continues to develop. In the search of pathways of influence, scholars posited that malnutrition has adverse consequences on physical and mental health/development, productivity, and the economic potential of an individual. Likewise, poverty and malnutrition both affect MCH in the following ways. Poverty can be a strong barrier to access good healthcare services on the one hand [15–17], and on the other hand, malnutrition can be detrimental for maternal and child health [18].

Although most SSA countries made progress to reduce poverty levels amid the COVD-19 pandemic, the region is still lagging very behind compared with other regions in the world. Therefore, it is important to further our understanding of structural barriers impeding most SSA countries from meeting SDGs targets on maternal and child health. Before moving there, let us take a look on common indicators of MCH in the region.

## **3. Maternal and child health in sub-Saharan Africa: key indicators**

This section addresses a number of MCH in sub-Saharan Africa, including antenatal care services, skilled birth attendant, facility-based delivery, utilization of postnatal care services, child health services, HIV testing, and prevention of mother-child transmission.

#### **3.1 Antenatal care service coverage**

Indicators to monitoring antenatal care services include, among others, utilization, frequency, and timing of ANC [17]. This chapter reports on two ANC indicators: (*i*) percentage of women who received four or more ANC visits during pregnancy according to WHO recommendations [19] and (*ii*) percentage of women who received ANC visit from a skilled provider (**Figure 1**). The number of women of reproductive ages in SSA countries has increased over time [20]. Data were available for 32 countries and findings showed that, on average, 56% of women received at least four visits during pregnancy. This figure ranged from 29.2% in Senegal to 90.5% in Ghana. Likely, Ghana has made tremendous progress in ANC coverage and access mainly due to a developed national insurance scheme [21] The percentage of women of reproductive ages who received antenatal care from a skilled provider was even higher on average in 36 countries with available data. Indeed, 88% of women received ANC visits from a skilled provided. While SSA countries made incredible progress on this area, there still are significant differences across countries. The lowest (51.6%) and highest (99.2%) percentages were observed in Togo and Burundi, respectively. It is worthy to mention that these two countries are among smallest countries in SSA in terms of superficies which can be a key element allowing national governments to better serve women of reproductive ages during pregnancies, a major cause of maternal deaths in the region.

Sub-Saharan Africa has a long history of Knowledge-Attitudes-Practices (KAP) studies since 1980s to better understand knowledge, attitudes, and practices of modern contraction among women of reproductive ages. It was expected like it was in the case of Asian Tigers that after more than four decades women have embraced modern contraception as a path to reduce/control the persistent higher fertility levels in the region. The reality is that women of reproductive ages in the region are still suffering of unmet needs for family planning (**Figure A.1**, appendix). Yet, without universal access to family planning, the population will continue to grow, even faster.

*The Role of Leadership in Sub-Saharan Africa in Promoting Maternal and Child Health DOI: http://dx.doi.org/10.5772/intechopen.105773*

#### **3.2 Skilled birth attendance**

Skilled birth attendance (SBA) has attracted much attention three decades ago when the Safe Motherhood campaign was launched in Kenya [22, 23]. It is posited that SBA can substantially reduce maternal deaths when skilled birth attendants (e.g. doctors) assist women during deliveries [22, 24–27]. Therefore, many preventable deaths during pregnancies in SSA are due to the quality of health professionals who assist women during deliveries. Data available on 28 countries indicated that, on average, 71% of women were assisted by a skilled professional at delivery, which contrasts a bit with the alarming level of maternal deaths in the region (**Figure 2**). Perhaps, the inequalities across countries concerning access to a skilled provided may explain the higher number of maternal deaths which is observed in the region. Indeed, only one-fourth of women of reproductive ages are assisted by a skilled birth attendant, while the corresponding figure is 96.7% in South Africa [25]. There are two things worthy to point out here. First, reliable data to provide evidence on the state of skilled birth attendance are still missing. Governments in SSA countries and the AU council should engage in providing sufficient finding to collect data supporting planning, implementation, and monitoring of MCH programs in the region at national and subnational levels. Second, it seems there is a correlation between the level of socioeconomic development and access to SBA when one looks into the bottom (Chad) and the top (South Africa). Further research could devote much attention on this hypothesis and if confirmed, this means that collective efforts in the region should be done to reduce these inequalities across countries.
