Recent United Nations data shows that Nigeria has the second highest maternal mortality rate in the world. The country’s 59,000 maternal deaths annually rank second to India’s 117,000. Locally, available statistics also show that the North West zone of the country has the second highest rate in Nigeria after the North-East. Understandably, Kano State accounts for much of this prevalence in the zone. Interestingly, the state represents a model on how to reduce maternal deaths which not only other states, but the federation should emulate. Roland Ogbonnaya writes with additional report by Taiwo Olawale
Hajiya Hassana Rabiu is a mother of five children; the youngest being three months old. The family leaves in one of the rural areas in Rano Local Government area of Kano State. Until her last baby, she was delivered of the first four children by a local birth attendant in the community. She told THISDAY that not many of the women that used the services of the local birth attendant at the time survived.
Hassana was able to deliver her four babies with the help of local birth attendant and alive to tell her story because of “providence.” She said that she never bothered to go to a hospital, which any way was not close to their community, because they could afford the cost of antenatal and delivery in any public or private hospital.
Fortunately, she had to attend the antenatal and delivery of her last baby at the Murtala Mohammed Specialist Hospital, Kano because it was free. Sounding very excited, she told THISDAY that during the antenatal and delivery of her baby, her husband did not spend a kobo as fees. No wonder the hospital and other similar ones in the state are besieged daily, stretching their facilities even as several lives that would have been wasted are saved.
Ironically, while the Kano State Government recognized that offering pregnant women free medical services will reduce the rate of maternal death in the state and Nigeria as whole, scores of other women continue to die in other states of the country because of their inability to access medical services because they can not pay for it as a result of poverty and ignorance.
Recent United Nations figures show that Nigeria has the second highest maternal mortality rate in the world. The country’s 59,000 maternal deaths rank second to India’s 117,000. Available statistics show that the North West zone of the country has the second highest rate in Nigeria. Understandably, Kano State accounts for much of this prevalence in the North West. What are the reasons for this prevalence and what is being done to stem the tide?
The maternal mortality rate (MMR) in Nigeria surely calls for urgent action. Though recent United Nations figures place Nigeria second to India on the MMR table; a closer look at the statistics shows that Nigeria has the worst figures in the world. In the first place, if the figures are placed in the context of the general population, Nigeria is definitely worse off. Nigeria’s population of 140 million people is only about 10 per cent of India’s nearly one billion people. So, 117,000 deaths out of one billion are surely lower than 59,000 out of 140 million.
Secondly, India actually improved between 2000 and 2005. In 2000, India’s maternal deaths were 136,000. It was this figure that dropped to 117,000 in 2005. On the other hand, Nigeria’s 37,000 deaths in 2000 rose to 59,000 in 2005! So, placed within the right context, Nigeria’s MMR is perhaps the most dangerously high in the world.
Providing an overview of the epidemic in Northern Nigeria at a round table organized for women politicians by the Development Research and Project Center (DPRC) in Kano last year, Dr. Hadiza Galadanchi, consultant gynaecologist, AKTH, told an overwhelmed audience that the North West has the second highest ratio in Nigeria. According to her, the zone has an average death rate of 1025 per 100,000 live births. She noted that the “estimates of maternal deaths are under reported by as much as 50 per cent because most maternal deaths are more often than not counted at all.”
And, Kano accounts for a significant part of the dire figures from the North West. It has the highest MMR of about 1,700/100,000 births according to latest statistics (SEEDS, NDHS 2003). In fact, some statistics claim Kano has an average ratio which is as high as 2420/100,000 live births, according to European Journal of O&G and Reproductive Biology, 2003.
With such a high ratio, it is obvious that the government and people of Kano have a big problem on their hands. Scholars and stakeholders in the state give several reasons for the high MMR in the state. The causes are divided broadly into direct and indirect causes. At the same time, they can be seen in the context of medical and health management, socio-economic and cultural factors.
According Galandachi, the direct medical causes of MM are haemorrhage (23 per cent), infection (17 per cent), malaria (11 per cent), anemia (11 per cent), obstructed labor (11 per cent), toxemia/eclampsia (11 per cent) and unsafe abortion (11 per cent). She said only five per cent of deaths are caused by other factors. She further categorized the factors into delays which she said are, most often than not, responsible for these complications, giving three levels of delays which aide the MMR.
She said the first delay “accounts for 30 to 40 per cent of MM” and identified aspects of the first delay as lack of information and inadequate knowledge about signs of complications of pregnancy and danger signals during labor; cultural practices that restrict women from seeking health care; accessibility and quality of care.
The second delay include inability to access health facilities; poor sitting of health facilities; poor roads and communication network; terrain and poor community support while the third delay involves delay between arriving and receiving care at the health facility; inadequate skilled personnel; inadequate equipment and supplies; lack of blood as well as poor motivation of staff. For these and a few more reasons which include poverty, women die in Kano and elsewhere in the country in their thousands every year. The situation was very challenging until the government intervened through free medical services.
However, the President of Market Men/Women Association Nigeria, Abuja branch, Chief Fatima Sani said the cause of maternal deaths has come to a climax and the truth is there for everybody to see. She said that Nigeria has pretended a lot on the issue as those who supposed to speak out against the problem which little girls of nine and ten years marry and get pregnant.
“We pretend that we don’t know the cause of death when a little girl dies from pregnancy. Some times we say it’s a tribal or religious thing. I have never seen any portion of the Bible or Qur’an that says a child of nine years should marry and have a child. That is why many are dying either by VVF or maternal mortality. Federal Government alone cannot do everything and the local governments have refused to take their responsibilities,” Sani emphasized.
For Dr. Tunde Adegboyega, a consultant with the World Health Organization (WHO), Nigeria like most developing countries is experiencing very bad statistics on maternal and child deaths. He said the simple reason is that “we have not placed the issue of women and children at the center of our heart. There is no attention given to them despite the fact that they are assets to us. Without their good health, we don’t have a future. The issues of mother and child are linked and we are failing to scale up high impact contribution that can save lives of mothers and children.”
According to the Kano State Commissioner for Health, Hajia Aisha Isyaku Kiru, government is tackling the problem with as much seriousness as the matter deserves. “Since this government came to power, it has focused its attention on the problem and with dedication and commitment; the statistics are gradually being reversed. We are lucky to have a governor who believes health is wealth, so, whatever has to do with health receives priority attention and the issue of MM has not been different,” she said.
The Commissioner further explained that government is taking several actions simultaneously to solve the problem in as little time as possible. She noted that because of the government’s multi-dimensional approach, the rate at which women die in the state is being reduced gradually and consistently. Perhaps the most fundamental of all the actions taken by the government is the provision of free, comprehensive antenatal care (ANC) at all government health facilities in the state.
Kiru explained that the free medical care includes minor and major surgical procedures. She explained that this program has greatly reduced the number of women who die from a whole range of complications arising from the lack of access to medicare due to poverty or lack of money. She noted that the budget for free ANC was increased in the 2008 budget to take better care of more women.
Interestingly, the Kano State free ANC which is no a model for some states, is not affecting the quality of service at government hospitals. Realizing that the state of the health facilities was one of the reasons for poor hospital attendance by women, the state government also undertook the renovation, repair and in some cases, reconstruction of maternity wards in all its health centers.
The commissioner said “an example is the major one at the Murtala Mohammed Specialist Hospital where a brand new, well equipped maternity ward has been built. It is also properly staffed to take care of all the women that attend clinic or are referred from other centers in the state. In all, about 48 hospitals and health centers have been renovated, repaired or reconstructed recently.”
She further noted that the training of Traditional Birth Attendants (TBAs) by government is expected to compliment the contributions of other health workers. “It is not possible to have enough midwives within a very short period. But we have always had TBAs in many communities in the state. Training them would not only assist to make them better intervention instruments, it would also enable them identify their limitations so that they know when to refer patients to the next level. This way, they don’t end up further complicating the problems of women they claim to be helping.”
One of the major causes of maternal mortality is malaria and it is believed that pregnant women are more vulnerable than other categories of women. Realizing this, the state government embarked on a number of programs aimed at treating, controlling and eradicating malaria in the state. Distribution of Insecticide Treated Nets (ITNs) to pregnant women free of charge is one of such programs. She said the provision of ITNs is often tied to campaign immunizations so that the government achieves two major successes at the same time. “A lot of women come out for campaign immunizations because of sustained drives. So the ITNs get to more people during immunizations. We are able to save mothers and children at the same time.”
The former Kano State Commissioner for Health, Dr. Al Mansur who was the in charge of the health ministry when the state introduced the free medical package told THISDAY in Abuja recently that when he assumed office, he quickly came to conclusion that those who seek medical attention are women and children, “while 80 per cent of deaths are constituted by these groups. For any responsible government, it’s imperative that funds are channeled for their course.” He confirmed that there has been improvement in the provision of health facilities to women and children in Kano State though a lot need to be done.
After the seemingly success story of Kano State in reducing maternal and child mortality, other states have come to emulate the concept. States like Nasarawa, Borno, Enugu, Rivers and Ebonyi have introduced various degrees of free medical facilities for pregnant women as well as for children. Experts last week told THISDAY that the Federal Government should also introduce such free facility for these sections of its citizenry if it’s genuine in reducing its bad record in maternal and child mortality.
For example, Dr. Ejike Orji, the Country Director of Ipas, an international organization that partnered Kano State government in reducing maternal death believes that provision of free medical services to pregnant women should go beyond state government level. He said the Federal Government has the capacity to care for this section of Nigerians. Ipas has done extensive work and partnership with governments and community based organizations to reduce the rate at which women—mothers are dying everyday.
Dr. Ogugua Osi-Ogbu, consultant at the National Hospital, Abuja admitted that maternal mortality is a scourge and believes that it should be a priority of Federal Government to do something about it. She said of course there should be right personnel and facilities in order to make meaning out of it. She is speaking from the background of argument that apart from lack of equipment and accessibility to health facilities, that there are not enough trained personnel to implement the free medical services package for pregnant women.
The president of Market Men/Women Association of Nigeria, Abuja said this could be achieved by reemploying retired nurses and midwives as well as training the traditional birth attendants. Apart from this, Osi-Ogbu added that there should be an increase in awareness and education in other to increase the knowledge of the people while government equips the hospitals and health centers.
Because awareness is a very important ingredient in the fight against maternal mortality, the Kano State Commissioner for Health said her state government has been carrying out campaigns explaining that the state government established a committee called the safe motherhood committee to take care of full and all year round sensitization of the populace. The committee is mandated to collaborate with community based organizations (CBOs) and other non-governmental organizations (NGOs) to reach out to women in all parts of the state.
“For example, the committee has been able to convince the National Union of Road Transport Workers to assist pregnant women by taking only a token or even carrying the women free when they are in labour. This is expected to remove life-threatening delays when a woman is in labour.”
With this elaborate approach to the problem, the Commissioner expressed optimism that the next United Nations report on MM would show a significant reduction in Kano’s MMR. This optimism is shared by most of the other stakeholders in the state’s reproductive health sector. Hajia Aisha Umar, Coordinator of ASHOTPAD, one of the NGOs involved in MM campaigns in the state commended the state government’s commitment to a sustained reduction of MMR within the shortest possible period.
She said, “the state government has shown an unequaled commitment to the reduction of maternal mortality in the state. The main reason for the successes recorded so far is the fact that the approach has been multi-dimensional and all stakeholders have been involved at all levels. The government has been serious and the results are increased ANC attendance, better life expectancy and lower MMR.”
The Ipas boss said “we also have a multi-sectoral approach to the problem. But our activities are tailored to compliment the activities of the state government. So, we help renovate and equip health centers as well as train and re-train health service providers. Then, we focus on immunization, child spacing, post abortion care, delivery, information and capacity building for community coalitions (CCs) to enable them focus on reproductive health issues and find solutions to them.”
Kano’s MMR is no doubt a serious issue. But the actions being taken are, from all intent and purpose, also very serious. If the actions are sustained and the partnerships formed are maintained, the state may be able to cut its MMR by as much as half by the middle of next year. If this can be achieved by a single state, one could imagine what would happen when other states in the federation as well as the Federal Government join in fighting the scourge.
For now, many say information is no doubt an important part of the fight and the partnership with NGOs and CBOs is the way to go. It is a battle which involves all stakeholders. For, if mothers must be saved, all hands must be on deck.
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