OPEN AND DISTANCE EDUCATION: A PANACEA FOR SOCIO- … · which usually results from prolonged obstructed labour in pregnant women (Ogunlela, 2010). Nigeria alone accounts for between

Sahel Analyst: ISSN 1117-4668 Page 137

OPEN AND DISTANCE EDUCATION: A PANACEA FOR SOCIO-

CULTURAL FACTORS OF MATERNAL HEALTH MANAGEMENT IN

NIGERIA

Yemisi I. Ogunlela PhD1

Abstract

Health is supposed to be a basic human right. However, this right eludes a lot of

women in Nigeria. In Nigeria, 1 in every 13 women faces a lifetime risk of dying

as a result of pregnancy-related causes. The factors contributing to this situation

as well as causing debilitating diseases such as fistula, with resulting in untold

hardship, can be attributed to both medical and socio-cultural factors. This

exploratory study was conducted, based on available data, to find out the social-

cultural causes of this poor state of women’s health, and to explain how a non-

conventional system of education such as the Open and Distance Learning (ODL)

system of education can be employed as a panacea to the abysmal situation. The

paper revealed that women die from pregnancy-related diseases or develop

fistula as a result of socio-cultural factors such as: prolonged labour, early

marriage, poor nutrition, and, poor access to skilled health care. It recommend

that open and distance learning education will enable them to explore ways of

acquiring skills that will improve their economic status; this will enable them to

be able to afford some of the reproductive health services which ordinarily may

be unaffordable.

Keywords: Socio-cultural factors, Maternal health, Education Open and distance

learning, Nigeria

Introduction

The World Health Organization (WHO) defines maternal health as the health of

women during pregnancy, childbirth, and the postpartum period. It refers to the

health of women during pregnancy, childbirth and the period immediately

following the birth (Women and children first.org.uk, accessed 01 March 2017).

While motherhood is often a positive and fulfilling experience, for too many

women, it is associated with suffering, ill-health and even death (John, 2012).

An estimated 585,000 (over half a million) mothers die each year from causes

related to childbirth, ninety-nine percent (99%) of these in developing countries

(Maine, 1987). In Nigeria, 1 in every 13 women face a lifetime risk of maternal

death in the United Kingdom (UK), it is 1 in 5,100, while in Canada, it is 1 in

7,700 (FMOH, n.d) yet, most maternal deaths are preventable mainly through

medical intervention and political will by the government (Shiffman & Okonfua,

1 Department of Administration, Faculty of Management Sciences, National Open

University Of Nigeria, 14/16 Ahmadu Bello Way, Victoria Island, Lagos.

[email protected] +234(0)8034518814; +234(0)8054848276

mailto:[email protected]

African Journal of Management (Vol.2, No.4, 2017), Business Admin. University of Maiduguri


2007). Key health care interventions can largely prevent women from dying of

pregnancy – related causes. Attendance of antenatal care, delivery in a medical

setting and having a skilled health worker at delivery, improve maternal health.

However, there are questions of access to the services rendered at the health

facilities and what barriers there are for the women, and how the barriers can be

overcome.

Statement of the Problem The death of a mother is more than a personal tragedy; it represents an enormous

cost to her nation, her community and her family. When a mother dies, her

children lose their primary care giver, communities are denied her paid and

unpaid labour, and countries forego her contributions to economic and social

development (Fathala, 1992; Boserup, 1995; Ogunlela & Ogunlela, 2008; John,

2012). Apart from the high number of women dying daily from pregnancy-related

causes, another estimated 2 million women are living with obstetric fistula, a

debilitating disease with its attendant social and economic consequences (WHO,

1993). The statements below were statements made by some obstetric fistula

patients at a Fistula Medical Centre, in Zaria:

“My brothers stopped eating food cooked by me…” (Hadiza in

Ogunlela, 2005). “…I am alone …I have no home to go to…

(Aisha in Ogunlela, 2005). “I have no friends anymore, they all

refuse to talk to or associate with me… my father in-law insisted

that my husband should divorce me… my parents refused me

living with them because I stink (Binta in Ogunlela, 2005).

Those words can be seen to have captured the extent of their misery, ostracism,

loneliness and anguish, all brought upon them by obstetric fistula: a disease

which usually results from prolonged obstructed labour in pregnant women

(Ogunlela, 2010).

Nigeria alone accounts for between 800,000 and 1,000,000 women with obstetric

fistula and 5000 new cases are added every year (UNFPA, 2009). Insufficient

care for pregnant women in labour has made Nigeria a country with one of the

highest rates of obstetric fistula in the world. The causes range from medical to

cultural and economic factors, which have all combined to present “leprosy of the

21st century” (UNFPA, 2009). Medical care has been found to be very crucial to

reducing maternal mortality, and maternal morbidity, yet, a high rate of women

still have their babies at homes instead of a modern health facility, even though

such facilities are available. It is therefore necessary to find out why some women

do not avail themselves of the services that are rendered in such medical

facilities. It is imperative to understand that certain factors must have been acting

as obstacles and hindering the women from accessing and utilizing modern

medical care; as this behavior, more often than not, results in either death of the

women, or in debilitating diseases in the form of fistula. The attendant

consequences of such diseases include: prolonged obstructed labour; which can

lead to the death of the mother, loss of the baby, urine or feces leakage, drop foot,

ostracism of the leaking woman, and even divorce of the woman by the husband.

Open and Distance Education: A Panacea for Socio-Cultural Factors of Maternal Health

Management in Nigeria

Sahel Analyst: ISSN 1117- 4668 Page 139

This paper highlights the causes of maternal mortality and obstetric fistula as

aspects of maternal health that need urgent action, with emphasis on the social

and cultural causative factors and how Open and Distance Learning can be

employed in the preventive and rehabilitative strategies to curb this menace.

Objective of the Paper The objective of this paper is to discuss the causes of Maternal Mortality and

Obstetric Fistula with emphasis on the social-cultural factors and how Open and

Distance Learning (ODL) can be used to address those factors in the preventive

and rehabilitative strategy towards improving maternal health.

Literature review

The following conceptual issues are hereby reviewed and classified as used in

this paper:

Maternal Health – is defined as the health of women during pregnancy,

childbirth and the period immediately following the birth (Women and children

first.org.uk, accessed 01 March 2017). Health, a basic human right that is vital to

sustainable development, eludes the majority of women (World Bank Report,

2003). While motherhood is often a positive and fulfilling experience, for too

many women it is associated with suffering, ill-health and even death (WHO,

1993). It refers to the health of women during pregnancy, childbirth and the

period immediately following the birth (Women and children first.org.uk,

accessed 01 March 2017). Motherhood should be a joyful and positive

experience, but for many women across the world, pregnancy and childbirth are a

dangerous and frightening time in their lives (Women and Childrenfirst.org.uk;

ibid). “Harmful cultural practices perpetuated on women and girls… particularly

during pregnancy; certain birthing practices…. result in the mitigation of their

health or their quality of life” (Dawitt, 1994).

Maternal Mortality – In 1948, the World Health Organization defined Maternal

Mortality as a maternal death which occurs while “pregnant or within 42 days of

the termination of pregnancy, irrespective of the duration and the site of the

pregnancy, from any cause related to or aggravated by the pregnancy or its

management but not from accidental or incidental causes” (WHO 1948). By

1993, Maternal Mortality or Maternal death was again defined by WHO as “the

death of a woman while pregnant, or within 42 days of termination of pregnancy,

irrespective of the duration and the site of the pregnancy, from any cause related

to, aggravated by the pregnancy or its management, but not from accidental

cause” (WHO, 1993). According to Khan, Wojdyla, Say, Gulmezoglu, and van

Look (2014), the reduction of maternal deaths is a key international development

goal, as exemplified by the Safe Motherhood Initiative of 1987, the Millennium

Development Goals (Goal 5) of year 2000-2015, and the Sustainable



Development Goals of 2015-2030; all attempting to bring about a considerable

reduction in the maternal mortality ratio.

Maternal Mortality Ratio - The “maternal mortality ratio” is the most frequently

used indicator to measure maternal deaths. It is defined as the number of women

who die as a result of complications of pregnancy or childbearing in a given year

per 100,000 live births in that year. A reduction in maternal mortality has

traditionally been used as a critical measure of progress in improving maternal

health (Al-Nadhedh, 1995). The aim of the United Nations Sustainable

Development Goals is to reduce maternal mortality ratio by 75% by the year

2030. However, despite the fact that the maternal mortality ratio is considered

one of the main indicators of a country's status in the area of maternal health, the

burden of maternal mortality is only a small fraction of the burden of maternal

morbidity – the health problems borne by women during pregnancy and the

postpartum period.

Maternal deaths have been described as the tip of the iceberg and maternal

morbidity as the base. For every woman who dies of pregnancy-related causes, 20

or 30 others experience acute or chronic morbidity, often with permanent

sequelae that undermine their normal functioning (Ashford, 2002; Pacagnella,

Cercatti, Camargo, Silveira, Zanardi & Souza, 2010). These sequelae can affect

women's physical, mental or sexual health, their ability to function in certain

domains (e.g. cognition, mobility, participation in society), their body image and

their social and economic status. Not surprisingly, the burden of maternal

morbidity – like that of maternal mortality – is estimated to be highest in low- and

middle-income countries, especially among the poorest women (Storeng, Murray,

Akoum, Ouattara & Filippi, 2010).

Most existing discussion of women’s health has centered on their reproductive

health issues particularly in the developing countries where women are primarily

seen as child bearers and child careers (Babalola & Adebayo, 2003). Although it

is pertinent to point out that any definition of women’s health must involve her

total well-being condition of life that is determined not only by her reproductive

functions, but also by the effects of work load, nutrition, stress, interest and

attitude. Any adequate conceptualization of women’s health must consider these

additional issues so as to formulate a conceptual framework that will facilitate

gender-sensitive health policy and action. However, most often, mortality and

morbidity are used to assess a population’s health status, and to compare the

status of different populations (Ralzan, Filerman & LeSar, 2000).

Maternal mortality as well as maternal morbidity is used to assess maternal

health. “Maternal mortality or maternal death is defined as the death of a woman

while pregnant or within 42 days of termination of pregnancy, due to both

obstetric causes and the conditions aggravated by pregnancy or delivery (Abou

Zahr & Wardlaw, 2001:562). It is regarded as the number of women who die as a




result of pregnancy-related complications per 100,000 live deliveries (Staton,

Abderrahim & Hill, 1997).

The State of Maternal Health in Nigeria

Zinser (2007:7) stated that “an estimated 15% of pregnancies experience

complications world-wide, but in Nigeria; it stands at over 40%. Many pregnant

women still deliver at home due to exorbitant antenatal and postnatal costs. In

most Nigerian villages, women still give birth with traditional birth attendants in

huts, with no running water, no sterilization, no equipment and no skilled birth

attendants capable of providing emergency obstetric care. Socio-cultural and

economic factors that relate to the low status of women, poverty, ignorance and

traditional harmful practices also account for the alarming Maternal Mortality

Rate as well as the statistics on obstetric fistula in Nigeria”.

An estimated 500,000 women die each year throughout the world from

complications of pregnancy and childbirth. One out of 16 women dies of

pregnancy-related causes in sub-Saharan Africa, while one out of 2,800 women

dies in the industrialized world (WHO, 2004a:1). Table 1 shows the Global

Distribution of maternal estimates by regions:

Table 1: Maternal Mortality Ratio (MMR; Maternal Deaths Per 100,000 live

Births) 1990 – 2015

Source: WHO, UNFPA and The World Bank. Trends in Maternal Mortality: 1990

to 2015. WHO, Geneva, 2015.

From Table 1, it could be seen that even though the MMR for each country seems

to be reducing, on the average, Nigeria and India still record the highest deaths

per 100,000 live births. The MMR for India dropped from 556 in 1990 to 174 per

100,000 live births in year 2015; Nigeria recorded 1350 in 1990 and 814 in year

2015. From these figures, one might conclude that a reduction in the figure

signifies that the challenge has been overcome. However, a cursory look at the

figures for the industrialized countries such as Germany, United Kingdom,

Norway and USA shows that in 1990, their MMR ranged from 7 to 12, and from

COUNTRY 1990 1995 2000 2005 2010 2015

Australia 8 8 9 7 6 6

Austria 8 6 5 5 4 4

Germany 11 9 8 7 7 6

United Kingdom 10 11 12 12 10 9

United States of America 12 12 12 13 14 14

Norway 7 7 7 7 6 5

*India 556 471 374 280 215 174

Pakistan 431 363 306 249 211 178

*Nigeria 1350 1250 1170 946 867 814

Ghana 634 532 467 376 325 319



5 to 14 in 2015. Even though the death of one woman in any country is a tragedy,

the burden of maternal death seems to be greater in Nigeria.

Causes of Maternal Mortality and Maternal Morbidity Sketelenburg, Kyanamina, Mukelabai, Wolffers and Van (2004) explained that

maternal mortality is influenced by factors which are interconnected; they are

mainly biological/medical and social/cultural in nature.

Biological/Medical Factors

The health status of a woman simply influences her risk of dying from

complications during and following pregnancy and childbirth; most of which 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:

i. Anaemia – Over 50% of women suffer severe anaemia in developing

countries (UNICEF, 1998:2) and anaemic women are 3.5 times more likely

to die in pregnancy than women without anaemia (Brabin, Hakimi, Pelletier

(2001).

ii. Reproductive status – This includes birth intervals, number of children and

age of the mother. Studies revealed that birth intervals of less than 15

months increase a woman’s risk of dying by 2.5 (Conde-Agudelo &

Belizan, 2000: 1257), while women who have had three births are more

likely to suffer complications (Vadnais et al, 2006:29). Women under the

age of 15 years are twice likely to die in pregnancy and child birth; girls

under 14 years are five times more likely to die than women aged 20 to 24

years (UNICEF, 1998:4). The reason is that the body of many adolescent

women is not developed to carry a child (Charliac, 1992 in Ujah et al.,

2005:3).

iii. Unsafe abortions – In many developing countries, abortions are illegal;

they are therefore conducted in inadequate settings where the process can

be life-threatening (WHO 1994, in Tsui et al., 1997:96). More than 150,000

teenagers die annually from abortion – related consequences and 95% of

such abortions take place in developing countries (WHO 1993, 2004, in

Freedman, Waldman, Pinho, and Wirth, 2005:73). Abortion is the leading

cause of death for girls between 15 and 19 years of age (Freedman, et al,

ibid). Women need access to contraception, safe abortion services to the full

extent of the law, and quality post-abortion care.

iv. Severe bleeding – Mostly bleeding after childbirth. This requires urgent

attention

v. Infections – Infections (usually after childbirth). The practice of good

hygiene and the detection of early signs of infection and early treatment,

can reduce this.

vi. High blood pressure during pregnancy (pre-eclampsia & eclampsia) –

The early detection and appropriate management can lower a woman’s risk

of developing eclampsia (convulsions).




vii. Complications from delivery. Skilled professional birth attendants in well-

equipped health centres can help to reduce this.

All these are causes of maternal mortality and morbidity, which are medical in

nature. They can be tackled through skilled medical intervention. But even

though they are medical in nature, and can be tackled through medical

intervention to a large extent, some social and cultural factors may act as

hindrances to women accessing the medical care. Hence, the intertwining social,

cultural and medical factors can lead to a woman, dying from pregnancy-related

causes or acquiring some diseases such as bladder incontinence as a result. In

fact, the social/cultural causes can even aggravate the negative medical conditions

of women. Hence, it is imperative to discuss the social and cultural factors, as this

is the crux of this study. The social and cultural factors can be seen as follows:

Socio- Cultural Factors i. Large number of children- studies have revealed that birth intervals of less

than 15months increase a woman’s risk of maternal death by 2.5 (Conde-

Agudelo & Belizan, 2000:1257).

ii. Early childbearing – Girls under the age of 14 have five times risk of dying

in pregnancy than women aged 20 to 24 (UNICEF, 1998:4). The reason is

that the body of many adolescent women is not developed enough to carry a

child (Chavliac 1992, in Ujah et al., 2005a:3).

iii. Poor Access to health care facility – Health centres that offer quality

maternal health serving in many cases, are often far from the rural areas.

This is often complicated by poor road network, undependable transport or

emergency transportation (Lule et al., 2005:17). A study by Lule and

Ssembatya (1996) in Malaria; revealed that out of 90 women interviewed,

who wanted to give birth in a healthcare institution, only 25% were able to

because of the great distance between their village and the health

institution. This usually results in women seeking health services from

provider who lack the skills and the equipment to treat obstetric

complications (Lule et al., 2005:17).

iv. Financial costs of health care – Gelband et al. (2001:6) noted that the cost

of a birth with professional assistance or at a hospital can cost between

US$7 and US$35 and a caesarean section can even be as expensive as

US$100. In Nigeria, these costs will translate to N2,520 and N12,600 and

N36,000 respectively, using the official Central Bank of Nigeria foreign

exchange conversion rate of N360 to a US dollar as at 21st May, 2017. It

could therefore be seen that the financial cost is on the high side and is

therefore not easily affordable to most women (Ogunlela, 2011). This is

because 44% of the Nigerian population are living on less than US$1 a day

(N360).

v. Lack/shortage of trained personnel and equipment to provide the needed

maternal healthcare services. There is immense migration of native

medical professionals in Africa to wealthier countries i.e. “brain drain”

(Freedman et al, 2005:9). According to WHO, 2005B:133, about 334,000



midwives are missing, and 140,000 health professionals and 27,000 doctors

lack proficient skills to provide adequate healthcare.

vi. Cultural food taboos and practices that lead to poor nutrition. Shiffman

(2000:276) argues that better nourished mothers as in developed countries,

are more likely to stay healthy during pregnancy and less likely than poor

women to experience birth complications.

vii. Lack of participation in household decision making – Mostly husbands

and relatives make decisions on care-seeking of women (Lule et al.,

2005:15-16). A study in Bangladesh by Lule et al. (2005:15-16) showed

that 35% of women interviewed stated that their religion does not allow

them to leave the house, particularly during pregnancy, and another 35%

cited objections of their husbands and relatives as a reason for not seeking

care (Piet-Pelon et al., 199, in Ensor & Cooper, 2004:70). Also, more than

50% of women in most developing countries today do not participate in

household decisions (Vadnais et al., 2006:75).

From all these, it could be seen that the reproductive and health status of a

woman as well as her health care behavior, which reflects her use of

maternal health care services (McCarthy & Maine, 1992:26-27), are

strongly influenced by her socio-economic and cultural background

(Ogunlela, 2011). However, relying solely on maternal mortality to assess a

country's status in the area of maternal health overlooks the importance of

maternal morbidity, which is not only a precursor to maternal mortality but

also a potential cause of lifetime disability and poor quality of life. Forceful

global response – akin to that generated by maternal mortality – is needed

to better explore the causes of maternal morbidity and its epidemiological

characteristics and to reduce its frequency. As we move towards 2030 and

beyond, it is important that we recalibrate the global goals focused on

mortality to address maternal morbidity and its long-term outcomes. Under

the sustainable development goals, it is also of utmost importance to

consider progress towards equitable coverage with reproductive health

services.

Efforts at Curbing Maternal Mortality and Morbidity in Nigeria Nigeria’s 2006 National Population Census figures revealed that Nigeria’s

population is 140,033,542 (National Population Commission; 2006). The female

population is 68,293,683, which is approximately half of the overall population of

the country; hence, any health condition which affects half of the overall

population, should in effect, constitute a national concern (John, ibid). This fact

was captured and highlighted by Awe, in Kisekka (1992) while commenting on

the importance of women’s health issues in Nigeria, that “the importance of a

healthy female population cannot be over-emphasized in any discussion of

women’s contribution to the development of this nation; for it is when women are

healthy that they can fulfill their reproductive and productive roles most

effectively”.




In order to combat this abysmal and appalling situation of maternal health,

Nigeria has formulated and launched many national policies. Among these were

the National Health Policy and Strategy (1988, 1998), which emphasized primary

health care as the key to the development of the health care delivery system in

Nigeria. The provisions of this policy were not strictly implemented especially

the maternal health component, hence the poor state of maternal health. Other

relevant policies include the National Policy on Population for Development,

Progress and Self-Reliance (1988); the Maternal and Child Health Policy (1994);

National Adolescent Health Policy (1995); National Policy on HICV/AIDS/STIs

Control (1997); National Policy on Elimination of Female Genital Mutilation

(1998); and Breastfeeding Policy (1994); The National Reproductive Health

Policy and Strategy to Achieve quality Reproductive and Sexual Health for All

Nigerians (2001). All these policies were actually relevant in one way or the

other, to the promotion of maternal health, but sometimes, their targets were

somewhat contradictory. The Safe Motherhood Initiative (1987) was launched

with an original goal to halve maternal mortality ratios by the year 2000. But not

much was achieved. In the year 2000, the 189 countries of the United Nations

adopted a total of eight (8) Millennium Development Goals (MGDs), aimed at

making substantial progress towards the eradication of poverty and achieving

other human development goals by the year 2015. One of them is goal number 5

which is “Improvement of Maternal Health”. The target was to “reduce by three

quarters, that is, to achieve a seventy five percent (75%) reduction in maternal

mortality between 1999 and 2015. However, in a community-based study of

women who delivered and are resident in Northern Nigeria, it was reported that

home delivery was still the norm throughout the zone, with 85. 3% delivery at

home and that up to 80.5% of the deliveries were supervised by personnel with no

verifiable training in sanitary birthing techniques (Galadanchi, Ejembi, Illiyasu,

Alagh & Umar, 2007). They concluded that maternal health care was far from the

ideal and commitment to MDG number 5 was externally far-reaching to reduce

the maternal mortality ratio by 75% by the year 2015 with this level of maternal

care (ibid:45).

The sustainable Development Goal (SDG) global target is to reduce the global

Maternal Mortality Ratio (MMR) to less than 70 per 100,000 live births by 2030.

Separate country level targets have also been set as follows:

a. The primary national target is that by 2030, every country should reduce

MMR by at least two-thirds from its 2010 baseline.

b. The secondary country target which applies to countries with the highest

maternal mortality burdens, is that no country should have an MMR greater

than 140 deaths per 100,000 live births by 2030.

There are wide disparities in MMR among countries, for example, national

MMRs range from 3 deaths per 100,000 live births in Finland, Greece, Iceland

and Poland to 1,360 deaths per 100,000 live births in Sierra Leone, 814 in Nigeria

and 706 in Gambia. This disparity illustrates that, unfortunately, a woman’s risk

of maternal death depends largely on where she lives (Source: Trends in maternal



Mortality: 1990 to 2015”. Estimates by WHO, UNICEF, UNFPA, World Bank

Group and the United Nations Population Division).

Medical care has been found to be very crucial to reducing maternal mortality,

and maternal morbidity, yet, a high rate of women still have their babies at homes

instead of a modern health facility, even though such facilities are available. It is

therefore necessary to find out why some women do not avail themselves of the

services that are rendered in such medical facilities. It is imperative to understand

that certain factors must be acting as obstacles and hindering the women from

accessing and utilizing modern medical care; as this behavior, more often than

not, results in either death for the women, or in debilitating diseases in the form

of fistula. The attendant consequences of such diseases include: prolonged

obstructed labour; which can lead to the death of the mother, loss of the baby,

urine or feces leakage, drop foot, ostracism of the leaking woman, and even

divorce of the woman by the husband.

This study has been undertaken to highlight causes of maternal mortality and

obstetric fistula as aspects of maternal health that need urgent action, with

emphasis on the social and cultural causative factors and how Open and Distance

Learning can be employed in the preventive and rehabilitative strategies to curb

this menace. Nigeria’s 2006 National Population Census figures revealed that

Nigeria’s population is 140,033,542 (National Population Commission; 2006).

The female population is 68,293,683, which is approximately half of the overall

population of by Awe, in Kisekka (1992) while commenting on the importance of

women’s health issues in Nigeria, that “the importance of a healthy female

population cannot be over-emphasized in any discussion of women’s contribution

to the development of this nation; for it is when women are healthy that they can

fulfill their reproductive and productive roles most effectively.

In order to combat this abysmal and appalling situation of maternal health,

Nigeria has formulated and launched many national policies. Among these were

the National Health Policy and Strategy (1988, 1998), which emphasized primary

health care as the key to the development of the health care delivery system in

Nigeria. The provisions of this policy were not strictly implemented especially

the maternal health component, hence the poor state of maternal health. Other

relevant policies include the National Policy on Population for Development,

Progress and Self-Reliance (1988); the Maternal and Child Health Policy (1994);

National Adolescent Health Policy (1995); National Policy on HICV/AIDS/STIs

Control (1997); National Policy on Elimination of Female Genital Mutilation

(1998); and Breastfeeding Policy (1994); The National Reproductive Health

Policy and Strategy to Achieve quality Reproductive and Sexual Health for All

Nigerians (2001). All these policies were actually relevant in one way or the

other, to the promotion of maternal health, but sometimes, their targets were

somewhat contradictory.




The Safe Motherhood Initiative (1987) was launched with an original goal to

halve maternal mortality ratios by the year 2000. But not much was achieved. In

the year 2000, the 189 countries of the United Nations adopted a total of eight (8)

Millennium Development Goals (MGDs), aimed at making substantial progress

towards the eradication of poverty and achieving other human development goals

by the year 2015. One of them is goal number 5 which is “Improvement of

Maternal Health”. The target was to “reduce by three quarters, that is, to achieve

a seventy five percent (75%) reduction in maternal mortality between 1999 and

2015. However, in a community-based study of women who delivered and are

resident in Northern Nigeria, it was reported that home delivery was still the

norm throughout the zone, with 85. 3% delivery at home and that up to 80.5% of

the deliveries were supervised by personnel with no verifiable training in sanitary

birthing techniques (Galadanchi, Ejembi, Illiyasu, Alagh & Umar, 2007). They

concluded that maternal health care was far from the ideal and commitment to

MDG number 5 was externally far-reaching to reduce the maternal mortality ratio

by 75% by the year 2015 with this level of maternal care (ibid:45).

The sustainable Development Goal (SDG) global target is to reduce the global

Maternal Mortality Ratio (MMR) to less than 70 per 100,000 live births by 2030.

Separate country level targets have also been set as follows:

c. The primary national target is that by 2030, every country should reduce

MMR by at least two-thirds from its 2010 baseline.

d. The secondary country target which applies to countries with the highest

maternal mortality burdens, is that no country should have an MMR greater

than 140 deaths per 100,000 live births by 2030.

There are wide disparities in MMR among countries, for example, national

MMRs range from 3 deaths per 100,000 live births in Finland, Greece, Iceland

and Poland to 1,360 deaths per 100,000 live births in Sierra Leone, 814 in Nigeria

and 706 in Gambia. This disparity illustrates that, unfortunately, a woman’s risk

of maternal death depends largely on where she lives (Source: Trends in maternal

Mortality: 1990 to 2015”. Estimates by WHO, UNICEF, UNFPA, World Bank

Group and the United Nations Population Division).

Medical care has been found to be very crucial to reducing maternal mortality,

and maternal morbidity, yet, a high rate of women still have their babies at homes

instead of a modern health facility, even though such facilities are available. It is

therefore necessary to find out why some women do not avail themselves of the

services that are rendered in such medical facilities. It is imperative to understand

that certain factors must be acting as obstacles and hindering the women from

accessing and utilizing modern medical care; as this behavior, more often than

not, results in either death for the women, or in debilitating diseases in the form

of fistula. The attendant consequences of such diseases include: prolonged

obstructed labour; which can lead to the death of the mother, loss of the baby,

urine or feces leakage, drop foot, ostracism of the leaking woman, and even

divorce of the woman by the husband.



Methodology

This study is an exploratory research. Data were gathered mainly from secondary

from secondary sources. The secondary data included findings of the study

carried out among fistula patients at Evangel Hospital , Jos, as reported by Wall,

Karshima, Kirschner and Arrowsmith (2003) and the report of the observations

made at the Fistula Centre in Zaria.

Findings

The paper revealed that women die from pregnancy-related diseases or develop

fistula as a result of the following socio-cultural factors:

i. Prolonged labour lasting for at least two (2) days. This is usually due to

ignorance, illiteracy, poverty and limited or total denial of decision-making

power (even over their own health).

ii. Early marriage as a result of cultural factors. This contributes to limiting the

young girls’ access to education in conventional educational institutions.

iii. Poor nutrition. This is usually due to poverty, ignorance and cultural food

taboos in pregnancy. This can adversely affect the health of pregnant

women and may result in death in severe cases.

iv. Poor access to skilled health care providers at health care at maternal health

care service delivery points. This is usually caused by lack of income-

generating skills on the part of the women. The husbands too may be poor.

Discussion

According to UNICEF (1998), the low status of girls and women in society, as

well as a lack of education are the main reasons for too early, too many and

unwanted pregnancies, which also contribute to high levels of maternal mortality

and morbidity. Lule et al. (2005:14) also observed that women with less than

seven years of education are twice more likely to have a child before the age of

20 than educated women; and that they are also less likely to make use of

reproductive and maternal health services. The Millennium Development Goals

Report (2006:7) also stated that girls and women in developing countries are still

denied access to schooling and young women often lack access to information

about reproductive health and related services (Freedman et al., 2005:71). In view

of the fact that a high number of girls and women are dying, while some are

afflicted with diseases that dehumanize them, all because they do not or have

limited access to education and necessary information about reproductive health,

this study proposes reaching out to such women through the Open and Distance

Learning system of education, in order to overcome the social and cultural

barriers.

Open Learning is used to describe policies and practices that permit entry to

learning with as few barriers as possible; it allows entry to learning with no or

minimum barriers with respect to age, gender, or time constraints (Asha Kanwar,

2016); it makes learning to take place anywhere, any, anytime, and enables

freedom to choose courses (Kember, 2007). The distance education aspect of it

refers to any form of organized educational experience in which teaching and




learning take place with the teacher at a distance from the learners most of the

time (Dodds, 1991), and it is focused on opening, access to education and

training, freeing learners from the constraints of time and place (UNESCO,

1997). It also provides learning in which teachers and tutors do not always meet

face-to-face to teach students like the conventional teaching and learning process

(Bunza, 1995). Scholars have written on how education can help to lift the status

of women (Okopi & Amini, 2012, Olojede, 2009; Alao, 1998). However, not

much has been done in the area of using Open and Distance Learning system as a

strategy to improve the health conditions of women, especially the unreached

rural women who either have no access to education, or have dropped out of the

educational system without completing their goals, and therefore cannot fully

participate in the economic and social development of their nations (Asha

Kanwar, 2016). This is the area this paper has tried to address.

The benefits of ODL are that it permits learning with no barrier or minimum

barrier in terms of age, gender, time constraints (Kanwar, 2016), it has the

capacity to accommodate diverse learning styles, it provides access to remote and

normally inaccessible under-represented groups and people in different

circumstances (Jain, 2001) the learning mode can be delivered through several

means like video, audio cassettes, telephone and radio (Jegede, 2003), it reaches

people in communities in which they would otherwise be deprived of

opportunities to learn (Ambe-Uva, 2007), it enables people to apply what they

have learned almost immediately as their training laboratory (Jegede, ibid), it

promotes the achievement of economies of scale, especially in a big country

(Daniel, 2009); this is because the cost of establishing conventional schools

increases as one gets out of cities and try to provide schools in the rural areas. As

Daniel (ibid) stated, this means additional costs that are out of reach for

governments struggling under unmet needs and many competing demands.

Conclusions

Education can be employed as a means to tackle the poor state of maternal health

in Nigeria. However, in order for education to have a wider reach, it may have to

use a non-conventional approach. The Open and Distance education system

(ODL) is a system of education that can take education to the population in a

more flexible way, without necessarily confining them to a regimented schedule.

It will help to bridge the gap of access to education.

Recommendations

i. Women’s access to education has been recognized as a fundamental right. At

the national level, educating women results in improved productivity, income,

and economic development, as well as a better quality of life, notably a

healthier and better nourished population (Jejeebhoy, 1995). It is therefore

clear that education through the ODL system will empower women, thus

providing them with increased autonomy.



ii. Education will enable them to explore ways of acquiring skills that will

improve their economic status; this will enable them to be able to afford some

of the reproductive health services which ordinarily may be unaffordable for

them. Even the skills can be taught through ODL to avoid the obstacle of lack

of access.

iii. While primary education may affect fertility indirectly, by mediating the

effect of various factors, secondary and higher education may influence

fertility more directly by making women more able to make independent

decisions based on assessment of the likely costs and benefits. Most studies of

education see schooling as imbuing students not with unthinking adherence to

what they are taught, but with the ability to evaluate information and

problems for themselves, and in particular to break loose from traditional

beliefs (Diamond, Newby & Varle, 1999). Education will enable women to

make informed choices about their fertility; this will assist them to either limit

the number of children they give birth to, or give enough gap between the

births, so as to reduce the risks of dying from pregnancy-related causes or

acquiring diseases like VVF.

iv. Even the young girls who were forced to drop out of school to get married

and are divorced due to the consequences of VVF, can still continue their

schooling through ODL. The most potent force for change is the breadth of

education (the proportion of the community receiving some schooling) rather

than the depth (the average duration of schooling among those who have

attended school).

References AbouZahr, C. & Wardlaw, T. (2001). Maternal Mortality at the End of a Decade:

Signs of Progress? Bulletin of the World Health Organization, Vol. 79, No.

6, pp. 561-568.

Adamu, Y.M & Salihu, H.M (2002): Barriers to the Use of Antenatal and

Obstetric Care Services in Rural Kano, Nigeria. Journal of Obstetrics and

Gynaecology, Vol. 22, No. 6, pp. 600-603.

Adamu, Y.M & Salihu, H.M; Sathiakumar, N. and Alexander, Greg, R. (2003).

Maternal Mortality in Northern Nigeria: A Population-Based Study.

European Journal of Obstetrics & Gynaecology and Reproductive Biology,

Vol. 109, Issue 2, pp. 153-159.

Adamu, Y.M. and Salihu, H.M. et al., (2003). “Maternal Mortality in Northern

Nigeria: A Population Based Study”, European Journal of Obstetrics and

Gynecology Reproductive Biology, 109: 153-159




Agudelo, C. & Belizan, J.M. (2000). Maternal Morbidity and Mortality

Associated with Interpregnancy Interval: Cross-Sectional Study. British

Medical Journal, Vol. 321, No. 7271, pp.1255-1259.

Ambe-Uvay, T.N. (2007). National Open University of Nigeria (NOUN). A

Historical Perspective and Challenges. Turkish Online Journal of Distance

Education. Vol. 8, No.1, Article 6, January.

Boserup, E. (1995). Women’s Role in Economic Development. South Africa,

Earthscan, India.

Cadwell, J.C. (1980). Mass education as a Determinant of the Timing of Fertility

Declibe. Population and Development Review, 225-255pp.

Daniel, J. (2009). Open Schooling is Part of the Answer. A Paper Presented at the

17th Conference of Commonwealth Education Ministers, Stakeholders’

Forum Kuala Lumpur, June 14 – 19.

Diamond, I; Newby, M.; & Varle, S. (1999). Female Education and fertility.

Examining the Links. Washington DC National Academy Press.

Dodds, T. (1991). “The Development of Distance Education: an Historical

Perspective”. Distance Education: A Review Edited by Janet, J. & Koul,

B.N. Cambridge. International Extension College. New Delhi; Indira

Ghandi National Open University.

Fathalla, M.F. (1992). Family Planning, Health and Well-being, Proceedings

from UN Expert Group Meeting on Family Planning, Health and Well-

being. Bangalore, India, 26-30 October, 1992. In Safe Motherhood and

Child Survival: The Importance of Family Planning, The Interdependence

of Services. Chapter xiii, pp 203-204. United Nations, 1996.

Fethalla, M. (1997). From Obstetrics and Gynaecology to Women’s Health: The

Road Ahead. New York, London, Parthenon.

Freedman, L. (2003). Strategic Advocacy and Maternal Mortality: Moving

Targets and Millennium Development Goals. Gender and Development,

Vol.11, No.1, pp.97-108.

Freedman, L.P., Waldman, R.J., de Pinho, H. & Wirth, M. E. (2005). Who’s Got

the Power, Transforming Health Systems for Women and Children. UN

Millennium Project, Task Force on Child Health and Maternal Health,

2005.

Galadanci, H.S., Illiyasu, Z, Ejembi, C.L., Alagh, B. & Umar, U.S. (2007).

Maternal Health in Northern Nigeria – A Cry Far From Ideal. BJOG: An



International Journal of Obstetrics and Gynecology, Vol. 114, No. 4, pp.

448-452.

HERA – Health Empowerment, Rights and Accountability.

Jeleebhoy, S.J. (1995). Women’s Education, Autonomy and Reproductive

Behaviour: Experience from Developing Countries. OUP Catalogue.

Kanwar, A.S. (2016). Can ODL Reach the Unreached? Lessons from the

Commonwealth. Public Lecture Delivered at the National Universities

Commission Auditorium, Abuja, on Wednesday, 27th July, 2016 for the

National Open University of Nigeria (NOUN).

Kayode, A. (1998). Women in Nigerian Educational System. In Sesay, A. &

Odebiyi, A. (1998). Nigerian Women in Society and Development. Ibadan,

Dokun Publishers.

Key, P. (1987). Women, Health and Development, With Special Reference to

Indian Women. Health Policy and Planning, Vol.2, Issue 1, pp 58-69.

Lule, E., Ramana, G.N.V, Ooman, N., Epp, J., Huntington, D. & Rosen, J.E.

(2005). Achieving the Millennium Development Goal of Improving

Maternal Health: Determinants, Interventions and Challenges. Health,

Nutrition and Population Discussion Paper, World Bank.

http://siteresources. worldbank. org/HEALTHNUTRITIONAND POPU-

LATION/Resources/281627-1095698140167/LuleAchievingtheMDGFinal

.pdf

Maine, D. & Rosenfield, A. (1999). The Safe Motherhood Initiative: Why Has It

Stalled? American Journal of Public Health, Vol. 89, NO. 4, April 1999.

McCarthy, J. & Maine, D. (1999). A Framework for Analyzing the Determinants

of Maternal Mortality. Studies in Family Planning, Vol. 23, No. 1, pp. 23-

22, Jan-Feb 1992.

Millennium Development Goals Report (2006). New York 2006, United Nations.

http://www.unmillenniumproject.org/documents/maternalchild-

complete.pdf

Morgan, S.P. & Niraula, B.B. (1995). Gender Inequality and Fertility in Two

Nepali Villages. Population and Development Review, 541 – 561pp.

National Reproductive Health Policy & Strategy to Achieve Quality

Reproductive & Sexual Health for All Nigerians (2001). Federal Ministry

of Health, Abuja, Nigeria. Nigerian Demographic and Health Surrey

(2004). NDHS Document

http://www.unmillenniumproject.org/documents/maternalchild-complete.pdf

http://www.unmillenniumproject.org/documents/maternalchild-complete.pdf




Obuekwe, I.F. & Marchie, C.L. (no date). Family Planning: A Possible

Intervention in Maternal Mortality. http://www.regional.org.au/au/mwia/

papers/full/33_flossy1. htm

Ogunlela, V.B. and Ogunlela, Y.I. (2008). “The Challenge of Rural Poverty

Alleviation in Nigeria: The role of the National Agricultural Research

System”. Journal of Food, agriculture and Environment, 6 (384): 493-499.

Porter, R. (1995:9). Knowledge Utilization and the Process of Policy

Formulation: towards a Framework for Africa. The SARA project and

USAID.

Ransom, E. & Yinger, N.V. (2002). Making Motherhood Safer – Overcoming

Obstacles on the Pathway to Care. Population Reference Bureau, February

2001.http://www.prb.org/pdf/MakMotherdSafer_Eng.PDF

Rieff, D. (1999). “The False Dawn of Civil Society”, The Nation, February 22,

1999http://www.thenation.com/doc.mhtm/

Sachs, J. (2005). The End of Poverty. How We Can Make it Happen in our

Lifetime. Penguin Books, London.

Sandiford, P.; Cassel, J.; Montenegro, M. & Sanchez, G. (1995). The Impact of

Women’s Literacy on Child Health and its Interaction with Access to

Health Services. Population Studies, 49 (1), 5 – 17.

Shiffman, J. & Okonofua, F.E. (2007). The State of Political Priority for Safe

Motherhood in Nigeria. BJOG: An International Journal of Obstetrics and

Gynaecology, Vol. 114, Issue 2, PP. 127-133.

Shiffman, J. (2003). Generating Political Will foe Safe Motherhood in Indonesia.

Social Science & Medicine, No. 56, pp. 1197-1207.

Starrs, A.M. (2006). Safe Motherhood Initiative: 20 Years and Counting. The

Lancet, Vol. 368, September 2006, pp. 1130-1132.

Stanton, C., Abderrrahim, N. & Hill, K. (1997). “DHS Maternal Mortality

Indicators: An Assessment of Data and Implications for Data Use”.

Demographic and Health Surveys Analytical Report. No.4. Calverton,

Maryland, USA, Macro International Inc. September.

Stekelenburg, J., Kyanamina, S., Mukelabai, M., Wolffers, I. & Van, R.J. (2004).

Waiting Too Long: Low Use of Maternal Health Services in Zambia.

Tropical Medicine and International Health, Vol.9, No. 3, pp. 390-398,

March 2004. Studies in Family Planning (2001). 32(2).

http://www.regional.org.au/au/mwia/%20papers/full/33_flossy1.%20htm

http://www.regional.org.au/au/mwia/%20papers/full/33_flossy1.%20htm

http://www.prb.org/pdf/MakMotherdSafer_Eng.PDF

http://www.thenation.com/doc.mhtm/



The Nation http://www.thenation.com/doc.mhtm/

Tsui, A.S. & Charles, A., O’Reilli, I (1989). Beyond Simple Demographic

Effects: The Importance of Relational Demography in Superior

Subordinate” The Academy of Management Journal, Vol. 32, No.2 (June,

1987) pp. 402-423.

Tsui, A.O, Wasserheit, J.N & Hagge, J.C (eds.) (1997). Reproductive Health in

Developing Countries – Expanding Dimensions, Building Solutions.

National Research Council, National Academy Press, Washington D.C.

Ujah, I.A.O. (2005). “Maternal Mortality Among Adolescent Women in Jos,

North Central, Nigeria” Journal of Obstetrics and Gynecology, January,

25(1): 3-6

Ujah, I.A.O. et al., (2005a). “Factors Contributing to Maternal Mortality in North

Central Nigeria”. Journal of Obstetrics and Gynecology, 25, 1: 3-6

Ujah, I.A.O. et al., (2008). Woman Trial in Nigeria Count Down to First Patient,

World Maternal Antifibrolytic Trial, Trials Coordinating Centre, London.

www.womantrial.lshtm.ac.uk

Ujah, I.A.O., Aisen, O.A., Mutihir, J.T, Vanderjagt, D.J., Glew, R.H. & Uguru,

V.E. (2005a). Maternal Mortality Among Adolescent Women in Jos, North-

Central Nigeria. Journal of Obstetrics and Gynaecology. Vol. 25,

No.1,pp.3-6, January 2005.

UNICEF (1998). The state of World’s Children.

United Nations (2006). The Millennium Development Goals Report.

Wall, L.L.; Karshima, J.A.; Kirschner, C.; Arrowsmith S.D. (2003). The Obtetric

Vesicovaginal Fistula: Characteristics of 899 patients from Jos, Nigeria.

resented at the Twenty-Second Annual Meeting of the American

Gynaecological and Obstetrical Society, Napa, California, September 18th –

20th

http://www.thenation.com/doc.mhtm/

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