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Maternal mortality and child malnutrition: Complications of the current crises in Yemen

Open AccessPublished:April 22, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101051

      Abstract

      UNICEF has declared Yemen as one of the largest humanitarian crises in the world. With the ongoing war, famine, and COVID-19 pandemic converging to create Yemen's current detrimental situation. This further exacerbated Yemen's dwindling resources, contributing to the lack of basic necessities, a poor healthcare system, poverty, food insecurity, illiteracy, pollution, and skyrocketing outbreaks of infectious diseases. Leading to alarming number of maternal mortality and child malnutrition cases. The socioeconomic disparities and financial constraints are making it nearly impossible for Yemen to recover. In the wake of current events, Yemen requires immediate assistance to prevent further crises complications and mortalities.

      Keywords

      1. Introduction

      Maternal mortality, according to United Nations International Children's Emergency Fund (UNICEF), occurs due to complications during pregnancy or childbirth.

      Maternal mortality rates and statistics - UNICEF DATA [Internet]. [cited 2022 Mar 14]. Available from: https://data.unicef.org/topic/maternal-health/maternal-mortality/.

      ,

      Yemen crisis | UNICEF [Internet]. [cited 2022 Mar 19]. Available from: https://www.unicef.org/emergencies/yemen-crisis.

      Many causes that contribute to maternal mortality include childbirth complications such as post-partum hemorrhage, pre-existing medical conditions, eclampsia & pre-eclampsia, sepsis, embolism, and unsafe abortion.

      Maternal mortality rates and statistics - UNICEF DATA [Internet]. [cited 2022 Mar 14]. Available from: https://data.unicef.org/topic/maternal-health/maternal-mortality/.

      The maternal mortality ratio (MMR) is defined as the number of maternal deaths per 100,000 live births during a time period.

      Maternal mortality ratio (per 100 000 live births) [Internet]. [cited 2022 Mar 14]. Available from: https://www.who.int/data/gho/indicator-metadata-registry/imr-details/26.

      Overtime, the maternal mortality ratio (MMR) worldwide has decreased by 38%, from 342 deaths in 2000 to 211 deaths in 2017 per 100,000 live births; however, the rates still remain relatively high in most of the third-world countries.

      Maternal mortality rates and statistics - UNICEF DATA [Internet]. [cited 2022 Mar 14]. Available from: https://data.unicef.org/topic/maternal-health/maternal-mortality/.

      Highest rates were recorded in west & central Africa (674/100,000), sub-Saharan Africa (533/100,000), Eastern and Southern Africa (384/100,000), and South Asia (163/100,000).

      Maternal mortality rates and statistics - UNICEF DATA [Internet]. [cited 2022 Mar 14]. Available from: https://data.unicef.org/topic/maternal-health/maternal-mortality/.

      In Yemen, the maternal mortality ratio (MMR) was 164 deaths per 100,000 live births in 2017.

      Yemen Maternal mortality ratio, 1960-2021 - knoema.com [Internet]. [cited 2022 Mar 14]. Available from: https://knoema.com/atlas/Yemen/Maternal-mortality-ratio.

      With Yemen already bearing the worst triple emergency humanitarian crisis (diminishing humanitarian aid, the ongoing war, and the COVID-19 pandemic),

      Hashim HT, Miranda AV, Babar MS, Essar MY, Hussain H, Ahmad S, et al. Yemen's triple emergency: Food crisis amid a civil war and COVID-19 pandemic. Public health in practice (Oxford, England) [Internet]. 2021 Nov [cited 2022 Mar 14];2:100082. Available from: https://pubmed.ncbi.nlm.nih.gov/34494006/.

      it comes with no surprise that the MMR in this country has risen sharply from five maternal deaths a day in 2013, to 12 a day in 2018.

      Yemen: maternal and newborn health ‘on the brink of total collapse’, UNICEF alerts | | UN News [Internet]. [cited 2022 Mar 14]. Available from: https://news.un.org/en/story/2019/06/1040531.

      According to World Health Organization (WHO), malnutrition is defined as deficiency, excess, or imbalance in nutritional and energy update of an individual.

      Fact sheets - Malnutrition [Internet]. [cited 2022 Mar 14]. Available from: https://www.who.int/news-room/fact-sheets/detail/malnutrition.

      Malnutrition can essentially lead to stunted growth, muscle wasting, inadequate uptake of vitamins & minerals (micronutrients), and obesity.

      Fact sheets - Malnutrition [Internet]. [cited 2022 Mar 14]. Available from: https://www.who.int/news-room/fact-sheets/detail/malnutrition.

      Population at risk of malnutrition includes women, children, adolescents, and infants.

      Fact sheets - Malnutrition [Internet]. [cited 2022 Mar 14]. Available from: https://www.who.int/news-room/fact-sheets/detail/malnutrition.

      Globally, around 149.2 million children under the age of 5 are stunted, 45.4 million are wasted and 38.9 million are overweight.

      2021 Global Nutrition Report | Executive summary - Global Nutrition Report [Internet]. [cited 2022 Mar 14]. Available from: https://globalnutritionreport.org/reports/2021-global-nutrition-report/executive-summary/.

      The rates of child malnutrition are particularly high in third-world countries like Africa (28 million), Afghanistan (3.2 million), Pakistan (10 million), Somalia (1.2 million).

      Child Starvation & Malnutrition in Africa | Save the Children [Internet]. [cited 2022 Mar 14]. Available from: https://www.savethechildren.org/us/what-we-do/emergency-response/helping-starving-african-children.

      A million Afghan children at risk of dying amid acute malnutrition, WHO says | Reuters [Internet]. [cited 2022 Mar 14]. Available from: https://www.reuters.com/world/asia-pacific/who-says-million-afghan-children-risk-dying-amid-acute-malnutrition-2021-11-12/.

      Nutrition | UNICEF Pakistan [Internet]. [cited 2022 Mar 14]. Available from: https://www.unicef.org/pakistan/nutrition-0.

      Nutrition | UNICEF Somalia [Internet]. [cited 2022 Mar 14]. Available from: https://www.unicef.org/somalia/nutrition.

      Yemen: Surge in child malnutrition as funding for world's largest humanitarian crisis falls short - Yemen | ReliefWeb [Internet]. [cited 2022 Mar 14]. Available from: https://reliefweb.int/report/yemen/yemen-surge-child-malnutrition-funding-world-s-largest-humanitarian-crisis-falls-short.

      In Yemen more than 2.3 million children under the age of five suffer from acute malnutrition.

      The silence of the lambs: Child morbidity and mortality from malnutrition in Yemen - Journal of Pediatric Nursing: Nursing Care of Children and Families [Internet]. [cited 2022 Mar 14]. Available from: https://www.pediatricnursing.org/article/S0882-5963(21)00374-2/fulltext.

      Additionally, it was reported that 1 million children younger than 5 years old are at risk of acute malnutrition— in Hodeida alone, more than 100,000 children are at risk of severe malnutrition.

      Malnutrition in Yemen: an invisible crisis - The Lancet [Internet]. [cited 2022 Mar 14]. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32592-2/fulltext.

      Poverty reinforces child-malnutrition by increasing the risk of food insecurity.
      Overall, Yemen's current situation is worse than perceived, with an interplay between the complicated political situation, COVID-19 pandemic, humanitarian crises, ongoing rise in infectious diseases, predisposing socioeconomic disparities. The population had already been battling with hunger, maternal mortalities, and lack of medical equipment even before COVID-19 struck. To make matters worse, this pandemic has further left Yemen in shambles.
      • Alsabri M.
      • Alhadheri A.
      • Alsakkaf L.M.
      • Cole J.
      Conflict and COVID-19 in Yemen: beyond the humanitarian crisis.
      More than 11, 781 cases have been reported in Yemen till 10th March 20, 22.

      Yemen: WHO Coronavirus Disease (COVID-19) Dashboard With Vaccination Data | WHO Coronavirus (COVID-19) Dashboard With Vaccination Data [Internet]. [cited 2022 Mar 14]. Available from: https://covid19.who.int/region/emro/country/ye.

      All of this led to many problems including financial constraints, lack of basic necessities, and a sub-standard healthcare system. Currently, 4.8 million people in Yemen lack access to primary health care, 7 million people are prey to food deprivation, and many children are acutely malnourished.

      Yemen's silent killers - The Lancet [Internet]. [cited 2022 Mar 14]. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30390-2/fulltext.

      High intensity conflict in Yemen has resulted in rising mortality and injury rates since March 2015, with the initial deterioration in lifespan, worsening levels of child malnutrition, and an increasing maternal mortality rate.

      Health system functionality in a low-income country in the midst of conflict: the case of Yemen - PubMed [Internet]. [cited 2022 Mar 14]. Available from: https://pubmed.ncbi.nlm.nih.gov/28402469/.

      This study highlights maternal mortality and child malnutrition as additional complications of the pre-existing crises in Yemen.

      2. Discussion

      Yemen ranks as one of the top countries with the highest maternal mortality and child malnutrition rates in the world.

      The silence of the lambs: Child morbidity and mortality from malnutrition in Yemen - Journal of Pediatric Nursing: Nursing Care of Children and Families [Internet]. [cited 2022 Mar 14]. Available from: https://www.pediatricnursing.org/article/S0882-5963(21)00374-2/fulltext.

      ,

      Crisis in Yemen: Protracted conflict pushes Yemenis deeper into need | International Rescue Committee (IRC) [Internet]. [cited 2022 Mar 14]. Available from: https://www.rescue.org/article/crisis-yemen-protracted-conflict-pushes-yemenis-deeper-need.

      One of the main reasons for this is the 7-year ongoing civil war between the Internationally Recognized Government (IRG) and the Southern Transitional Council (STC).

      Crisis in Yemen: Protracted conflict pushes Yemenis deeper into need | International Rescue Committee (IRC) [Internet]. [cited 2022 Mar 14]. Available from: https://www.rescue.org/article/crisis-yemen-protracted-conflict-pushes-yemenis-deeper-need.

      Yemen is considered to be a country where the humanitarian crises are worsening rapidly. This crisis leaves more than half of Yemen's population with no access to food, and with an ever-increasing poverty rate.

      Crisis in Yemen: Protracted conflict pushes Yemenis deeper into need | International Rescue Committee (IRC) [Internet]. [cited 2022 Mar 14]. Available from: https://www.rescue.org/article/crisis-yemen-protracted-conflict-pushes-yemenis-deeper-need.

      Due to the ongoing humanitarian crises, Yemen's economy faced a significant loss which led to the destruction of over half of the healthcare facilities and the remaining did not have enough capacities and resources to handle the whole population.

      Access to health care and medical facilities - Yemen | ReliefWeb [Internet]. [cited 2022 Mar 14]. Available from: https://reliefweb.int/report/yemen/access-health-care-and-medical-facilities.

      Following the collapse of the economy, 148 hospitals have been destroyed or are being used for different purposes since 2015.

      Yemen: Surge in child malnutrition as funding for world's largest humanitarian crisis falls short - Yemen | ReliefWeb [Internet]. [cited 2022 Mar 14]. Available from: https://reliefweb.int/report/yemen/yemen-surge-child-malnutrition-funding-world-s-largest-humanitarian-crisis-falls-short.

      Along with the foregoing concern, the limited number of healthcare workers also affected the MMR and child malnutrition rate.

      Access to health care and medical facilities - Yemen | ReliefWeb [Internet]. [cited 2022 Mar 14]. Available from: https://reliefweb.int/report/yemen/access-health-care-and-medical-facilities.

      It was estimated that less than 50% of births were attended by skilled health personnel which along with the preceding challenges, accounts for the high MMR.

      Access to health care and medical facilities - Yemen | ReliefWeb [Internet]. [cited 2022 Mar 14]. Available from: https://reliefweb.int/report/yemen/access-health-care-and-medical-facilities.

      An additional major factor which led to worsening of the healthcare system, economic collapse, high MMR, and child malnutrition was the COVID-19 pandemic. During the first half of 2021, total number of confirmed COVID-19 cases reached up to 6931 with 1363 deaths reported, reaching a 19.7% case fatality rate (CFR).

      UNICEF Yemen Humanitarian Situation Report - 1 January to 30 June 2021 - Yemen | ReliefWeb [Internet]. [cited 2022 Mar 14]. Available from: https://reliefweb.int/report/yemen/unicef-yemen-humanitarian-situation-report-1-january-30-june-2021.

      The lack of access to vaccines in Yemen has meant that there is immediate threat towards achieving population immunity.

      Lack of access to COVID-19 vaccines could be a greater threat than vaccine hesitancy in low-income and conflict nations: the case of Yemen - PubMed [Internet]. [cited 2022 Mar 14]. Available from: https://pubmed.ncbi.nlm.nih.gov/35134160/.

      During these times around 54%

      Yemen: Surge in child malnutrition as funding for world's largest humanitarian crisis falls short - Yemen | ReliefWeb [Internet]. [cited 2022 Mar 14]. Available from: https://reliefweb.int/report/yemen/yemen-surge-child-malnutrition-funding-world-s-largest-humanitarian-crisis-falls-short.

      of the population faced food insecurity which added to the already high child malnutrition count of more than 2 million during that year.

      UNICEF Yemen Humanitarian Situation Report - 1 January to 30 June 2021 - Yemen | ReliefWeb [Internet]. [cited 2022 Mar 14]. Available from: https://reliefweb.int/report/yemen/unicef-yemen-humanitarian-situation-report-1-january-30-june-2021.

      Other challenges to be considered is the underreporting and low diagnostic capacity due to several constraints. Leading the exact statistics of COVID-19, MMR, and child malnutrition to likely not be completely accurate, because during these sensitive times it is arduous for the government and local institutions to conduct surveys in order to find out the exact numbers. The fact that the MMR last reported was in 2017,

      Yemen Maternal mortality ratio, 1960-2021 - knoema.com [Internet]. [cited 2022 Mar 14]. Available from: https://knoema.com/atlas/Yemen/Maternal-mortality-ratio.

      which was 5 years ago, proves the aforementioned contemplation.

      3. Implications

      The continuation of these humanitarian crises in Yemen will result in disastrous situations.
      One move with detrimental implications is that the United Nations has slashed Yemen's funding making drastic cuts in critical aid at 300 health centers in Yemen and a reduction in food rations which were imperative for the survival of many Yemenis.

      UN slashes healthcare in Yemen due to lack of funding | United Nations News | Al Jazeera [Internet]. [cited 2022 Mar 19]. Available from: https://www.aljazeera.com/news/2020/9/23/un-slashes-healthcare-in-yemen-due-to-lack-of-funding.

      Additionally, the long-term food insecurity will lead to exacerbation of the widespread famine. This will present with fatigue, weakness, and higher mortality rates. It will also lead to a weaker immune system in children making them more susceptible to infections. Resulting in a surge of cases of cholera, diphtheria, and measles.
      • Alsabri M.
      • Alhadheri A.
      • Alsakkaf L.M.
      • Cole J.
      Conflict and COVID-19 in Yemen: beyond the humanitarian crisis.
      The country barely had enough resources to try to get through during the war but now due to the pandemic they're on the brink of completely deteriorating after the previous collapse. Peace talks to resolve the war had been in works in the past, some even reached conclusions such as the Stockholm agreement back in 2018, but all have made none to limited progress.

      Yemen's Tragedy: War, Stalemate, and Suffering | Council on Foreign Relations [Internet]. [cited 2022 Mar 14]. Available from: https://www.cfr.org/backgrounder/yemen-crisis.

      4. Efforts

      There are many programs and ventures being held in order to reduce the MMR and child malnutrition cases Yemen. For example, supports 4400 primary healthcare centers that grant outpatient therapeutic treatment programs. These programs provide families necessary lifesaving treatments including care to pregnant women, children, newborns.

      Malnutrition: a constant threat for children in Yemen | UNICEF Yemen [Internet]. [cited 2022 Mar 14]. Available from: https://www.unicef.org/yemen/stories/malnutrition-constant-threat-children-yemen.

      Furthermore, UNICEF also supports 134 feeding centers which provide ready to use therapeutic food [RUTF] specifically aimed at helping acutely malnourished children.

      Malnutrition: a constant threat for children in Yemen | UNICEF Yemen [Internet]. [cited 2022 Mar 14]. Available from: https://www.unicef.org/yemen/stories/malnutrition-constant-threat-children-yemen.

      The World Food Program is another organization that focuses on providing nutrition and tackling the food crises further reducing the number of child malnutrition cases. In response to the issue of child malnutrition specifically, the World Food Program provided nutritional support to 3.3 million mothers and their children. They did this by providing daily nutritional snacks to 1.55 million children at school. Additionally, the World Food Program has also focused on long term solutions to the crises as it has provided assistance to 1.2 million people with individual projects such as rebuilding infrastructure, agricultural land, irrigation systems, and health care facilities with training to match.

      Yemen | World Food Programme [Internet]. [cited 2022 Mar 14]. Available from: https://www.wfp.org/countries/yemen.

      On the other hand, there are also programs run by organizations which focus solely on maternal health such as USAID which has trained more than 260 midwives to help pregnant women and infants in Yemen while also coordinating with UNICEF, WHO, and the Yemen Ministry of Public Health and population to improve maternal health and make sure its accessible to those in need.

      Maternal Health in Yemen - The Borgen Project [Internet]. [cited 2022 Mar 14]. Available from:: https://borgenproject.org/tag/maternal-health-in-yemen/.

      In addition, there has been an incredible amount of donations made to the Humanitarian Response plan which received US$ 1.9 billion dollars in 2020 to be used to help alleviate the humanitarian crises in Yemen.

      Acute malnutrition threatens half of children under five in Yemen in 2021: UN [Internet]. [cited 2022 Mar 14]. Available from: https://www.who.int/news/item/12-02-2021-acute-malnutrition-threatens-half-of-children-under-five-in-yemen-in-2021-un.

      5. Recommendations

      Recommendations for Yemen are incredibly varied as there are a multitude of factors which contribute to the maternal mortality rate as well as the high number of children who are malnourished. There are many programs which help provide nutrition directly and help with improving agriculture by helping local farmers for the long-term improvement in the amount of food resources available in Yemen. However, this will naturally lead to an increase of supply and thus a reduction in price of said goods. It is imperative to protect these farmers' livelihood from the prices of the commodities dropping down as it could result in these farmers abandoning their crops for a more profitable alternative such as the local narcotic, Qat. Therefore, it is necessary to have organizations buy local food at a markup to prevent this shift from occurring.

      Health in Yemen: losing ground in war time - PMC [Internet]. [cited 2022 Mar 14]. Available from: https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC5918919/.

      Another key problem is Yemen's lack of and failing sewage systems. Many Yemeni citizens live in areas surrounded by pollution due to a lack of a proper sanitation system which leads to sewage accumulating in these populated areas. This can lead to a spike of cases involving malaria and symptoms of diarrhea, both of which can lead to an increase of incidents of malnutrition among children. By improving and building new sanitation systems we can reduce the number of diseases and simultaneously reduce the number of cases of child malnutrition in Yemen.
      Yemen is one of the impecunious countries around the world, which means that the indigent women lack the basic healthcare framework and necessary education to deliver their young ones protectively. Unfortunately, many Yemeni women are unaware as to the benefits of giving birth in hospitals as only three out of ten children are born in a healthcare facility.

      Maternal Health in Yemen - The Borgen Project [Internet]. [cited 2022 Mar 14]. Available from:: https://borgenproject.org/tag/maternal-health-in-yemen/.

      ,

      Maternal and Infant Mortality in Yemen: Khaizaran's Story [Internet]. [cited 2022 Mar 14]. Available from: https://www.unicef.ie/stories/maternal-infant-mortality-yemen/.

      To help educate on the benefits of proper maternal and natal care that such establishments provide, informational campaigns can be done via social media, educational segments in schools, and pamphlets in the local marketplaces. This will help increase the number of expecting mothers seeking proper care and going to hospitals. Thus, resulting in a reduction of the MMR in Yemen.
      Furthermore, the Covid-19 pandemic has exacerbated many current issues present in Yemen such as straining the already collapsing economy and burdening the struggling healthcare system which in turn leads to increased cases of maternal mortality and child malnutrition. Therefore, it would be beneficial to help supply Yemen with any excess Covid-19 vaccinations in countries that no longer have a pressing need for them in order to help alleviate certain issues that the virus may worsen.
      Additionally, by acquiring additional funding, new and better programs, with an extended reach and more efficiency, can be initiated in order to reduce many of the current issues plaguing Yemen.

      Acute malnutrition threatens half of children under five in Yemen in 2021: UN [Internet]. [cited 2022 Mar 14]. Available from: https://www.who.int/news/item/12-02-2021-acute-malnutrition-threatens-half-of-children-under-five-in-yemen-in-2021-un.

      6. Conclusion

      To conclude, there are many factors contributing to the many crises in Yemen which led to substantially high rates of maternal mortality and child malnutrition. The aforementioned causes mainly comprised of the results of the ongoing war and the COVID-19 pandemic. Some of these causes include food insecurity, poverty, pollution, illiteracy, and lack of access to basic major resources. The situation in Yemen goes beyond the scope of the worsening humanitarian crises. Immediate action needs to be taken to prevent the situation from reaching to a point where it would be nearly impossible to recover. First and foremost, the main way to help alleviate Yemen's situation is by managing and solving the underlying causes/crises alongside focusing on the ways to decrease the MMR and child malnutrition.

      Funding

      Not applicable.

      Ethics approval and consent to participate

      Not applicable.

      Consent for publication

      All authors agreed to the publication of this manuscript.

      Declaration of competing interest

      The authors declare that they have no competing interests.

      Acknowledgements

      None.

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