Description
ABSTRACT
Maternal mortality in Nigeria continues to be a serious public health problem and contributes to the low life expectancy among women in Nigeria. This study has identified several factors that have an important influence on maternal mortality in the study area. Among these are variables such as place of consultation/diagnosis, the person who pays the treatment costs, awareness of pregnancy complications and knowledge of the place of antenatal treatment, among others. Maternal mortality ratio in Nigeria is one of the highest in the world. This paper reports a facility based study in Nigeria to determine the magnitude, trends, causes and characteristics of maternal deaths before and after the launch of the Safe Motherhood Initiative in Nigeria, with a view to suggesting strategic interventions to reduce these deaths
COVER PAGE
TITLE PAGE
APPROVAL PAGE
DEDICATION
ACKNOWELDGEMENT
ABSTRACT
CHAPTER ONE
- INTRODUCTION
- BACKGROUND OF THE PROJECT
- MATERNAL MORTALITY DEFINED
- AIM OF THE STUDY
- OBJECTIVE OF THE STUDY
- SIGNIFICANCE OF THE STUDY
- CAUSES OF HIGH MATERNAL MORTALITY IN NIGERIA
- PREVENTIVE MEASURES FOR MATERNAL MORTALITY IN NIGERIA
- WHO’s RESPONSE OVER MATERNAL MORTALITY IN NIGERIA
- CONCLUSION AND RECOMMENDATIONS
- REFERENCES
CHAPTER ONE
1.0 INTRODUCTION
1.1 BACKGROUND OF THE STUDY
In the year 2000, the country with the highest estimated number of maternal death is India (136,000) followed by Nigeria (37,000) (World Health Organization, 2004). Obstetric causes of maternal death are often documented in Nigeria but little attention is paid to the major contributing factors. The 2003 Nigeria Demographic Health Survey reported that one-third of births in Nigeria are attended by doctors, nurses or midwives. One-fifth of births received the assistance of a traditional birth attendant. One in every four births is assisted by a relative or some other untrained persons, while 17 percent are unassisted (National Population Commission, 2004). Apart from this report, several other researchers have shown that there were drastic decline in hospital births, apparently as a result of the country’s deepening economic crisis.
The 2003, Nigeria Demographic Health Survey included a series of questions aimed at obtaining information on the problems which women perceive as barriers to accessing health care for themselves. The most commonly cited problems is getting money for treatment (30 percent), followed by problem of distance to health facilities and having to take transportation (24 percent), some women reported concern that there may not be a female provider (17 percent), some reported not wanting to go alone (14 percent) and others reported that getting permission to go to the hospital is a problem. These problems can be clearly categorized into three factors; namely poverty, poor governmental policies and cultural factors. Maternal death review in this paper will focus on investigation of the major causes and circumstances surrounding maternal death.
2.0 MATERNAL MORTALITY DEFINED
Maternal mortality means female deaths associated with pregnancy, labor and the puerperium, the period immediately following child-birth (Yaukey & Anderton, 2001). Similarly, the Tenth Revision of the International Classification of Diseases (ICD-10) defines maternal death as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any causes related to or aggravated by the pregnancy or its management (WHO, 2004).
Maternal death is divided into two group namely direct and indirect obstetric death:
- Direct obstetric death are those resulting from obstetric complications of the pregnant state (pregnancy, labour and the pueperium) from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above.
- Indirect obstetric death are those resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but was aggravated by the physiological effects of pregnancy ( WHO, 2004).
The high maternal mortality rate in Nigeria can be attributed to several causes which range from direct medical causes to indirect causes like taboos, inefficient infrastructure and other social and cultural factors. Commonly use approaches for obtaining data on levels of maternal mortality vary considerably in terms of methodology, source of data and precision of results. The main approaches are vital registration of deaths by causes, direct house hold survey methods, indirect sisterhood method (a survey-based measurement technique) direct sisterhood method, reproductive age mortality studies (which involves identifying and investigating the causes of all deaths of women of reproductive age) verbal autopsy and census.
3.0 AIM OF THE STUDY
The main aim of this study was to determine the medical and nonmedical factors that influence maternal mortality in the study.
4.0 OBJECTIVES OF THE STUDY
The objectives of the study were:
- to determine the magnitude of and trends in maternal mortality ratio in Nigeria before and after the launch of the Safe Motherhood Initiative (SMI);
- to determine the causes and characteristics of maternal deaths in Nigeria; and
- to examine factors that may have contributed to the failure of SMI in
5.0 SIGNIFICANCE OF THE STUDY
This study helps to identify the medical and non-medical determinants that will provide baseline data for future investigation into maternal mortality and its contributing factors in the region. It will also aid in adopting interventions on maternal health services and policies for improving the management and reduction of maternal mortality in the entire country – Nigeria.
- CAUSES OF HIGH MATERNAL MORTALITY IN NIGERIA
Poverty as a cause of Maternal Mortality in Nigeria
Poverty is a multi-dimensional phenomenon, which can be measured in terms of income and expenditure levels but can also be perceived in terms of individual’s social interactions and state of mental well-being ( Oduro & Aryee, 2003). In Nigeria, poverty is widespread and severe when compared to the most recent poverty indicators, the World Population Data Sheet (2005) shows that 91 percent of Nigeria’s population lives below 2 dollars per day, but in a further research USAID (2006) reported that close to 60 percent of Nigerians live in extreme poverty, as such, insufficient money to pay for medical expenses serve as a barrier for treatment.
Poverty limits accessibility to basic services like health; it influence negatively the ability to utilize modern health facilities, such limitation tend to cause high mortality especially among the poor. Problems of poverty limit access to food and balanced diet, thereby causing hunger and malnutrition which are closely related because hunger is manifested by the prevalence of malnutrition; malnutrition is an indication of a population’s inability to provide the requisites balanced diet for a healthy living. It has been found that malnutrition causes increased vulnerability to serious and chronic illness, mental retardation and early death (USAID, 2002). Malnutrition affect the immune system’s response to infection and interfere with the body’s ability to utilize food (condition not conducive to longevity), it increases the risk of infection, particularly among children and women of reproductive age. During pregnancy, apart from posing a threat to maternal survival it also put the life of the child at risk (Wermuth, 2003).
The effect of poverty is multi-dimensional, several studies have shown that there were drastic decline in hospital births apparently as a result of the country’s deepening economic crises (Thaddeus & Maine, 1990). According to the World Health Organization report (1997), only 31 percent of women in Nigeria deliver with a skilled attendants assistance this is why the life time risk of a woman dying as a result of pregnancy or childbirth is high; 1 woman in every 13 (WHO, 1997 cited in Adamu, 2005). Several other factors like cultural restrictions may be responsible for such phenomenon but not withstanding, it is obvious that women have less access to crucial resources such as education, skill trainings and health. Majority of Nigerian women work in the informal sector as petty traders, subsistence farmers, low – income factory workers and so on (Women In Development Profile, 1999). As such, the effect of poverty is more pronounced on them since they have to combine the direct impact of poverty with several cultural restrictions.
Poor Government policies as a cause of Maternal Mortality in Nigeria
Many years of poor governance, unaccountable rules with power concentrated in the hands of small elites eroded health infrastructure and breaded corruption, the civil society remains largely excluded from broad participation in health policy, as such, the majority of the population is not part of a fully operating medical care system. It is evident that the primary health care systems simply do not deliver adequate services to their clients. Delivery and reproductive health services in Nigeria are weak, availability and use of affordable maternal health services is appallingly low. While health service delivery is poor nationwide, it is weakest in the north (United State Agency for International Development, 2006). Especially in the rural areas where health programmes intended for the development of women do not go to them fully and directly due to lack of effective policy and embezzlement of public funds.
Government policies can play a major role in alleviating (or worsening) the problem of low accessibility to health, as such, investment in health services with due consideration of the general populace is an important means of empowering the individuals (health-wise). There have always been constant cuts in health and social services spending in Nigeria, these policies have been identified as major causes of worsened health condition among the populace that cannot adequately access health facilities. The multiple increases in the prices of goods, utilities and services like health and education and the depreciation of naira are as a result of continuous introduction of in-effective policies. Such conditions continue to increase the level of poverty and produce negative impact on maternal health and survival, for instance a study conducted by Alti-Muazu (1995) reveals that the economic crises has compelled most women to deliver their babies at home with the assistance of traditional birth attendants.
Nigeria’s economic policy and performance has been disappointing since independence, the economy is heavily dependent on oil; such dependence coupled with unstable policy environment and weak economic management adversely impact economic growth; which in turn affect adequate provision of all other basic infrastructures like good health and sound education. Despite all so-call attempts for achieving socio- economic development, there is continuous deterioration of all round productivity amidst of high population growth which has increasingly attenuate resources and raise the level of poverty.
Poor policies that neglect the environment, its sanitary effect and health hazards are endangering the health of its populace, especially maternal and child health. It is medically acknowledged that mosquito and pest control, education on basic hygiene and nutrition are public health measures with immediate and life saving benefits (Wermuth, 2003). In Nigeria, such measures are not given adequate consideration, a study reported by USAID in 2006 have shown that Nigeria has Africa’s largest malaria burden, nationally it is the leading cause of morbidity and mortality, over 60 million suffers malaria episode annually and the allocated resources of just 2-3 million dollars (annually) for malaria prevention and treatment are inadequate to address the magnitude of the problem (USAID, 2006). The most vulnerable people in most of the malaria endemic areas are pregnant women and children.
Cultural factors as a cause of Maternal Mortality in Nigeria
Health seeking behaviour, particularly of women is often determined by social norms of behaviour, beliefs and practices (UNFPA, 2001). Most women tend to conform to culturally defined norms when it comes to health-seeking during pregnancy and childbirth, despite the presence of formal health services, they are often bypassed for traditional providers. These can not be separated from the fact that, the community where the mother resides influence her attitude and behaviour (Machando & Hill, 2004). Reproductive health entails a number of problems for women in Africa. In the first place, the traditional perception of pregnancy and child birth is that of a natural condition, not requiring special health care because it is a normal fact of life. In the second place, women tends to be the major clients of the traditional healers, the natural outcome of this situation is a higher rate of maternal mortality (El-Safty, 2001).
National baseline survey of positive and harmful traditional practice affecting Women and Girls in Nigeria was conducted and analyzed in 1998, the findings revealed that there are about 250 ethnic groups and these groups have various beliefs and practices, some of which are harmful to health. The negative effect of these practices affect between a quarter and one-fifth of women in the north, in the south-south area, it affect about 12.1% and in the middle belt it affect 10% (WID Profile, 1999). In the north, there are several practices like massaging the womb and eating of local herbs during pregnancy and child birth. A study conducted by Alti-Muazu (1995) reveals that in some traditional Hausa communities, during labour a woman is given raw beans which have been soaked in water for hours to help speed labour, a fairly long stick is pushed into the woman’s mouth to induce vomiting and help expel placenta. Most of these practices can be harmful to maternal and infant health. Circumcision of pregnant women is a common practice among the Urhobos and Isokos of Delta State in Southern Nigeria, it is a commonly held belief among these people that a girl cannot graduate into womanhood unless she is circumcised and this circumcision must take place during the advanced stage of her first pregnancy, usually about seven months (National Council for Population and Environmental activities (1995). This same source revealed that such practice has serious medical implications especially at child-birth, it reported that prolong labour is more common among women who have undergone these circumcision.
Age at marriage, age at first birth (maternal age) and how many children to have are very much influenced by the social institution of marriage. Nigerian women marry young and bear on average six children (USAID, 2006). It is believed that early marriage lowers the risk of pre-marital sexuality, as such, it is widely practiced, but at the same time ‘very early’ marriage can put the young particularly the girl at high health risks of morbidity and mortality. A study on maternal death conducted by United Nations population Fund (2001) reveals that the risk of death at child birth is three times higher among the adolescent girls between the ages of 15-19 years than among their older cohort (20-24). In some traditional communities, girls are engaged in marriage at their very early ages of life (12-13) and they are usually exposed to the pressure of having male children not only to belong to the husband’s lineage but also to secure access to inheritance. For instance in the traditional community of Mbaises in Imo state, a woman who has 10 or more children is compensated with a cow on the 10th live birth (NCPEA, 1995). Such cultural practices can expose women/girls to the health risks of early and frequent pregnancies that can lead to high maternal morbidity and mortality.
Food taboos are prevalent in several Nigerian communities, during pregnancy and child birth; women’s eating habits are guided by these local taboos, which deny the consumption of certain food that can fall within the range of protein, carbohydrate or fruits. For instance, some communities among the Yorubas prohibit the ingestion of meat, egg, beans or other protein-containing foods during pregnancy (Osken, 1993). Similarly in some communities of both the eastern and southern parts of Nigeria, pregnant women are discouraged from eating egg as they believe that it reduces contraction strength during labour, hence leading to difficult labour. Other forbidden foods are Okro soup and snail, for fear of excessive salivation of the infant; garden egg for fear of impaired speech in infant; fish for fear of extra digits and plantain for fear of delayed ossification of the anterior fortanelle; palm oil for fear of jaundice and certain fruits for fear of baldness (Adebajo, 1992). A look at the itemized foods shows clearly that they are food of high nutritional values that are vital for pregnant women, because they enhance adequate foetal growth, maternal health and can help a woman to attain healthy labour. Absence of such food can lead to malnutrition; lack of a well balanced diet in the body of the mother, malnutrition during pregnancy and child birth is life threatening, it can lead to anaemia which in turn can result to both maternal and infant death. Wermuth (2003) reported that in India, anaemia in pregnant women is related to numerous micro nutrient deficiencies in infant; it is associated with low birth weight and array of developmental risk for the child, in severe cases it can lead to both maternal and infant death.
From another dimension, a study conducted by UNFPA (2001) reports that in developing countries, women’s decision in relation to health treatment (especially among the poor) are made by the husband, the household head or the mother in law, as such, unless support comes from family, husband or friends, women often tend not to seek treatment. Similarly, in a study on Kebbi state women, Shehu (1999) explained that cultural restrictions imposed by male house hold heads, tend to hinder women’s autonomy because women cannot decide to seek care from health facility in the absence of the husband and other male relatives. Such practice is prevalent in some other parts of the world, for instance, a research conducted in maharashtra- India, reveals that reduced maternal autonomy is associated with higher maternal and infant death. Though most of these studies have revealed that women have low participation level in their own health decision making (especially in cases where a mother need to go to the hospital), but some other studies reported that majority of the women themselves prefer to conform to their cultural norms. An earlier study by Alti-Muazu (1995) reveals that majority of mothers express preference to being attended to in their own homes by the TBAs, especially if they are assured of safe and expert care. This is because childbirth at home takes place in a familiar environment marked by emotional and social support from family and friends. In a similar finding Ityavyar (1984 cited in Thadddeus & Maine 1990) reported that in Nigeria’s Sokoto state, Hausa women in Bodinga Local Government area hold negative views of modern maternity hospital and complain that hospitals make episiotomies a routine requirement for delivery.
Complications as a cause of Maternal Mortality in Nigeria
Women die as a result of complications during and following pregnancy and childbirth. Most of these complications develop during pregnancy and most are preventable or treatable. Other complications may exist before pregnancy but are worsened during pregnancy, especially if not managed as part of the woman’s care. The major complications that account for nearly 75% of all maternal deaths are (4):
- severe bleeding (mostly bleeding after childbirth)
- infections (usually after childbirth)
- high blood pressure during pregnancy (pre-eclampsia and eclampsia)
- complications from delivery
- unsafe abortion.
The remainder are caused by or associated with diseases such as malaria, and AIDS during pregnancy.
- PREVENTIVE MEASURES FOR MATERNAL MORTALITY IN NIGERIA
Most maternal deaths are preventable, as the health-care solutions to prevent or manage complications are well known. All women need access to antenatal care in pregnancy, skilled care during childbirth, and care and support in the weeks after childbirth. Maternal health and newborn health are closely linked. It was estimated that approximately 2.7 million newborn babies died in 2015 (5), and an additional 2.6 million are stillborn (6). It is particularly important that all births are attended by skilled health professionals, as timely management and treatment can make the difference between life and death for both the mother and the baby.
Severe bleeding after birth can kill a healthy woman within hours if she is unattended. Injecting oxytocin immediately after childbirth effectively reduces the risk of bleeding.
Infection after childbirth can be eliminated if good hygiene is practiced and if early signs of infection are recognized and treated in a timely manner.
Pre-eclampsia should be detected and appropriately managed before the onset of convulsions (eclampsia) and other life-threatening complications. Administering drugs such as magnesium sulfate for pre-eclampsia can lower a woman’s risk of developing eclampsia.
To avoid maternal deaths, it is also vital to prevent unwanted and too-early pregnancies. All women, including adolescents, need access to contraception, safe abortion services to the full extent of the law, and quality post-abortion care.
1.8 WHO’s RESPONSE OVER MATERNAL MORTALITY IN NIGERIA
Improving maternal health is one of WHO’s key priorities. WHO works to contribute to the reduction of maternal mortality by increasing research evidence, providing evidence-based clinical and programmatic guidance, setting global standards, and providing technical support to Member States.
In addition, WHO advocates for more affordable and effective treatments, designs training materials and guidelines for health workers, and supports countries to implement policies and programmes and monitor progress.
During the United Nations General Assembly 2015, in New York, UN Secretary-General Ban Ki-moon launched the Global Strategy for Women’s, Children’s and Adolescents’ Health, 2016-2030 (7). The Strategy is a road map for the post-2015 agenda as described by the Sustainable Development Goals and seeks to end all preventable deaths of women, children and adolescents and create an environment in which these groups not only survive, but thrive, and see their environments, health and wellbeing transformed.
As part of the Global Strategy and goal of Ending Preventable Maternal Mortality, WHO is working with partners towards:
- addressing inequalities in access to and quality of reproductive, maternal, and newborn health care services;
- ensuring universal health coverage for comprehensive reproductive, maternal, and newborn health care;
- addressing all causes of maternal mortality, reproductive and maternal morbidities, and related disabilities; and
- strengthening health systems to collect high quality data in order to respond to the needs and priorities of women and girls; and
- ensuring accountability in order to improve quality of care and equity.
- CONCLUSION AND RECOMMENDATIONS
The paper has briefly discussed poverty, poor government policies and negative cultural practices as major causes of maternal death in Nigeria, despite the plethora of poverty alleviation programme in Nigeria, several Nigerians still remain poverty stricken- ridden, facts are apparent that the problem revolves around poor co-ordination, content deficiency, corruption and lack of continuity. A well co-ordinated policy that provide skilled medical assistance during child-birth, whether at home or in a medical facility, irrespective of geographical location can save women’s live. The training of more primary health workers and traditional birth attendants into modern hygienic ways of child delivery, within the context of community needs will help reduce maternal health problems. Traditional births attendants can not be neglected in a country like Nigeria because a large proportion of deliveries are attended by the TBAs and quality maternal care is not accessible to the majority of the population. Poverty eradication policies that sincerely focus on the general populace will help alleviate the plight of reproductive mothers. Government’s intervention on highlighting the negative consequences of some unfavourable cultural practices will go along way in saving the life of women.
There is need for serious counselling of women and married men (in both the urban and rural area) on the issues of maternal death, the media should be involved in highlighting the consequences of some negative attitudes and cultural practices that could lead to maternal death. Religious leaders and traditional rulers in all parts of Nigeria should be engaged in the effort to reduce maternal mortality in Nigeria. Teachers in higher institution should be encourage to engage in discussing the issues of maternal death, there should an introduction of a course to cover this aspect, it should aim at revealing the multi-dimensional causes and consequences of maternal death, in addition to proffering adequate and varying solutions to students. In the northern areas of Nigeria rural women or girls who engage in house to house plaiting and henna decoration (lalle) should be trained, and engaged in the counselling activities, these group of women or girls can play very important roles in enlightening the rural women about the negative impact of some cultural practices; like refusing modern medical care where services are available; delay to hospital during abnormalities until condition becomes critical; over reliance on home delivery and remedies; the culture of hiding pregnancy and delivery; the disadvantage of engaging an under age girl in early childbearing; the practice of food taboos during pregnancy and the culture of giving out the best part of food to spouses, while the pregnant mother deserved it most.
REFERENCES:
Adamu, Y. M. (2005). Patterns of maternal morbidity and mortality in Kano State: A geographical analysis. Journal of Social and Management Sciences, 9 (Special edition): 196 – 221.
Adebajo, C. F. (1992). ‘‘Female circumcision and other dangerous practices to women’s health’’. In: Women’s health issues in Nigeria (Kisekka M. N. ed.). Tamaza Publ.Company LTD.
Alti-Muazu, M. (1995). A case study of traditional birth attendants in Zaria. ‘‘An Unpublished M. Sc. Thesis submitted to Department of Sociology. Zaria: Ahmadu Bello University.
El–Safty, M. (2001). ‘‘Cultural, Public Health and Community Development’’. Health and Environmental Education Association of Egypt (HEEA).
Machando, C. J. & Hill, K. (2004). Maternal, Neonatal and Community Factors Influencing Neonatal Mortality in Brazil. J. Blossoc. Sci. 37: 193 – 208.
National Population Commission (2004). National Population Commission and ORC Macro.
NCPEA (1995). National Council for Population and Environmental Activities: Press Kit on Population and Family Planning in Nigeria
Oduro, A. D. & Aryee, I. (2003). ‘‘Investigating Chronic Poverty in West Africa’’, Chronic Poverty Research Centre, working paper 28. April.
Hosken, P. (1993). The Hosken Report: Genital and Sexual Mutilation of Females (fourth revised edition). Women’s International Network News: Lexington 114-115.
Shehu, D. J. (1999). ‘‘Upgrading community awareness of obstetric complications in North Western, Nigeria” In Journal of Reproductive Health Matters. August – December.
Theddues, S. and Maine, D. (1990). ‘‘Too far to walk: Maternal mortality in context’’. Prevention of Maternal Mortality Programme (PMMP), Columbia University
UNFPA (2001). United Nations Population Fund. Contextual factors influencing people’s health seeking behaviour. Module 2: Socio – cultural aspects of reproductive health.
USAID (2002). ‘‘United State Agency for International Development. Youth and HIV/AIDS.’’ <http//www.usaid.gov/pop_health/aids/TechAreas/youthhandhliv/youthfactsheet.html>
USAID (2006). ‘‘United State Agency for International Development’’. Country Strategy Statement. Page
Wermuth, L. (2003). Global Inequality and Human Needs: Health and Illness In An Increasing Unequal World. Person Education, Inc.
World Population Data Sheet (2005).
WID Profile (1999). ‘‘Women in Development’’. Japan International Agency Planning Department.
WHO, (2004). Maternal mortality in 2000: Estimate developed by WHO, UNICEF and UNFPA: Department of reproductive health and research WHO, Geneve.
Yaukey, D. & Anderson, D. L. (2001). Demography: the Study of Human Population. (Second Edition), Wave Land Press Inc.
Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group.
Alkema L, Chou D, Hogan D, Zhang S, Moller AB, Gemmill A, et al. Lancet. 2016; 387 (10017): 462-74.
Maternal-perinatal morbidity and mortality associated with adolescent pregnancy in Latin America: Cross-sectional study.
Conde-Agudelo A, Belizan JM, Lammers C. American Journal of Obstetrics and Gynecology, 2004, 192:342–349.
Global patterns of mortality in young people: a systematic analysis of population health data.
Patton GC, Coffey C, Sawyer SM, Viner RM, Haller DM, Bose K, Vos T, Ferguson J, Mathers CD. Lancet, 2009, 374:881–892.
Global Causes of Maternal Death: A WHO Systematic Analysis.
Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels JD, et al. Lancet Global Health. 2014;2(6): e323-e333.
Levels and Trends in Child Mortality. Report 2015.
The Inter-agency Group for Child Mortality Estimation (UN IGME). UNICEF, WHO, The World Bank, United Nations Population Division. New York, USA, UNICEF, 2015.
National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis.
Blencowe H, Cousens S, Jassir FB, Say L, Chou D, Mathers C et al. Lancet Glob Health. 2016 Feb;4(2):e98-e108. doi: 10.1016/S2214-109X(15)00275-2.
Global Strategy for Women’s, Children’s and Adolescents’ Health, 2016-2030.
New York: United Nations; 2015.
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