MATERNAL MORTALITY IN NIGERIA

MATERNAL MORTALITY IN NIGERIA

BY; TIJAN SHERIFF OLUWAMAYOWA

Just as piece of information may save lots of lives from unanticipated death, maternal mortality particularly is an area people pay less attention to despite the number of lives lost as far as the term is concerned. In a quest to improve the awareness and in the process save the lives of many mothers not due to death during childbirth or death during pregnancy but death due to ignorance and nonchalance, a comprehensive study has been made into the causes, details and prevention of maternal deaths and most especially to sustain the lives of our mothers and intending mothers.

Maternal death is defined 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 or aggravated by the pregnancy or its management, but not from accidental or incidental causes."

The world mortality rate has declined 45% since 1990, but still 800 women die every day from pregnancy or childbirth related causes. According to the United Nations Population Fund (UNFPA) this is equivalent to “about one woman every two minutes and for every woman who dies, 20 or 30 encounter complications with serious or long-lasting consequences. Most of these deaths and injuries are entirely preventable.”

UNFPA estimated that 289,000 women died of pregnancy or childbirth related causes in 2013. These causes range from severe bleeding to obstructed labour, all of which have highly effective interventions. As women have gained access to family planning and skilled birth attendance with backup emergency obstetric care, the global maternal mortality ratio has fallen from 380 maternal deaths per 100,000 live births in 1990 to 210 deaths per 100,000 live births in 2013. This has resulted in many countries halving their maternal death rates.

ACHIEVING THE FIFTH MILLENNIUM DEVELOPMENT GOAL ON MATERNAL MATERNITY

Improving maternal health is 1 of the 8 Millennium Development Goals (MDGs) adopted by the international community in 2000. Under MDG5, countries committed to reducing maternal mortality by three quarters between 1990 and 2015. Since 1990, maternal deaths worldwide have dropped by 45%.

In sub-Saharan Africa, a number of countries have halved their levels of maternal mortality since 1990. In other regions, including Asia and North Africa, even greater headway has been made. However, between 1990 and 2013, the global maternal mortality ratio (i.e. the number of maternal deaths per 100 000 live births) declined by only 2.6% per year. This is far from the annual decline of 5.5% required to achieve MDG5.

WHERE DO MATERNAL DEATHS OCCUR?

The high number of maternal deaths in some areas of the world reflects inequities in access to health services, and highlights the gap between rich and poor. Almost all maternal deaths (99%) occur in developing countries. More than half of these deaths occur in sub-Saharan Africa and almost one third occur in South Asia.

The maternal mortality ratio in developing countries in 2013 is 230 per 100 000 live births versus 16 per 100 000 live births in developed countries. There are large disparities between countries, with few countries having extremely high maternal mortality ratios around 1000 per 100 000 live births. There are also large disparities within countries, between women with high and low income and between women living in rural and urban areas.

The risk of maternal mortality is highest for adolescent girls under 15 years old and complications in pregnancy and childbirth are the leading cause of death among adolescent girls in developing countries.1, 2

Women in developing countries have on average many more pregnancies than women in developed countries, and their lifetime risk of death due to pregnancy is higher. A woman’s lifetime risk of maternal death – the probability that a 15 year old woman will eventually die from a maternal cause – is 1 in 3700 in developed countries, versus 1 in 160 in developing countries.

NIGERIAN CASE STUDY

Every single day, Nigeria loses about 2,300 under-five year olds and 145 women of childbearing age. This makes the country the second largest contributor to the under–five and maternal mortality rate in the world.

Underneath the statistics lies the pain of human tragedy, for thousands of families who have lost their children. Even more devastating is the knowledge that, according to recent research, essential interventions reaching women and babies on time would have averted most of these deaths.

Although analyses of recent trends show that the country is making progress in cutting down infant and under-five mortality rates, the pace still remains too slow to achieve the Millennium Development Goals of reducing child mortality by a third by 2015.

Preventable or treatable infectious diseases such as malaria, pneumonia, diarrhoea, measles and HIV/AIDS account for more than 70 per cent of the estimated one million under-five deaths in Nigeria.

Malnutrition is the underlying cause of morbidity and mortality of a large proportion of children under-5 in Nigeria. It accounts for more than 50 per cent of deaths of children in this age bracket.

The deaths of newborn babies in Nigeria represent a quarter of the total number of deaths of children under-five. The majority of these occur within the first week of life, mainly due to complications during pregnancy and delivery reflecting the intimate link between newborn survival and the quality of maternal care. Main causes of neonatal deaths are birth asphyxia, severe infection including tetanus and premature birth.

Similarly, a woman’s chance of dying from pregnancy and childbirth in Nigeria is 1 in 13. Although many of these deaths are preventable, the coverage and quality of health care services in Nigeria continue to fail women and children. Presently, less than 20 per cent of health facilities offer emergency obstetric care and only 35 per cent of deliveries are attended by skilled birth attendants. This shows the close relationship between the wellbeing of the mother and the child, and justifies the need to integrate maternal, newborn and child health interventions.

It is important to note that wide regional disparities exist in child health indicators with the North-East and North-West geopolitical zones of the country having the worst child survival figures of maternal death rates with an estimated 36,000 women dying in pregnancy or at child birth each year. At least 5500 of these deaths are among teenage mothers. This is as Jigawa topped the list of teenage mothers with 78 percent of its girls between ages 15-19 in early marriage. Jigawa is closely followed by Katsina, Zamfara, Bauchi and Sokoto states.

These figures were revealed in the Demographic Health Survey 2013 which also noted that 70 percent of the maternal deaths in Nigeria are due to four conditions: haemorrhage, eclampsia, sepsis and abortion complications. It disclosed that only 9.8 percent of Nigerian women use modern family planning methods, while 16.1 percent have an expressed unmet need for family planning.

"51 percent of pregnant women had at least four antenatal care visits...only 38 percent of the annual 6.6 million births in Nigeria were assisted by a skilled attendant,"

Data made available by the United Nations Population Fund (UNFPA) however noted that over the last 20 years, Nigeria has made significant progress in reducing the maternal mortality ratio. It however added that Nigeria has to make concerted efforts to reach the Millenium Development Goal of 300 per 100,000 (or under 20,000 annual deaths) by 2015.

Nigeria also has about 260,000 neonatal deaths annually, 13 percent of which can be prevented with live saving interventions such as provision of required maternal health medicines and supplies. 

On child marriage, it was revealed that Nigeria has one of the highest child marriage prevalence rates in the world.

CAUSES OF MATERNAL DEATH

Factors that increase maternal death can be direct or indirect. Generally, there is a distinction between a direct maternal death that is the result of a complication of the pregnancy, delivery, or management of the two, and an indirect maternal death. That is a pregnancy-related death in a patient with a preexisting or newly developed health problem unrelated to pregnancy. Fatalities during but unrelated to a pregnancy are termed accidental, incidental, or non-obstetrical maternal deaths.

The most common causes are post-partum bleeding (15%), complications from unsafe abortion (15%), hypertensive disorders of pregnancy (10%), postpartum infections (8%), and obstructed labour (6%). Other causes include blood clots (3%) and pre-existing conditions (28%). Indirect causes are malaria, anaemia, HIV/AIDS, and cardiovascular disease, all of which may complicate pregnancy or be aggravated by it.

Sociodemographic factors such as age, access to resources and income level are significant indicators of maternal outcomes. Young mothers face higher risks of complications and death during pregnancy than older mothers, especially adolescents aged 15 years or younger. Adolescents have higher risks for postpartum hemorrhage, puerperal endometritis, operative vaginal delivery, episiotomy, low birth weight, preterm delivery, and small-for-gestational-age infants, all of which can lead to maternal death. Structural support and family support influences maternal outcomes. Furthermore, social disadvantage and social isolation adversely affects maternal health which can lead to increases in maternal death. Additionally, lack of access to skilled medical care during childbirth, the travel distance to the nearest clinic to receive proper care, number of prior births, barriers to accessing prenatal medical care and poor infrastructure all increase maternal deaths.

Unsafe abortion is another major cause of maternal death. According to the World Health Organization, every eight minutes a woman dies from complications arising from unsafe abortions. Complications include hemorrhage, infection, sepsis and genital trauma. Globally, preventable deaths from improperly performed procedures constitute 13% of maternal mortality, and 25% or more in some countries where maternal mortality from other causes is relatively low, making unsafe abortion the leading single cause of maternal mortality worldwide.

·         severe bleeding (mostly bleeding after childbirth);

·         infections (usually after childbirth);

·         high blood pressure during pregnancy (pre-eclampsia and eclampsia);

·         complications from delivery;

·         Unsafe abortion.

PREVENTION OF MATERNAL DEATH

Four elements are essential to maternal death prevention, according to UNFPA. First, prenatal care. It is recommended that expectant mothers receive at least four antenatal visits to check and monitor the health of mother and foetus. Second, skilled birth attendance with emergency backup such as doctors, nurses and midwives who have the skills to manage normal deliveries and recognize the onset of complications. Third, emergency obstetric care to address the major causes of maternal death which are haemorrhage, sepsis, unsafe abortion, hypertensive disorders and obstructed labour. Lastly, postnatal care which is the six weeks following delivery. During this time bleeding, sepsis and hypertensive disorders can occur and newborns are extremely vulnerable in the immediate aftermath of birth. Therefore, follow-up visits by a health worker is assess the health of both mother and child in the postnatal period is strongly recommended.

·         Medical Technologies

·         Public health

·         Policy

·         Family planning approaches include avoiding pregnancy at too young of an age or too old of an age and spacing births. Access to primary care for women even before they become pregnant is essential along with access to contraceptives.

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. 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.

·         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.

CONCLUSION

From the study it has been discovered that no pregnant woman would deprive herself of the adequate health care except the very few who suffer from ignorance and healthcare negligence.

In high-income countries, virtually all women have at least 4 antenatal care visits, are attended by a skilled health worker during childbirth and receive postpartum care. In low-income countries, just over a third of all pregnant women have the recommended 4 antenatal care visits.

Poor women in remote areas are the least likely to receive adequate health care. This is especially true for regions with low numbers of skilled health workers, such as sub-Saharan Africa and South Asia. While levels of antenatal care have increased in many parts of the world during the past decade, only 46% of women in low-income countries benefit from skilled care during childbirth. This means that millions of births are not assisted by a midwife, a doctor or a trained nurse.

Other factors that prevent women from receiving or seeking care during pregnancy and childbirth are:

·         poverty

·         distance

·         lack of information

·         inadequate services

·         cultural practices.

To improve maternal health, barriers that limit access to quality maternal health services must be identified and addressed at all levels of the health system.

PROJECT CREDIT

Ø  Conde-Agudelo A, Belizan JM, Lammers C. Maternal-perinatal morbidity and mortality associated with adolescent pregnancy in Latin America: Cross-sectional study. American Journal of Obstetrics and Gynecology, 2004, 192:342–349.

Ø  Patton GC, Coffey C, Sawyer SM, Viner RM, Haller DM, Bose K, Vos T, Ferguson J, Mathers CD. Global patterns of mortality in young people: a systematic analysis of population health data. Lancet, 2009, 374:881–892.

Ø  Say L et al. Global Causes of Maternal Death: A WHO Systematic Analysis. Lancet. 2014.

Ø  UNICEF, WHO, The World Bank, United Nations Population Division. The Inter-agency Group for Child Mortality Estimation (UN IGME). Levels and Trends in Child Mortality. Report 2013. New York, USA, UNICEF, 2013.

Ø  Cousens S, Blencowe H, Stanton C, Chou D, Ahmed S, Steinhardt L, Creanga AA, Tunçalp O, Balsara ZP, Gupta S, Say L, Lawn JE. National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis. Lancet, 2011, Apr 16, 377(9774):1319-30. [in press, will be published 15 May 2014]

Ø  WHO. World Health Statistics 2014. Geneva, World Health Organization; 2014.

Ø  Ban K. The Global Strategy for Women’s and Children’s Health. New York, NY, USA, United Nations, 2010.