The Togolese authorities must urgently strengthen access to maternal healthcare in the country and reduce infant and neonatal mortality, Amnesty International said today to mark African Women’s Day.

Togo has an infant mortality rate of 43 deaths per 1000 live births and a neonatal mortality rate, which refers to newborns dying before reaching 28 days of age, of 24 deaths per 1000 live births, according to UNICEF. Togo’s maternal mortality rate is also high, with 399 maternal deaths recorded for every 100,000 live births.

Although the Togolese authorities have taken steps to make maternal healthcare more affordable, it is crucial that they introduce new measures to ensure that pregnant women are able to give birth with dignity in facilities where they are properly assisted and cared for.

Aimé Adi, Director of Amnesty International Togo

Amnesty International delegates conducted interviews with 21 people, including 13 patients, four midwives and four doctors, in five public healthcare facilities in Lomé, the capital, and Aného, in town in south-eastern Togo, in February and March 2023.

In most healthcare facilities, Amnesty International delegates noted staff shortages, dilapidated equipment, and poor quality of care.

The right to health is guaranteed by Article 12 of the International Covenant on Economic, Social and Cultural Rights, Article 16 of the African Charter on Human and Peoples’ Rights, Article 14 of its Additional Protocol on the Rights of Women and Article 16 of the Togolese Constitution. Article 97 of Togo’s Health Code states “every pregnant woman has the right to good pregnancy monitoring, safe childbirth and postnatal care for herself and her child”.

Staff shortages and inadequate medical equipment

The maternity units visited did not have enough staff and lacked adequate equipment and sanitary facilities. As a result, the few midwives who were employed struggled to cope with their excessive workloads. Three midwives told Amnesty International that on-call duty often lasts for more than 15 hours. According to the United Nations Population Fund, there are only two midwives for every 10,000 people in Togo.

A member of the Togo’s Association of Midwives told Amnesty International that the shortage of midwives is due to a lack of regular examinations for entry into the public service, which hinders the recruitment of midwifery school graduates. There are also very few gynaecologists in public hospitals.

One gynaecologist told Amnesty International: “Gynaecologists are often exhausted. We’re involved in consultations, operating theatres, complicated deliveries, etc. That’s why gynaecologists are rare in the public sector. They go into the private sector to earn as much as they put in. For example, there are only two in the public hospital of Bè. Some [public hospitals] have operating theatres but no gynaecologists.”

On social media, the Secretary General of the National Union of Hospital Practitioners of Togo said that, out of 127 gynaecologists registered with the Togolese National Medical Association, only 25 work in public hospitals.

All maternity units visited also lacked the basic equipment needed to receive patients or provide care. In one of the Socio-Medical Centres (CMS) in Lomé, Amnesty International delegates found dilapidated examination tables in the antenatal consultation room, while the lack of scialytic lamps meant that midwives had to use torches on their mobile phones during consultations.

One midwife at CMS said they had only one delivery table, while several items of equipment were malfunctioning, faulty or in short supply, including resuscitation balloons, mucus aspirators and episiotomy scissors.

At Sylvanius Olympio University Hospital, another healthcare facility visited by Amnesty International, one midwife said: “You can see women giving birth on the floor, on mattresses, and sometimes even simply on a piece of cloth when there is no mattress. There are new delivery tables but also old ones that are dilapidated and mouldy.”

Strained patient-staff relations

The shortages of equipment and staff have also had a negative impact on the quality of care offered to patients during prenatal consultations and childbirth.

One patient told Amnesty International: “In paediatrics, there isn’t always room for a mother to bring her child. We had to buy a chair. Sometimes women are forced to stand with their children.”

The poor working conditions have also negatively affected patient-staff relations. Several patients told Amnesty International that they had been verbally abused or humiliated by staff.

One midwife told Amnesty: “We’re overloaded, we can’t give our best, we spill over onto the patients, we don’t welcome them properly and we can make errors in our work. Tasks are delegated to students who make mistakes.”

Midwives also told Amnesty International that they are frequently the targets of verbal and sometimes physical violence from patients or their relatives.

Access to affordable healthcare

In August 2021, the Togolese authorities improved women’s access to maternal healthcare services by creating a national support programme for pregnant women and new-born children, called “Wezou” (life), which was designed to “reduce maternal and neonatal mortality rates” by allowing women to access maternal healthcare services for a cut-price fee.

Amnesty International found that the programme was highly visible in the five maternity units visited, and several patients said they had benefited from it.

Prior to the launch of Wezou, however, official websites said the programme would provide “free care for pregnant women”. In practice, only certain services are free, and only for women over the age of 18. Antibiotics that are often required after childbirth are also not included in the Wezou plan.

While the Wezou initiative is an important step forward, there is room for improvement. Amnesty International is calling on the Togolese authorities to respect, protect and fulfil the right to health by ensuring there is a sufficient number of qualified medical staff available for patients. They should also ensure that programmes aimed at making healthcare affordable are available to all people, without discrimination, and allocate at least 15% of the State budget to the health sector, in line with the commitments made in the Abuja Declaration adopted by the African Union in 2001.

The Togolese authorities must make a substantial effort to improve access to healthcare and, in particular, the quality of equipment and care available in maternal health facilities.

Fabien Offner, researcher at Amnesty International’s office for West and Central Africa