Despite having one of the highest rates of maternal mortality in the world, many cases of women dying during childbirth in Nigeria are still unreported, a report has shown.

The report also shows some of the causes of such maternal deaths in six states across Nigeria.

Released on Monday, ‘Giving Birth In Nigeria’, a survey conducted in six states across Nigeria within the space of 18 months, provided some insights into maternal health outcomes in some Nigerian communities.

The survey focused on establishing a foundation to catalyse greater accountability for previously undocumented maternal deaths in Nigeria.

“Each maternal death should be counted, and action taken to review or set up systems to make sure no woman dies while giving birth, especially in the communities,” said Vivianne Ihekweazu, the director of the Nigerian Health Watch, the organisation that led advocacies and multi-stakeholder relations of the survey project.

She made a presentation during the unveiling of the survey held virtually.

“Pregnancy is not a disease. It should not lead to deaths. Every maternal death should be regarded as an abnormality,” she said.

Grim statistics

According to the latest UN global estimates, 303,000 women a year die in childbirth, or as a result of complications arising from pregnancy. This equates to about 830 women dying each day – roughly one every two minutes.

About two-thirds of all maternal deaths take place in sub-Saharan Africa. Nigeria and India alone account for one-third of global deaths.

According to the United Nations Economic Commission for Africa, one in seven global maternal deaths occur in Nigeria. That is more than 50,000 women dying per year in Nigeria. About 95 per cent of deaths during childbirth are preventable.

In 2001, UN member states agreed to the Millennium Development Goals (MDGs), which included a call for the number of maternal deaths to be cut by three-quarters by 2015. While the MDGs boosted efforts, the goal was not met in the countries with the highest death rates.

Despite the money and expertise invested over the years into overcoming Nigeria’s position as the second largest contributor to maternal mortality worldwide, the statistics still make for stark reading.

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Health experts say this is largely because only a third of Nigerian women deliver in a facility or are attended to by someone skilled.

Worst still, many deliveries and maternal deaths remain underreported and unexplained.

According to the 2018 Nigeria Demographic and Health Survey, 61 per cent of live births do not take place in a health facility.

Without a strong national maternal death surveillance and response system in place, the number and causes of maternal deaths taking place in facilities and communities are poorly understood.

The survey

In April last year, a consortium consisting of Africare, an international NGO focused exclusively on Africa, EpiAFRIC, an African health consultancy group, and the Nigeria Health Watch, an NGO with focus on strengthening the capacity of health sector organisations in Nigeria , began an 18-month project called ‘Giving Birth In Nigeria’.

During the programme, Africare led community mobilisation efforts, with Nigeria Health Watch leading on advocacy and multi-stakeholder relations, and EpiAFRIC leading on research, data analysis, and monitoring.

According to the coordinators, the report focused on shining a light on the high prevalence of maternal deaths in communities where there has been no previous systematic attempt to ensure that deaths that did not occur in a health facility were incorporated into any routine review or Maternal and Perinatal Death Review and Response (MPDSR).

“While the outcomes are adverse, every maternal death, wherever it occurs, must be counted and investigated, and lessons learnt to drive improvements in maternal health care,” an executive summary of the review stated.

The research was supported by funding from MSD, through MSD for Mothers, the company’s $500 million initiative to help create a world where no woman dies giving life. MSD for Mothers is an initiative of Merck & Co., Inc., Kenilworth, NJ, U.S.

The survey was carried out in six states representing each geopolitical zone in Nigeria: Bauchi, Bayelsa, Ebonyi, Kebbi, Lagos, and Niger states and the FCT between May 2019 and May 2020.

Findings

During the review period, 133 maternal deaths were documented in 18 communities in the six focus states.

Out of the 133 maternal deaths, only 17 occurred in a designated health facility, signalling the high density of unaccounted mothers dying during childbirth.

About 52 deaths took place at home, 28 deaths occurred in the home of a Traditional Birth Attendant (TBA), while 18 deaths occurred in a faith-based institution.

There are a number of reasons why these deaths occurred and they are deeply rooted in poverty, inequality, religious beliefs, poor knowledge and awareness, and sexism.

Generally, delays in seeking care, reaching care, and receiving care are some of the leading causes of untimely deaths.

In the report, the causes of the deaths were recorded on a state by state basis.

Postpartum haemorrhage, prolonged obstructive labour, convulsion, infection from fever and complications from abortions were the leading contributors.

Key state highlights

Bauchi State

From the maternal deaths that occurred during the one-year review period, the largest contributor was postpartum haemorrhage, contributing to 50 per cent of maternal deaths recorded in the review. Prolonged obstructed labour was responsible for 33 per cent.

Results from the review in Bauchi showed that 75 per cent of maternal deaths occurred at a health facility with 25 per cent of maternal deaths occurring at home.

“From our inquiry into the deaths, all deaths that were recorded at the facility were late referrals from the community,” the report stated.

Prevalent in Bauchi, according to the survey, is the disapproval by husbands for male doctors to attend to their wives.

“This has resulted in women being prevented from visiting health facilities to seek health care due to the predominance of male doctors over female doctors. This has resulted in adverse maternal health outcomes because complications arise when healthcare is administered in out-of-facility locations such as home, religious centre or by a TBA.”

Bayelsa State

Among the women surveyed during the baseline survey in Bayelsa, 23 per cent cited the ‘chemist’ (pharmacist) as their main source of seeking health care, while 17 per cent said traditional healers are their primary or first stop in seeking health care.

Forty one per cent said that finance greatly influenced their health-seeking behaviour, and that lack of finance posed a challenge in seeking healthcare at a health facility. Eleven per cent said that the poor proximity to quality care prevented them from seeking better healthcare.

In Bayelsa, postpartum haemorrhage was also responsible for the majority of maternal deaths as it was in Bauchi, contributing to 50 per cent of all maternal deaths recorded, while prolonged obstructed labour contributed to 33 per cent, and convulsions, 17 per cent.

Traditional birth attendants account for the majority of births and also, the majority of maternal deaths recorded in the review.

Ebonyi State

In Ebonyi, postpartum haemorrhage contributed to 36 per cent of recorded maternal deaths with prolonged obstructive labour contributing to 32 per cent. Convulsion contributed to 13 per cent, followed by infection from fever at four per cent, and complications from abortions at two per cent.

Many women in Ebonyi State do not attend health facilities without the permission of their husbands and this is a bottleneck that must be addressed if maternal deaths must end in Ebonyi State. This is a prevalent hindrance to attending health facilities for maternal healthcare, the report stated.

Kebbi State

In Kebbi State, the highest contributor to maternal deaths recorded in the review is infection with fever, contributing to 50 per cent. Prolonged obstructed labour contributed to 38 per cent. Postpartum haemorrhage contributed to 12 per cent.

As it was found in other parts of the northern region, prevalent in Kebbi State is the disapproval by husbands of male doctors to attend to their wives. This has resulted in women being prevented from visiting health facilities to seek care due to the predominance of male doctors over female doctors, the report stated.

Lagos

About 21 per cent of the women surveyed in Lagos said poverty was a major source of worry during pregnancy. For this reason, they resorted to faith-based homes and TBAs for care during pregnancy. Other reasons cited by the women in Lagos State are concerns about unplanned pregnancies, anxiety about safe delivery, and the fear of dying while giving birth.

Two major causes, postpartum haemorrhage and prolonged obstructed labour, contributed to 26 per cent of all maternal deaths. Convulsion was the second-highest, contributing to 23 per cent. Complications arising from abortion procedures contributed to six per cent while ruptured ectopic pregnancy contributed to five per cent. Infection from fever contributed to two per cent.

Niger State

For Niger State, prolonged obstructed labour contributed to 67 per cent of all maternal deaths recorded in the community review, with postpartum haemorrhage contributing to 33 per cent.

A common complaint from the local women about attending health facilities is the poor attitude of health workers.

Recommendations

Generally, the survey arrived at a conclusion that accurate maternal mortality figures require strong in-country data collection, which are largely unavailable in Nigeria, meaning that the number of deaths will be underreported.

The report recommended that health programming on maternal mortality must be focused at the community level.

“State governments must commit to building existing socio-cultural structures to accelerate accountability for maternal deaths at the community level, through community leadership, and to advocate for the adoption of safe practices in maternal health care.

“At the community level, state governments must facilitate the establishment of maternal death reporting structures that incorporate the involvement of traditional and religious leaders as they are the first point of contact by the families of the women when these deaths occur. A simple notification system at a ward office when a woman dies a maternal death should be created”, it recommended.

“Systemic and socioeconomic issues such as the influence of family, access to health facilities and religion on maternal health seeking decisions must be tackled alongside the strategic establishment, storage and distribution of medicines and blood banks.

“Traditional birth attendants are trusted by local community women. They must be better equipped and trained in identifying danger signs and referring women to health facilities at the first sight of any danger sign. State governments must ensure that the activities of unskilled birth attendants are institutionalized and regulated.

“At the national level, the federal government must, not just create guideline documents, but facilitate, implement and support the creation and sustained operation of PHCs in each LGA in Nigeria.”



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