Determinants of Maternal Mortality Reduction In Nigeria

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Author: Inegbenebor, Ute

Introduction Maternal mortality in Nigeria has reached an alarming rate. According to World health Organization estimates for Nigeria, 37,000 women died in the year 2000 from pregnancy related causes. 1

It was also estimated that 830 women die whenever 100,000 babies are given birth to. In a country where records are poor, these figures are probably lower estimates of the real values.

Maternal mortality has been related to delays in making decision to use a modern health facility, delays in transfers of women with complications to apropriate centers and delay in treatment even in good centers due to lack of supplies, inadequate availability of trained personnel and attitude of the health care providers. 2

Reductions of these delays call for intersectoral and inter-governmental collaboration.

At the Millenium conference in New York in the year 2000, all 191 United Nations member states including Nigeria, pledged to to reduce maternal mortality ratio by 3 quarters (3/4) by the year 2015, as part of their commitment towards the Millenium Development Goals. 3

At the Alma Ata declaration of 1978, all participants including Nigeria accepted the Primary Health Care as the first point of contact between individuals and health services. It was defined as " an essential health care for all , based on practical, scientifially sound and socially acceptable methods and technology made universally accessible to individuals and families in the community, through their participation and at a cost that the community can afford to maintain at every stage of their development in the spirit of self reliance and self determination." 4

The Primary Health Care was intended to be a permanent feature of all health services. It was also accepted that the quality of care should steadily improve and be appropriate to the resource and needs of the community. It was not intended to function in isolation but in collaboration with referal and specialist services. Without good primary health care, the referal srvices would be overwhelmed by problems , which could have been dealt with efficiently at the primary level.Many of these would be advanced cases with complications, which could have been prevented by early detection and prompt treatment at the Primary Health Center. The referal centers wre expected to cope with problems beyond the scope of the peripheral units.

Root Cause In Nigeria, the concept of Primary health care has not been addressed in line with modern thinking. It has remained a basic health care - the status it had before the Alma Ata declaration of 1978. There has been no improvement in style of delivery of services over the years. Inspite of growth in popoulation and improvement in human and material resources, the Primary Health Centers have been staffed essentially by midwives, community health extension workers and traditional birth attendants. Doctors, the custodian of early diagnosis and treatment, have been left out in the scheme of things. The policy that the medical officer of health for the local government should be the coordinator of the Primary health services has not been properly interpreted. Local goverment commisions have implemented this policy by employing one doctor to cover each local govrnment area. This doctor , called the Primary Health Care coordinator, is essentially an administrator, who visits the health centers about once in two weeks.

His visist are not intended to see patients but to address cases of alleged negligence and to apportion blame. Yet several doctors roam the streets in search of Jobs ! Up to March 2007, when the Federal Ministry of Health accepted in principle to place graduating midwives as interns in primary health centers, only one or two midwives were often employed for the 24 hour coverage of primary health centers. In most cases, they worked during the day and left the nights for the traditional birth attendants. 5 No matter how good a traditional birth attendant is, she is unlikely to predict an impending problem such as post delivery bleeding (Postpartum hemorrhage) and pregnancy induced convulsions (eclampsia). She is also unlikely to be able to stop a severe bleeding or convulsion when it starts. These and other causes of maternal mortality such as sepsis, anemia, obstructed labor need the presence of a skilled attendant, who must identify patients, who are predisposed to these problems and refer cases, which are beyond his scope to the appropriate referal center.

In Nigeria, 70% of the population live in rural and semi-urban areas and most of the facilities such as electricity, water, good roads, good schools and hospitals and most services are located in the urban areas. This has caused rural urban migration and allowed a lot of urban poor to be located in big cities, where they cannot afford the exhorbitant bills of the fee for service physicians. The government hospitals in the cites are overcrowded with the urban poor, who have no money to pay for services. This situation overstretches supplies and gives the impression that governments cannot fund hospitals. This has allowed all forms of challatans to take over health care delivery. These include religious leaders, who deliver women and manage severe illnesses in churches and licensed and unlicensed traditional healers, who often exceed their limits. Most government workers including health care providers, prefer to work in the cities because of the presence of social and infrasructural amenities.

This calls for a revision of the current situation, where most ministries and government departments are located in the state headquarters. Decentralisation of the ministries will allow each local government of the federation to have all ministries in their domain. This will not only bring facilities closer to the people but will cause rapid and sustainable development of all local government areas. All government workers including health care providers will then have equally educated peers and neighbours to socialize with and will not need to travel out of station in search of friends and families. This will also prompt state governments to develop all parts of the state equally as most government officials will then be resident in the local governments and not the headquarters. It might be argued that that communication amongst ministries and with the state house will be difficult. A close look at the bank activities will show that it is possible for decentralised ministries to communicate using internet services. The higher government officials who need to see the governors regularly wil be left in the headquarters.

Conclusion

Maternal mortality reduction will be achieved through a combined effort of all tiers of government. The federal government should shift emphasis to primary health care, which are generally closer and more accessible to majority of the people. The fedreal government should come out with a bill on the full complement of doctors, pharmacist,/pharmacy techician, laboratory scientist/ laboratoy techician, midwives and ward assistants for the primary health centers. Legislation is needed to prevent traditional birth attendants, religious leaders, nurses/midwives and private general medical practitioners from keeping a woman in labour for more than 24 hours before refering to hospitals with adequate facilities. Government should discourage award of certificates of proficiency to traditional birth attendants as this encourages them to accept and retain complicated cases.

Decentralisation of State ministries and parastatals will allow even and rapid development of all local government areas and encourage health care providers to live and render service in rural areas. State government should extend electricity to all rural areas as a matter of priority.

The local governments are custodians of primary health centers and should be able to provide a minimum of one health center per ward and four boreholes per ward with one located at the primary health center. The health centers should have a doctor and four midwvives to provide a 24 hour coverage. A central ambulance center with at least three ambulance cars should be available in each local government area for transfer of emergencies especially at night when public transport is not available.6 The ambulance centers can be reached with mobile telephone any time of the day or night. Other health care providers such as pharmacy techicians and laboratory techicians who can improve the services of the health centers should also be employed by the local governments. Fedreal and state governments should collaborate with the local governments to ensure success in funding this arrangement.

The key to the reduction of all forms of mortalities including maternal mortality, child mortality, HIV/AIDS induced mortality, road traffic acident dependent mortality lies in the proper funding, organization, staffing and efficient utilization of the primary zahealth care services, which are located close to majority of the people.

References 1. WHO. Maternal mortality in 2000: Estimates developed by WHO, UNICEF and UNFPA. Geneva: WHO, 2004: 25 2. Thaddeus, S. Maine, D. Too far to walk: Maternal mortality in context. Soc.sci.med. 1994: Apr. 38(8) 1091-1110 3. WHO. World Health Report 2003, Shaping the future. Geneva: WHO 4. Lucas,A.O. PUBLIC HEALTH: The Spirit of "Alma Ata" Declaration. In: Archives of Ibadan Medicine. 2000: Apr. 1(2 ) supp 1: 6-9 5. Inegbenebor, Ute. Conceptual model for the prevention of maternal mortality in Nigeria. Tropical Doctor. 2007: Apr.37(2) 104-106(3)