Balarabe Danladi Zakariya, a resident of Gabari, Kano State thinks he is jinxed and the reason is not far-fetched. He was married twice and lost both his wives in childbirth. His first marriage had a sweet beginning until his wife, Lami, died of breast cancer months after giving birth to their first child.
Zakariya found love again and married Hannatu, but that marriage was also short-lived. Hannatu got pregnant and died due to complications from childbirth one short year after their marriage.
Zakariya recounts painfully the harrowing conditions around his second wife's death. "I rushed my wife to a nearby hospital when she went into labour few days to the due date. At the hospital, I was told to fetch her hospital bag and also pay for bed space. I went to get the bag, made the payment and quickly ran back to the waiting area. A few minutes, the doctor called me to his office to inform me of how they tried to save her but could not. He said she died due to incessant bleeding and high blood pressure. The nurse told me that they gave her a lot of injections, but the bleeding was too much and did not stop. bleeding," Zakariya said with tears rolling down his cheeks.
Somehow, Zakariya now a single father, cannot seem to stop blaming himself for his wife's death.
Described as death that occurs during pregnancy or childbirth or within 42 days after giving birth: maternal mortality, is still disproportionately high in Nigeria. Sadly, Hannatu's death is a statistic in the growing maternal death count in Nigeria with approximately 512 deaths per 100,000 live births recorded in 2018, according to the 2018 Nigeria Demographic and Health Survey.
Disaggregating maternal deaths
Nigeria, like many low and middle-income countries accounts for some of the highest burdens of maternal deaths. Nigeria accounts for about 20% of global maternal deaths. More women especially aged 15-19 die from pregnancy-related complications. The most common causes of maternal deaths in Nigeria are postpartum haemorrghage, sepsis (infections), and high blood pressure during pregnancy (pre-eclampsia and eclampsia). However, postpartum hemorrhage is the leading cause of maternal deaths accounting for about 25% of all maternal deaths in Nigeria.
Maternal deaths are preventable with the appropriate administration and widespread availability of a core group of medicines, magnesium sulfate, oxytocin and misoprostol, according to a 2012 UN report.
"And this is where the challenge lies for Nigeria", says Prof. Chimezie Anyakora, Chief Executive Officer, Bloom Public Health, a think tank bridging the gap in public health in Africa. Anyakora has been at the forefront of advocating for improved maternal health and medicines in Nigeria. He believes the enormity of maternal deaths caused by postpartum hemorrhage in Nigeria requires urgent prioritization of strengthened systems that ensure quality maternal medicines during pregnancy and childbirth.
Efforts to reduce maternal mortality by successive governments focused on the provision of physical infrastructure and health workers, with less priority given to the quality of maternal medicines. Additionally, the need to store some of these medicines at the right temperatures, has widened the gap for the proliferation of substandard medicines.
Zainab Abdullahi, a resident of Hausawa Sabon Titi in Kano, had a first-hand experience with substandard oxytocin. Oxytocin is a medication most commonly used in Nigeria for the prevention and treatment of postpartum hemorrhage. She barely survived childbirth after the administration of oxytocin injections which could not stop the excessive bleeding.
"My child died shortly after birth due to unknown reasons. Hours later, I was struggling for my life because I could not stop bleeding. The medical team tried their best. I was given oxytocin injections to stop the bleeding, but it didn't work. I was in great discomfort and was afraid for my life." she said.
Quality of Medicines and impact on maternal outcomes
The quality of oxytocin is a global issue. A 2015 survey looking at the quality of life-saving medicines by the United Nations showed that the quality of oxytocin in 10 countries including Nigeria had 64% sample failure. Furthermore, a nationwide study conducted in 2018 showed the prevalence of sub-standard quality oxytocin across the 6 geo-political zones in Nigeria. Approximately, 74.2% of oxytocin injection samples were seen to be substandard at facility levels.
"The harmful effect of sub-standard and fake drugs is now an undeniable challenge to the integrity of Nigeria's public health system. Whether it antimicrobial resistance or maternal mortality, the pharmaceutical ecosystem needs to be overhauled," says Prof. Busayo Olayinka, a pharmaceutical microbiologist at the Ahmadu Bello University, Zaria.
These are critical factors that must be considered, says Anyakora. He stressed that interventions in the sector must factor in the dynamics of the pharmaceutical supply chain for environmentally sensitive lifesaving maternal medicines.
While government's efforts which culminated in the local production of oxytocin injection are commendable, strengthening the whole cold chain system for the procurement, transportation, handling and storage of medicines is a major determinant of the quality of these medicines and it needs to be prioritized across states in Nigeria. In addition, health workers need to be trained on the correct safety protocols for storing and handling maternal medicines.
Rural communities in Nigeria with high maternal death rates due to PPH continue to struggle with storing life-saving maternal medicines like oxytocin at the recommended temperature (between 2 and 8°C). Until this is addressed, and access to quality maternal medicines in Nigeria is prioritised, the stories of Hannatu and Zainab will continue to persist.