Kano — An expectant mother in northern Nigeria faces higher risks in childbirth than in most any other place in the world, according to international public health surveys.
But the staff at Murtala Mohammed Specialist Hospital, the largest government hospital in this region, are doing everything they can to make these grim odds a thing of the past– and they are having some success.
They have embraced unconventional but effective tools, simple and easily taught practices, mass public awareness campaigns and partnerships with religious and traditional community leaders. As a result, they are making a dent in the maternal mortality crisis that has ravaged this underdeveloped and neglected region of Nigeria for decades.
"If you were here 10 years back, you would not be able to believe the dramatic changes [today]," said Hauwa Isa Borado, the chief matron of the 16-bed maternity ward.
Facing the Challenges
From poor sanitation to failing facilities to staffing problems, Murtala Mohammed Specialist Hospital was ailing after a series of military dictatorships, Borado said.
Soon after civilian rule was restored in 1999, the new state and federal governments supported doctors and nurses in Kano government hospitals to take the lead in pioneering a model for free maternal health that could be replicated across the north. It is a region where the sheer numbers of babies born here annually to impoverished mothers, who often begin child bearing as young as 15, poses an ongoing challenge to healthcare providers.
Dr. Bello Umar Dikko, an obstetrician-gynecologist and chief medical director of the Murtala Mohammed hospital, said that its previous administrators told the government that a lack of means and knowledge were preventing more mothers from delivering their babies in hospitals.
He said in the past more people attributed the death of women in childbirth to "evil spirits" or God's will and they preferred to deliver at home. Now, in the sprawling city of Kano, more women are opting to deliver in hospitals like Murtala Mohammed where free, safe care is readily available, he said.
"We advocated for the government to subsidize pre-maternal services," said Dr. Dikko. He said these efforts helped convince the government of former president Olesegun Obasanjo in 2002 to begin offering free services at all of Kano's public hospitals.
Dr. Dikko said an essential part of his team's effort was doing outreach and advocacy in local communities, particularly with religious leaders. "We got in touch with the Ulama [Islamic affairs] Council, and they consented to give information at Friday prayers [about the free maternal services]," he said.
Halima Ben Umar, director of the Kano-based activist group Women in Media, said that involving traditional and religious authorities is essential to encouraging changes in perceptions about hospital delivery and in promoting family planning.
The results of the hospital's efforts are visible. The free antenatal care clinic at Murtala Mohammed is bustling with pregnant women willing to wait in long lines for an ultrasound of their wombs to advice on nutrition during pregnancy.
Nurse Hauwa Mansour Waziri said the antenatal care program "focuses on quality" and reduces the typical number of hospital visits to ease the burden on expectant mothers who may be traveling from a remote village or even a neighboring state.
She said that on Monday mornings all of the pregnant women scheduled to receive care that week – typically 350-450 patients - turn up. They are divided into groups based on how many babies they have previously delivered. They are then told to come back on Tuesday if it is their first or second pregnancy, Wednesday if it's their third to fifth, and so on. This helps ease the burden on how many patients the nurses will see each day.
There are plenty of nurses but not enough doctors to see patients with complications, Waziri said.
Making free care available was the first step, but administrators said reducing maternal death at the hospital required more than the goodwill of the medical staff
The leading cause of maternal death in northern Nigeria is post-partum hemorrhaging, which is more prevalent in mothers who have given birth many times and with short intervals between deliveries.
Dr. Dikko said a key problem in the past was a lack of staff trained in preventing post-partum bleeding, but more importantly, lack of a ready blood supply for life-saving transfusions.
Staff used to use an innovative device called the anti-shock pressure garment to control bleeding. Posters detailing how to detect signs of shock induced by blood loss and how to use the device still hang in the maternity ward. But Dr. Dikko said the hospital's blood bank, which opened in 2009, has reduced the need for the device.
He said the blood bank is consistently well-supplied thanks to regular donations made by civil servants, particularly the armed forces in Kano, who have participated in donation campaigns organized by the hospital. Ready access to blood in an emergency prevents mothers from dying after delivery.
Changes in the Delivery Ward
Meanwhile, another technique, taught to nurses and midwives has helped to prevent post-partum bleeding from starting in the first place. The "active management" technique has been taught with support from the organization Pathfinder, which is funded by the U.S. Agency for International Development (USAID), and the MacArthur Foundation. Additionally, posters in the maternity ward contain instructions reminding staff of the procedure.
On a recent sweltering day in the delivery ward in Murtala Mohammed hospital, the head matron in the ward, Rakiya Balarabe Abdu, looked on while a younger nurse employed "active management" immediately after a 28-year-old mother had successfully delivered her fourth child. Immediately removing the placenta and massaging the uterus in order to help it contract after the birth, the nurse administered an anti-bleeding drug called mistropostol and closely monitored Zulfa'a Aminu's condition as she rested with her newborn.
In the past, Abdu explained, the nurses would wait for the placenta to detach from the uterus naturally, which, if the process was delayed, could lead to excessive bleeding. With the advent of new techniques to actively prevent bleeding, the hospital staff are able to proactively address one of the leading causes of death in childbirth.
Not every story ends as well. A few thin dividers separated Aminu from a woman who delivered a stillborn child minutes after Aminu's baby boy began crying. The nurse explained that the woman had not come to the antenatal clinic during her pregnancy as Aminu had done, and waited a day after she stopped feeling fetal movements before coming to the hospital.
"We try to help everyone who arrives on our doorstep," said chief matron Borado. She said women who have already sought antenatal care typically stand a much better chance of delivering safely. They are given advice on danger signs during pregnancy and are urged to arrive at a hospital before delivery while they can still walk before delivery.
Creating More Awareness
Although the successes that Murtala Mohammed hospital has registered over the past decade are an excellent start in making childbirth safer for northern Nigerian women, Dije Abdul of Pathfinder in Kano says that progress in urban hospitals is only the first step.
"We need to create more awareness," Abdul said. She noted that there are more than 1,000 health centres in Kano state, and very few of them have been able to achieve anything near the standard of care reached at Murtala Mohammed, one of 17 government hospitals in the city of Kano.
Abdul said that making quality care available in the vast expanses of the north would be an essential step in reducing maternal mortality rates in the years to come. For now, women with the means to travel from their villages - and the support from their husbands to do so - remain in the extreme minority.
A positive sign is that women like Aminu are helping to spread the word in their own communities.
Nursing her healthy newborn boy, she said in the local Hausa language that she encourages her neighbors and relatives to deliver in the hospital for their own safety and for the health of their babies.
With the continued efforts of dedicated hospital staff, effective public health and community awareness projects, and the support of religious leaders, it appears that childbirth in northern Nigeria will grow progressively less life-threatening over time.