Nigeria: Why Nigeria's Maternal Mortality Amongst Highest in the World

newborn baby infant maternity pregnant pregnancy
9 January 2021

Contributes 20 per cent to global maternal deaths

Inadequate health personnel/facilities, poverty, early marriage, key factors

Banditry, insurgency hinder pregnant women from ante-natal services

Nigeria is one of the countries with the highest maternal mortality rates in the world, with the country accounting for about 20 per cent of global maternal deaths. Daily Trust Saturday, in this report, examines some of the factors responsible for this ugly trend.

Maternal mortality ratio (MMR) in several low-and-middle-income countries is alarming, with about 34% of global maternal deaths occurring in Nigeria and India alone.

Traditional birth attendants at a training

According to the World Health Organization (WHO), the MMR of Nigeria is 814 deaths (per 100,000 live births).

The lifetime risk of a Nigerian woman dying during pregnancy, childbirth, postpartum or post-abortion is one in 22, in contrast to the lifetime risk in developed countries estimated at 1 in 4,900

Nigerian women are also said to be 500 times more likely to lose their lives in childbirth when compared to most advanced nations of the world.

An online research media, indexmundi puts Nigeria's maternal mortality rate at 917 deaths/100,000 live births.

Speaking on the increasing rate of maternal mortality in the country, the Programme and Communication Officer, Resource Centre for Human Rights and Civic Education, Mr Armsfree Ajanaku said, from their experience as an organization that has been working to mitigate the devastating impact of scourge of maternal and child health in Nigeria, they have observed a number of factors contributing to the situation.

"In the first place, the poor governance of the Primary Healthcare Sector is a major issue. A situation where PHCs, which are supposed to be the first port of call for expectant mothers and infants are ill equipped to respond to basic treatment needs, exposes large number of mothers and babies to untimely death," he said.

He said they have situations, especially in rural areas, where equipment as basic as beds, thermometers, and blood pressure monitors are not available in PHCs resulting in patients being treated without the right indices.

Mr Ajanaku said many Nigerians in urban centres take some of these things for granted, but in the rural areas, "they are luxuries, which are hard to come by."

He urged the government and stakeholders in the health sector to look deeply into the PHCs and make available facilities and human capital needed to make them function well to enable pregnant women have access to quality healthcare services at the grassroots to reduce the rate of maternal deaths recorded yearly.

In Northern Nigeria, many women die from pregnancy-related complications as many reports have exposed.

It is believed that this is because of the inaccessibility of health care facilities for expectant mothers, which is because of a plethora of reasons.

Poverty, early marriage big factors in Kano

In 2020, Daily Trust Saturday profiled a group of women in the Gwammaja area of Kano State, who had identified some of these problems around them.

The women, led by one Hajiya Amina Tanko, had first identified poverty as the foremost problem amongst them.

"Women and their relatives simply had no money to invest in antenatal care, or for safe deliveries in reputable hospitals.

"Among us, some died while giving birth or their children will die because some husbands will say they do not have money to take them to the hospital, and that was why we had to do something to help our members, so that nobody will be dying anyhow," Hajiya Tanko said.

A Nigerian is classified as poor when he lives below $1 per day, which is about N400.

A traditional birth attendant examines a pregnant woman

On a geopolitical zone assessment, North-Western Nigeria has 77.7% of its population living in poverty, with Kano having 55.1% on a state level.

"A woman cannot even eat till her husband gives her money to buy food, and how much is that money? You see someone with seven, eight children, and the husband will give her N100 to eat. It is not enough. Where will they now get money for drugs if there is no money to eat?" Hajiya Tanko asked.

With more than half the population of Kano State said to be living below the poverty belt, chances of having enough finance to consider proper healthcare is very minimal.

When the group was able to combat the issue of finance by empowering themselves and sourcing for funds from trade and communal contributions, the next obstacle was the Primary Healthcare Centre (PHC) next to them.

In Kano, most PHCs available to women merely exist in name but lack adequate personnel and facilities.

The women had complained that there were no doctors available for them, and the centres were not conducive for births neither were they open for 24 hours, hence, births that come at night pose a serious risk to mother and child.

PHCs mostly consist of a room or two, with benches and personnel, who are either impassionate about their jobs or overwhelmed and overworked.

Early marriage, which is also very rampant in Northern Nigeria, is considered one of the major contributors to maternal health complications with the WHO estimating that most complications come from pregnant teens.

WHO posits that if northern women had better control of their finances and were better educated, they would be empowered enough to make better decisions about their lives; this would invariably curtail maternal deaths and dangerous maternal complications.

According to Dr Yusuf Habib, a specialist in Obstetrics and Gynaecology, the major causes of complications in pregnant women results from improper checks and observations.

Dr Habib advised that women take their prenatal care very seriously.

"We even advise women to come in for what we call 'pre-conception check-up,' where we run tests and check women for any diseases they may be predisposed to or any complications they may be predisposed to before they conceive.

"That way, we can prescribe some supplements that may help women prevent complications like this. Also, women should always follow their doctors' advice and check their blood pressures regularly while pregnant."

But in a region where the majority of the people are poor and struggling to eat, the finance to consider check-ups, vitamins and proper healthcare will remain a myth.

Governor Abdullahi Ganduje had during the 2020 Primary Healthcare Summit held in Kano, said they were perfecting plans to establish a Primary Healthcare Center in each of 484 wards of the state.

Governor Ganduje insisted that healthcare needs of the Kano people remain sacrosanct and are important to the government.

According to him, more funds would be committed to uplifting the health status of the state.

While medical experts at the summit said they were impressed with the projects and programmes already executed by the Ganduje government towards providing adequate healthcare service delivery in the state, the Minister for Health, Osagie Ehanire said he believed Kano had efficient human resources to meet the universal healthcare coverage needs.

Inadequate PHCs, illiteracy fuel maternal mortality in Benue

In Benue State, experts have attributed high maternal mortality rates in the state largely to inadequate and ill-equipped Primary Health Care (PHC) facilities; illiteracy and poverty among others.

Dr Joseph Ngbea, who was recently sworn into office as the State's Commissioner for Health and Human Services, explains that majorly, the 'three delay model' remain the commonest factors which contribute to pregnant women dying at the point of delivery.

"The first delay is that at the level of the patient in terms of decision making, most women are either too illiterate to take correct health decisions or lack the financial backing to seek adequate healthcare. Most depend on their husbands to decide for them, who also may not have enough funds to provide adequate healthcare for them. They end up in the hands of quacks or traditionalist who lack the knowledge and skill to treat them.

"The second delay is that associated with transportation and communication.

There are not enough functional PHCs and where there are, there are poor access roads and poor means of communication to aid prompt responses when there's an emergency. The third is the delay at the level of the health facility in terms of inadequate skilled manpower, lack of materials, power and so on," he said.

Ngbea added however that the causes of maternal mortality could be classified into direct, indirect and remote causes, stressing that the direct causes include hemorrhage, majorly postpartum haemorrhage, eclampsia, unsafe abortions and infections.

He maintained that while all of these, interwoven with the three levels of delays explain the high incidence of maternal mortality in Benue localities, the availability and accessibility of health services in the state continues to improve on regular basis.

"We are not where we ought to be but it's better than it used to be and also a work in progress. Under Ortom's administration, more PHCs have been built and equipped. The bond scheme has provided more manpower at the downstream levels of healthcare and with the State Health Insurance Scheme taking off, with proper implementation, healthcare should be accessible and affordable by majority of the Benue populace when it fully kicks off and is running," he said.

Also, Dr Josiah Ikwulono, a senior Medical Officer currently working at the General Hospital, Adikpo in Kwande Local Government area of the state listed poverty among issues that lead to high maternal mortality in Benue State.

"I have seen instances where I confirmed women to be pregnant and when counselled for ante natal, they will abruptly tell you that they have no money to attend ante natal clinic and they are right. So, they will continue to nurse the pregnancy at home. Some will come down with malaria in pregnancy or anemia in pregnancy and die via the complications.

"I heard of a woman who developed ante partum hemorrhage but there was no money to take her to hospital. That was how the woman bled to death at home. There are many instances like that," he said.

According to him, inadequate health personnel in the available facilities poses additional challenge, pointing out that in some General hospitals, only one medical doctor will be found there.

He noted however that the situation is now changing for good because of the 'bond doctors' available, adding however that when few health personnel are available, proper care of the pregnant women will not be taken which can lead to maternal mortality.

Insecurity, inadequate health facilities/personnel challenge in Kaduna

Several factors are said to be responsible for maternal mortality in Kaduna State and the challenges range from poor human resources to unavailability of drugs for pregnant women and insecurity, which hinders pregnant women from accessing antenatal care and delivery services.

The Co-Chairman of Kaduna Maternal Accountability Mechanism who doubles as co-chairman of Open Government Partnership, Kaduna State, Mustapha Jumare told Daily Trust Saturday that most health facilities have inadequate human resources which explains why patients leave their homes as early as 4 am to get to the hospital only to return home at night.

"This could discourage pregnant women from going to the hospital," he said, adding that because some of the traditional birth attendants have no adequate training, they sometimes do more harm than good while certain health facilities lack the basic emergency drugs that should be given to pregnant women during antenatal.

"Sometimes, the health facilities lack folic acid and folates for pregnant women while availability of malaria drugs is questionable in some of these health facilities in the rural areas. You will find that intravenous fluids are also lacking in some facilities," he said.

According to Jumare, "Sometimes, the women could come for antenatal three or four times but when it's time for the actual childbirth, they stay at home and sometimes there could be complications; there could be postpartum hemorrhage which could lead to death. Sometimes there could be eclampsia."

He said another challenge contributing to high maternal mortality was the attitude of health workers to pregnant women, stressing that there are several cases where health workers treat pregnant women badly and hence, discourage them from visiting health facilities.

He said the maternal death review in Kaduna State takes place quarterly and analysis of maternal deaths in the state by focusing on about 30 secondary healthcare facility which are referral centres neglecting the Primary Health Care centres which also offer anti-natal services.

He said until these issues are attended to, the issues surrounding maternal mortality would continue to fester.

Daily Trust Saturday gathered that from the Primary Healthcare facility in Galadimawa of Giwa Local Government Area in Kaduna State that as many as 90 pregnant women crowd the facility from surrounding villages for ante-natal every Wednesday being the market day. However, due to insecurity, health workers say the number has reduced by more than half.

"We will be lucky to see 30 women these days because they fear that bandits may ambush them on their way to Galadimawa because it is the only active PHC in the ward headquarters," said a health worker.

"Another challenge is that motorcyclists no longer go to the villages because the bandits usually attack and kill them and then steal their motorcycles; and so, the women lack a means of transportation," the health official added.

He said no matter the number of patients in the health centre, the facility has to be locked at 5 pm due to security challenges.

He however said that experienced midwives and traditional birth attendants in the villages have assisted in several deliveries.

"I can't say whether the mortality figure is high or not because sometimes, we don't get any mortality while other times, we get some deaths but all I can say is that without these birth attendants, the death rate would definitely be higher," he said.

Insurgency, poor nutrition raise maternal mortality rate in Borno

Data obtained from the Borno State government showed that 344 maternal deaths were recorded at health facilities in 2020 out of which 94 were deaths relating to pregnancies.

A senior heath official said poor nutrition among thousands of women displaced by insurgency as well as hypertensive disorders were part of the factors that led to increased maternal mortality in the state. Also, obstructed labour and other diseases have to some extent contributed in the death of women during child birth.

He said more awareness was being created about pregnancy-related problems as more health facilities and personnel were being improved in communities ravaged by the insurgents.

Bayelsa govt worries over maternal mortality rate

The Bayelsa State government has expressed concern over the rate of maternal mortality in the state.

Worried by the high rate of maternal mortality, the state government under former Governor Seriake Dickson had launched the "Safe Motherhood Scheme" to kick-start the payment of monthly stipends to pregnant women in the state as transport fare to nearby hospitals for antenatal.

The government said the launch was in line with its determination to reduce incidences of maternal and infant mortality in the state

Speaking in Yenagoa recently during the Bayelsa Reproductive Maternal Child and Adolescent Health (RMNCAH), Commissioner for Health, Dr Newton Igwele, expressed concern over the maternal mortality rate after receiving the scorecard for the third quarter of 2020 presented by the state team in collaboration with the United Nations International Children Emergency Fund (UNICEF).

He said the scorecard was an eye-opener that the state still had a lot to do in the area of healthcare delivery.

He said from the scorecard, it was noticed that all the poor healthcare indicators were tied to one thing--maternal care, adding that the state government would do all within its power to cater to the needs of the mothers to change the narrative.

"However, the situation is like joint demands. They are all tied to one thing - the maternal health. If we tackle the mothers, it will positively impact the other areas. Maternal care coverage is poor and we need to tackle it. We need to improve the number of mothers attending clinics and by so doing; we will improve our health care delivery," he said.

Daily Trust Saturday gathered that the reason for the rising maternal mortality rate was largely due to the riverine nature of the state which often makes it difficult for pregnant women to access health facilities, with most people in interior places travelling to Yenagoa, the state capital for antenatal services.

Hypertension, bleeding major causes of maternal death in Adamawa

Pregnancy induced hypertension, bleeding and poor access to health care are major causes of death in pregnant women in Adamawa State.

A gynaecologist at the Federal Medical Center (FMC) Yola, Dr. Bitrus Fidelis Chagwa said the last study conducted across the North East showed that hypertension is the major cause of death in pregnant women followed by bleeding.

According to him, the death rate is higher in rural areas due to poor access to health facilities and the fact that patients had to travel long distances.

He noted that lack of money to pay for medication could lead to death in state government hospitals where there was no revolving funds to be used as intervention measures to take care of poor patients.

"A situation where a pregnant woman is bleeding and she has B.P., she needed magnesium sulphate but if they don't have the money to buy it, then, such a woman could die," he said.

In Nasarawa, a source at the State's Primary Healthcare Development Agency (NAPHCDA) said there are no available statistics on maternal mortality rates in the state.

The source said that the causes or factors leading to high maternal mortality in Nigeria generally are categorized into two namely, medical and non medical factors.

"Non-medical factors are manpower shortage (skilled birth attendants); delay in seeking care; delay in reaching points of care; delay in referrals; cultural beliefs/ practices; poverty; lack of equipment/medications/blood; failure to recognize danger signs and inadequate power supply

"While the medical causes are; hemorrhage (blood loss during or after delivery); sepsis (infection); complications of abortion (miscarriage); pregnancy-induced hypertension; ruptured uterus and prolonged obstructed labour," he said.

On the availability and accessibility of health facilities for people especially at the grassroots in Nasarawa State, he said it has over 770 PHCs and 18 General Hospitals spread across the 13 LGAs, adding that every ward has at least one PHC center or is close to one, which he said are "pretty accessible."

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