Article

The challenge of access to maternal health care for women in the Central African Republic

Photographs by Hugh Kinsella Cunningham, winner of the 14th ICRC Humanitarian Visa d’Or award.
Patients arriving for appointments at Doukouma health centre, supported by the ICRC. Doukouma, Central African Republic, 9th December 2024.
Hugh Kinsella Cunningham

In the Central African Republic, women face major obstacles to access the maternal health care they need. In a country racked by instability and violence, medical care is often badly affected. Because of a lack of funding and qualified health workers, the health-care system is fragile, leaving thousands of people without health care.

The lack of proper health care in the Central African Republic (CAR) is particularly concerning for pregnant women and newborn babies, whose chance of dying as a result of their condition ranks among the highest in the world – mortality risk linked to pregnancy or childbirth is 104 times higher for a woman in the CAR than a woman in France,¹ and 2.8 per cent of newborn babies die within a month of being born.² Given these statistics, maternal health care in the CAR – which was already fragile in times of peace – has become one of the most pressing challenges in the current humanitarian crisis.

The invisible obstacles to access to maternal health care

Several factors are contributing to the crisis. The lack of transport, in particular in the most remote areas, prevents women from getting to health centres to give birth or have prenatal check-ups. Roads are often impassable and the cost of transport, when transport actually exists, is beyond most women’s modest means.

Nurses at the Doukouma health centre use a motorcycle ambulance to transport Bakote Kitiesa, illustrating how they move expectant mothers with complications from remote areas to seek healthcare at hospitals.  Doukouma, Central African Republic, 9th December 2024.
Nurses from the Doukouma health centre transport Bakote Kitiesa, a woman with pregnancy complications, on a motorcycle ambulance. This is often the only means of transport that can operate in remote areas and takes people to hospital for emergency care.
Nurses at the Doukouma health centre use a motorcycle ambulance to transport Bakote Kitiesa, illustrating how they move expectant mothers with complications from remote areas to seek healthcare at hospitals.  Doukouma, Central African Republic, 9th December 2024.

Traditions and cultural beliefs have a major influence on women’s choices in terms of health care. In some communities, many women will not go to health facilities to receive care out of distrust of modern medical practices. This pushes some to choose to give birth at home, often with a traditional midwife, despite the dangers such a choice entails. Nearly one woman in two gives birth at home² – which considerably increases the risk of complications.

In addition, women’s lack of decision-making power in relation to reproductive health issues constitutes another important obstacle. In many families, it is men who take decisions about health-care issues; women may need men’s consent for any medical procedure. This is stopping a large number of women from going to health centres. 

The consequences of such obstacles are tragic. Many women give birth in precarious conditions, sometimes with no professional help. And the absence of regular prenatal check-ups means that medical issues that could be treated in their early stages are not caught until they have become life-threatening emergencies.

Eveline Dimanche, who has just given birth to her 6th child at the Kaga-Bandoro hospital. Kaga-Bandoro, Central African Republic, 11th December 2024.
Eveline Dimanche after giving birth to her sixth child at Kaga-Bandoro Hospital.
Elise Mbeti who recently gave birth at Doukouma health centre.   Elise is a farmer and mother of 3, and has not yet named her new baby. Elise was previously displaced by fighting in the area, and remembers taking refuge in the bush. She has been able to return to her home village, and brings her children to the ICRC health centre of Doukouma when they fall ill. Doukouma, Central African Republic, 9th December 2024.
Farmer and mother of three children, Elise Mbeti recently gave birth at the health centre in Doukouma. Because of the fighting in the area, she has often had to seek safety in the bush. Now back in her own village, she regularly comes to this ICRC-supported health centre to care for her children.

The lack of health workers in the country is a major issue. The World Health Organization (WHO) recommends a threshold density of 23 doctors, nurses and midwives per 10,000 people. In the CAR, the ratio is well below this threshold, standing at 7.3 per 10,000. In some areas, it falls as low as 1.3. The lack of midwives and gynaecologists is particularly acute, especially in rural areas.

The ICRC’s response to the maternal health-care crisis

To make up for the shortage of qualified professionals, the ICRC has launched a training programme in the prefecture of Nana Gribizi. The programme aims to train local women, often traditional midwives, to recognize the warning signs and the dangers to people’s health and to refer people to health centres. “The project has three important roles,” says Viola Nizigiyimana, an ICRC midwife. “First, we train traditional midwives in early referral. Then, we teach them to identify risks and complications. Finally, if a woman is about to give birth and is far from a health centre, they need to be able to deliver the baby.” The programme will partly compensate for the lack of qualified health workers in rural areas, while also functioning as a bridge between traditional practices and the official health-care system.

Viola Nizigiyimana, an ICRC midwife, leads a session for local health workers training to be matrons who will assist pregnant women in their home villages. Kaga-Bandoro, Central African Republic, 6th December 2024.
Viola Nizigiyimana, an ICRC midwife, leads a session for local health workers training to be matrons who will assist pregnant women in their home villages.   Kaga-Bandoro, Central African Republic, 6th December 2024.
Viola Nizigiyimana, an ICRC midwife, trains women in Kaga-Bandoro to be midwives. They will care for pregnant women in their villages, places where access to health care is often limited.

The ICRC has ramped up efforts to meet the needs of pregnant women and newborns in the CAR. In 2024, more than 3,000 women received prenatal check-ups in ICRC-supported health centres. In addition, nearly 850 women gave birth safely in Nana Gribizi District Hospital, of which around 100 births were by caesarean.

Nadege Benezon is taken to the operating theatre at Kaga-Bandoro Hospital for an emergency caesarean.
Nadege Benezon is taken to the operating theatre at Kaga-Bandoro Hospital for an emergency caesarean.
The surgical team at Kaga-Bandoro Hospital perform a caesarean section on Nadege Benezon, delivering a little boy.
The surgical team at Kaga-Bandoro Hospital perform a caesarean section on Nadege Benezon, delivering a little boy.

To provide these medical services, the ICRC is funding upgrades to medical infrastructure. For example, three health centres in Patcho, Grevai and Doukouma have been built or renovated, significantly improving conditions for patients and working conditions for staff.

Given the challenges surrounding transport, the ICRC is also putting money into improving the road network. After repairing bridges on the Bianga–Sabegoudé, Alindao–Seignere and Bocaranga–Boleré routes, nearly 20,000 people can now get to health centres more easily.

These endeavours are aimed at strengthening local capacities and ensuring that women can get access to the health care they need, no matter where they live.

But despite all the work of humanitarian actors in the country, huge challenges remain. Both international mobilization and the support of the local communities are still needed to improve access to health care and save lives. Women’s health is a key indicator of a country’s resilience, and it must be given the attention it deserves.


[1] United Nations Population Fund, State of World Population report, 2024 available at: https://www.unfpa.org/sites/default/files/pub-pdf/swp2024-english-240327-web.pdf.
[2] UNICEF, “The midwives at the heart of improving maternal health in the Central African Republic”, 2023, available at: https://www.unicef.org/car/en/stories/midwives-heart-improving-maternal-health-central-african-republic.