Maternal Health in Northern Nigeria: Challenges & Opportunities

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By

Mazi Ejeckam Chukwuebuka . C.

Friday, 8th December 2017

Outline

Background - Causes

….and Elizabeth became one of the 145

Definition of Concept

Impact of Maternal Mortality

Factors Influencing Maternal Health in Nigeria

Maternal Health Issues in Northern Nigeria - EOC

Opportunities

Strategies

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BackgroundNigeria has one of the highest rates of Maternal mortality in the developing world, and in the globe.

Nigeria though only 2% of the global population accounts for 10% of the global estimate of maternal mortality.

Estimates of maternal mortality are grossly under reported by as much as 50% because most maternal deaths are more often than not counted at all.

For women who survive the ordeal of pregnancy and labour, a substantial number suffer long-term morbidity including Vesico-Vaginal fistulae, Infertility and chronic pelvic disability.

The lifetime risk of dying from pregnancy related causes is 1 in 1750(developed countries), 1 in 870(East Asia), 1 in 90 (Latin America), 1 in 24 (Africa). For Nigeria, it is estimated at 1 in 13 .

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Background ( Cont’d).Nigeria has a maternal mortality rate of 576 per 100,000 live births – a far cry from the then projected 250 per 100 000 live births under the MDG 2015 target framework.

A joint report by W.H.O, UNFPA, UNICEF and World Bank surmised that in 2015 alone 58,000 Nigeria women lost their lives to pregnancy and child related causes.

According to a 10 year study of all maternal deaths at the Lagos State University Teaching Hospital from January 1, 2005 to December 31, 2014, the five highest causes of deaths are: severe bleeding, infections, hypertensive disorders in pregnancy( eclampsia), obstructed labor and complications following unsafe abortions. Severe bleeding was the most common cause, followed by eclampsia. All these complications are highly AVOIDABLE & PREVENTABLE.

Factors that contribute to this are diverse, ranging from education to culture to religion and lack of access to skilled health workers and necessary drugs. Others include living in an urban or rural area, socio- economic status, geo-political zone ( Northeast- 1549/100,000) vs ( Southwest-165/100,000)

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Background Con’tdNDHS 2013 showed that only 1 in 3 deliveries occur in modern health facility.

Also, while 90 percent of women from the south-east receive ante-natal care from skilled health providers, this would be the case for only about 40 percent in the North –west for example.

Nigeria ranks far behind other neighbouring economies ( e.g. Ghana & Benin) that both have MMR of about 350 per 100, 000 live births. South Africa has

The Maternal Mortality rates are highest ( e.g. North) where women have many babies in a short time periods while also facing malnutrition, poor hygienic conditions and poor access to medical treatment.

Severe bleeding, obstructed/prolonged labour, unsafe abortions, hypertensive pregnancy disorders(e.g eclampsia) are some of the DIRECT causes of death. HIV/AIDs, FGM, Malaria are some of the INDIRECT causes. Poverty, Delays in referral for specialist services and the use of ‘’ Spiritual houses” for deliveries also contribute immensely to maternal deaths.

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Background Con’tdLess than a fifth (18.5%) of facilities offering maternal health care services met standards for EOC nationally. This is worse off in the North.

In the public sector, 4.2% of facilities met the EOC criteria ( 1.2% for basic and 3.9% for comprehensive)

In the private sector, 5.3% for BEOC and 27.5% for CEOC.

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Causes of Maternal Deaths – in %

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Haemorrhage23%

Sepsis17%

Toxemia/Eclampsia11%

Unsafe Abortion11%

Obstructed Labor11%

Malaria11%

Anaemia11%

Others5%

Giving Birth- The Staggering Odds Against Women In Nigeria.

Every single day, Nigeria loses about 145 women of childbearing age, making her the second largest contributor to the maternal mortality rate in the world, according to UNICEF. When this statistic came out earlier this year, it elicited different responses from different people online, and started up a debate among friends, co-workers and total strangers over it’s veracity. For others, it was just one more piece to add to Nigeria’s estimated poor development numbers game.

However, for ELNATHAN HEZEKIAH, It was more than a number. It was a painful memory. Maternal mortality, to him, had a face and a form. On March 26th 2017, it walked into his life and took his wife. She became one of the 145.

In an exclusive Interview with Nigeria Health Watch, Hezekiah said it was his wife’s third pregnancy and ‘’ because she was a few days overdue, I drove her to the hospital to be induced”.

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Con’tdBetween the two, nobody could tell who was more excited at the baby’s coming; Mrs Hezekiah, at the fact that she was going to meet the baby she had carried for nine months, or Mr. Hezekiah because he was getting back his wife- shape, temperament and all, and the big one –the baby. He had made plans to welcome back the mother and the new baby. ‘’ I bought a new washing machine, painted the house bright cheerful colors and did all I could to make sure that it was comfortable for my wife and our new baby,” he said.

Back at the hospital, Mrs. Hezekiah labored and finally gave birth to a 4.6kg baby boy. But tears of joy quickly turned into heightened levels of panic when she did not stop bleeding, suffering from one of the most common complications, postpartum haemorrhage. At 1.28am the next morning, panic turned into sorrow, when she, exhausted from labor and blood loss, died.

The hospital did not give Mr. Hezekiah any reason for his wife’s blood loss.

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Cont’d‘’ The drugs they needed to stop her from losing any more blood were not in stock and so I went out to buy them. But when she died, nobody told me why ”. After her death, I contemplated taking legal actions against the hospital but then I had no way to prove that they had been negligent . I thought of the many people who like me had lost someone and had decided to take the hospital to court. Nothing came of it. Nobody gets punished, no matter what we do so why bother? The hospital has the backing of the NMA and I have no one. So, I decided to leave it to God. Besides, nothing I do will bring her back.

I can’t describe the emotions I felt at her passing. There ‘s been so much pain, I can’t measure it. There has also been a lot of disappointment because I hoped that it would not end like this. –Elnathan Hezekiah.

(Culled from Nigeria Health Watch, August 2017)

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Definition of ConceptMaternal Mortality is defined 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 cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.

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Impact of Maternal MortalityMaternal Mortality is one of the key indices of the state of health and quality of healthcare in any society.

It provides one of the worst differentials in health indices between developed and developing worlds.

The death of a woman has devastating effect on the whole family. It is often a tragic loss, not only to the family, but also to the community and nation as a whole. For example, somestudies have shown the link or correlation between countries with low GDP and maternal deaths.

Death of a mother increases the chances of death of her children between 2- 4 times.

Why should a woman loose her life trying to give life ? Can someone just tell me why?

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Factors Influencing Maternal Health in NigeriaNational TFR is 5.7

16% of total births occur amongst adolescent girls

Unsafe abortions- estimated at about 610,000 per year in Nigeria. Globally, there are 56 million abortions every year with about 17 million being unsafe according to the W.H.O

HIV/AIDs pandemic. Though there has been a steady reduction in national prevalence over the years.

High malnutrition rate. Nigeria comes third after India and China ( who have exponentially larger populations) in the world list of undernourished children and is currently one of the two African countries listed among the twenty responsible for the 80% of global malnutrition.

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Maternal Health Issues in Northern NigeriaSome factors that contribute to maternal , ranging from low or no education to culture to religion and lack of access to skilled health workers and necessary drugs. Others include living in an urban or rural area, socio- economic status. Though these could be argued to be somewhat general – their impact seems greatest in the northern zone of the country.

Northern Nigeria has also the worst socio-economic and development indices relative to the south. This has also impacted on her poor maternal outcomes.

There seems to be a major cultural resistance to the emancipation of women in the north relative to the south. This sometimes influences delays in seeking care, especially at the first level.

Patronage of standard health facilities is lowest in the north and the lowest supply of professional human resources for health occurs in the north.

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SouthWest Southeast South South North-Central North-East North West

% Facility Delivery

South West Southeast SouthSouth NorthCentral NorthEast NorthWest

Maternal Mortality per 100,000 live births

Human Resource for Maternal Health

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469

571

394

818

428

625

482

576

402

1016

862

672

South West

SouthSouth

South East

NorthWest

North East

North Central

MSS Facilities: (Midwives as at 2013)

Required On Ground

446

425

75

506

432

81

NorthWest

North East

North Central

MSS Facilities: (CHEWs as at 2013)

Required On Ground

Human Resource for Maternal Health

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South West

SouthSouth

South East

NorthWest

North East

North Central

SURE-P Facilities (Midwives as at 2013)

Required On Ground

South West

SouthSouth

South East

NorthWest

North East

North Central

SURE-P Facilities ( CHEWs as at 2013)

Required On Ground

Main Factors implicatedHaemorrhage

Septis/Infection

Toxeamia/Eclampsia

Unsafe Abortion

Prolonged/Obstructed Labour

Malaria

Anaemia

Others

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Levels of Delay in Seeking Care

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1st•Accounts for as much as 30-

40% of MM

•Lack of information and inadequate knowledge about signs and complications of pregnancy and danger signs during labour

•Cultural practices that restrict women from seeking care

2nd •Inability to access health facility- poor siting, poor road and communication network, Poor community support.

3rd•Inadequate skilled

personnel

•Inadequate equipment & supplies

•Lack of blood

•Lack of staff motivation

Emergency Obstetrics CareAll socio-economic program, while good in themselves for maternal wellbeing, cannot prevent direct medical complication IF and WHEN they occur in pregnancy.

Strategies needs to be in place to treat these condition whenever/wherever they occur.

EOC – Life saving procedures in emergencies

It is lack of one or more of these under listed that contributes to death in emergencies:-

Perform Caesarean Section, Perform Vacuum Extraction, Perform Manual Vacuum Aspiration, Manual Removal of Placenta, Administer Antibiotics

Administer Anaesthesia, Administer Oxytocin, Administer anticonvulsants ( MgSO4), Blood Transfusion

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OpportunitiesApparent no-lack of fatigue at international/national levels on issues affecting mothers, girls and children.

Many interventions over time in Nigeria – Free maternal and Child Health care Programme( FMCHCP), The Nigerian Integrated Maternal , New-born and Child Health Strategy, Midwives Service Scheme (MSS) and Subsidy Reinvestment and Empowerment Program ( MCH), MamaYe, Saving One Million Lives, etc.

Window of opportunity also exist for a wholistic approach in tackling ‘’ womanhood’’ & Reproductive Health issues through the new ‘’ life cycle’’ paradign.

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Opportunities – SURE-P MCH Leverage

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Total ANC Visits New ANC Visits Deliveries by SBAs FP New Acceptors # attending FP Clinic # of Postnatal checks

Baseline ( Apr-Sept 2012) 140503 51807 16695 11176 26292 25870

6 months After ( Oct - Feb 2013) 154133 61623 18285 14987 29190 26338

Comparison of Baseline vs 6 months After data in SURE-P MCH facilities

Strategies

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Generate political will via continuous Advocacy/Activism

Girl child Education & Women Empowerment

Community Health Education

Male Involvement in Maternal & Reproductive Health – partners

Improve infrastructures (roads, transportation, ambulance services, etc)

Provide effective referral services

Provision of adequate SUPPLY & DEMAND components for Maternal Health interventions

Friendly Health worker attitudes towards pregnant women

………..can you add to this list

‘’…. the focus must be on the right of women to have these basic maternal health services. Government and communities must see this not as an ‘’ extra’’, but as a fundamental component of women’s health, child health and family health ‘’.

Carol Bellamy ( UNICEF)

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THANK YOU for LISTENING

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