Review Article
Reducing Maternal Mortality in Nigeria: Why Progress is Stalled and the Way Forward
Kuti O1,2; Ayodeji OF4; Awowole IO1,2; Adesina OA3; Raji HO5; Makinde ON1,2; Adeyemi AB1,2; Esan OT6. Kuti OA7.
Obafemi Awolowo University Ile-Ife, Nigeria.
Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria.
University of Ibadan, Ibadan, Nigeria
University of Medical Sciences, Ondo, Nigeria.
University of Ilorin, Ilorin, Nigeria.
Obafemi Awolowo University, Ile-Ife, Nigeria.
Corresponding Author:
Oluwafemi Kuti,
Department of Obstetrics, Gynaecology and Perinatology,
Obafemi Awolowo University Ile-Ife, Nigeria.
okuti_victory@yahoo.com; okuti@oauife.edu.ng.
GSM: 08038132121.
ABSTRACT
Nigeria alone contributed 23% of the global burden of maternal mortality in 2015. The statistics remain bothersome despite the fact that the country has always been part of the global efforts to address the high maternal mortality ratio in developing countries for decades. Home-grown initiatives, some of which had received international financial support and accolades, have been added to the mix. Ironically, at the end of the Millennium Development Goal era, Nigeria was classified as having made “No progress” in reducing maternal mortality by the United Nations. The need to design a pragmatic, context-specific, achievable, accessible and sustainable national strategy, is therefore imperative. Professionalization of midwifery care is an evidence-based strategy for reducing direct maternal deaths when there is concomitant accessibility to such care. We therefore propose a NATIONAL SAFE DELIVERY PROGRAMME (NSDP), to be implemented in phases, as a pivot, using an institution-based template to distribute such care. To ensure sustainability, we recommend a “bottom-up” approach to engender political will and propose the establishment of a MOTHERS TRUST FUND, dedicated to funding obstetric care nationally, which will be backed by legislation from the National Assembly. Finally, constant vigilance by relevant community stakeholders through unrelenting advocacy for women health issues, will ensure that the political leadership remains focussed on maternal mortality reduction.
Keywords: Maternal Mortality, MDG, SDG, Mothers Trust Fund
INTRODUCTION
The death of a woman during pregnancy, childbirth and after delivery is a tragedy of immeasurable proportions. The World Health Organisation defines maternal death as the death of a woman while pregnant or within 42 days of termination of pregnancy from any cause or its management but not from accidental or incidental causes.1 Nigeria is currently the global capital of maternal deaths, contributing 23% of the global burden of maternal mortality, (67,000 out of 300,000) in 2015 2; India which is 7 times the population of Nigeria came a distant second with a total maternal death of 35,000 2 in the same year.
Like most sub-Saharan countries, direct obstetric complications, which include obstetric haemorrhage, sepsis, hypertensive diseases in pregnancy, obstructed labour, abortion, and ectopic pregnancy, are responsible for more than 90% of the maternal deaths in Nigeria 3-5. Despite the availability of safe and effective interventions for these complications, the case fatality rates remain high due to late presentation and poor health infrastructure 4. Majority of women present to the referral hospitals in a moribund state, which will be daunting to the available infrastructure, with many of them dying within 12 hours of admission 3,4.
Besides its serious impact on the survival of the existing children and the newborns, the deaths of these mothers have a considerable adverse social, economic, and psychological impact on the immediate and extended families and the attending medical staff 6-8. For the medical staff, who witness the scenario daily, the deaths have gone beyond statistics, rather, it is a constant source of psychological distress 8.
The stories surrounding these deaths are usually tragic, with the patients having been mismanaged and even medically abused in the referring centres 9. It becomes even more painful to know that more than 90% of these deaths are preventable, had the women presented earlier 3,4.
Over the years, successive governments in Nigeria, Non-Governmental organisations and International Donor Agencies have launched various programmes to reduce the maternal mortality ratio in the country. Nigeria has always been part of the global effort for addressing the high maternal mortality ratio in developing countries, from the launching of the Safe Motherhood Initiative in 1987 through the Millennium Development Goal agenda, to the current Global Vision of Ending Preventable Maternal Deaths. In 2017, the then Minister of Health inaugurated a 34-member task force for the accelerated reduction of maternal mortality in Nigeria 10. More recently in February 2019, the Executive Director of the Primary Health Care Board declared a state of emergency on the menace of maternal deaths in Nigeria 11. Unfortunately, all these programmes and promises have not translated into positive results.
The United Nations Sustainable Development Goal 3.1 requires every country to reduce the maternal mortality ratio to less than 140 per 100,000 live births by the year 2030 12. With a current maternal mortality ratio of 917 per 100,000 live births [2], Nigeria should aim for an Average Annual Rate of Reduction (ARR) of 17% to be able to achieve the SDG goal. In the MDG era, we had an ARR of 2.0%, far below the expected rate of 5.5% required to achieve the MDG. If Nigeria is to achieve the SDG, we need a critical appraisal of the strategies we had employed in the past to determine where we had gone wrong, with their implementation. This is towards developing a context-specific, accessible, acceptable and sustainable strategy with the potential for favourable implementation outcomes, not only to enable us to achieve the SDG but also to achieve the Global vision of Ending Preventable Maternal Deaths.
Previous Safe Motherhood Programmes in Nigeria and Why They Stalled
Nigeria was part of the safe-motherhood initiative when it was launched in Nairobi, Kenya in 1987. It was hoped that this initiative would lead to a substantial reduction in maternal death ratios in developing countries. Unfortunately, apart from creating global awareness of the high maternal mortality rates in developing countries, the goal of the initiative was not achieved in most developing countries 13.
To reduce the burden of maternal deaths in Nigeria, the Federal and State Governments, National and International Donor Agencies and Professional Organisations had launched several programmes. Many of these programmes however were generic, patchy and unsustainable. Programs such as Maternal Newborn Child Health, Life-Saving Skills, Task Shifting and Task Sharing are generic as they were not stand-alone strategies solely aimed at reducing maternal deaths 14-16.
Other programmes such as the Conditional Cash Transfer, (implemented in 12 of 36 states in Nigeria), and the Midwives Service Scheme, implemented in 10% of the Local Governments in Nigeria, though targeted at maternal mortality reduction, were patchy, poorly planned and badly implemented 17-19. Besides, many of the laudable programmes executed by state governments, such as the "Abiye" Program in Ondo State 20, were not sustainable and ended with the regime of the government that started them.
The recently launched Maternal Perinatal Death Surveillance and Response Programme was aimed at reviewing all maternal and perinatal deaths both at institutional and community levels to identify avoidable deaths and to make recommendations to prevent future occurrences 21. Implementation of the programme, however, has been sparse across the country and even where it has been practised, recommendations from the review meetings have not been affected 22.
Progress In Maternal Mortality Reduction Since 1990
The consequence of all the above-mentioned poorly implemented programmes in Nigeria is a failure of a significant reduction in the maternal mortality ratio in the last 30 years! In 2015, a report by the WHO, the United Nations Population Fund (UNFPA) and the World Bank showed that Nigeria had not made any progress at the end of the MDG period 23. During this period, MMR in Nigeria dropped from 1,350 maternal deaths per 100,000 live births in 1990 to 814 maternal deaths per 100,000 live births in 2015, a reduction of 39.7% as against the MDG target of 75% reduction. The annual Average Rate of Reduction (ARR) of 2.0% 22 was also far below the expected rate of reduction of 5.5%. Of greater concern is the declining annual rate of reduction of maternal mortality ratio in Nigeria.
Table 1. Comparative Trends in MRR – Nigeria, India and Rwanda 1990 – 2017
A recent assessment of progress between 2000 and 2017 2 revealed a further decline of the ARR to 1.6, compared to the progress observed in low and middle-income countries such as India and Rwanda that have made consistent progress in their ARR from 1990 (Table 1).
For Nigeria to achieve the SDG 3.1 of a maternal mortality ratio of 140 per 100,000 live births and to join the Global Vision of Ending Preventable Maternal Deaths, we should aim for an average annual reduction of maternal mortality ratio of 17%. We certainly cannot achieve this if we continue to do business as usual. We, therefore, need to design and properly implement a more pragmatic, context-specific, achievable, accessible and sustainable national strategy that is focused directly on addressing the complications that cause maternal deaths.
The Way Forward
Most stakeholders have attributed the absence of the impact of the Safe Motherhood Initiative on maternal death reduction to the use of wrong strategies 12,13,24. Previous strategies focusing on the education of mothers, training of Traditional Birth Attendants, and Risk Assessment in the Antenatal Clinics, have been shown to have very little impact, if any, on reducing maternal mortality 12,24. The current evidence-based strategy for reducing direct maternal deaths is the professionalisation of midwifery care and ensuing accessibility to such care 24-26. Experience from developed countries that achieved low maternal mortality ratios, within a relatively short period, has confirmed the pivotal role of professionalisation of midwifery care. Sweden was the first to professionalise obstetric care in the late 18th century and by 1900, midwives attended 78% of births and their maternal MMR was 228 per 100,000 live births 24. In Nigeria, only 39% of births are currently attended by skilled birth attendants 27, a rate below that of Sweden of 40% in 186124. Following the example of Sweden, the Netherlands, Denmark, and Norway all achieved a maternal mortality ratio below 300 per 100,000 live births in the early 20th century. However, in 1900 the MMR in England was 500 per 100,000 live births and in 1918, that of the United States of America was 885 per 100,000 live births.
In both countries, during these periods, deliveries were still conducted mainly by TBAs 24. Following the visit of a special mission of the United Kingdom to Sweden, Denmark and the Netherlands in 1932, for advice on obstetric care, England and Wales started the professionalisation of midwifery care in the early 1930s and within 20 years their MMR dropped from 500 per 100,000 live births to 85/100,000 24. It is also worthy of note that the few African countries that made significant progress in reducing MMR have all employed strategies that professionalised midwifery care and removed barriers to accessing care 12,28. The WHO Making Pregnancy Safe Initiative supported a national strategy of skilled birth attendants during pregnancy, delivery and the immediate postpartum period as a veritable solution to reducing maternal mortality 29.
In line with global thinking, therefore, the way forward in reducing the high burden of maternal deaths in Nigeria is to develop a national strategy that will address the direct obstetric complications which are still the major causes of maternal deaths in Nigeria 12,29,30. For the strategy to be impactful, it should be institutional based and composed of a package of interventions for early diagnosis and treatment of the five major direct obstetric complications – postpartum haemorrhage, hypertensive diseases in pregnancy, obstructed labour, sepsis, and unsafe abortion. Interventions to treat these complications have been known for years and are widely available even in developing countries like Nigeria. The challenges that we need to overcome include training more health professionals for diagnosing and managing these complications and removing the economic, geographical and social barriers to accessing care by mothers.
To reduce the cost of implementing the strategy and improve geographical accessibility, basic health centres should be used as the means of distribution. This will not require a new structural outlay, except to upgrade existing health facilities and employ more midwives. Currently, many of these health centres are either non-functional or underutilised 31. Sustainability will require strong advocacy by all stakeholders, including professional bodies and women's organisations to engender political commitment 12. This was the experience in England leading to the formation of the "Mother's Charter" of 1902 and the Royal College of Obstetricians and Gynaecologists in 1929[24].
We, therefore, propose a National Safe Delivery Programme as a strategy to reduce the current maternal deaths in Nigeria rapidly, (Appendix I). Implementation of this project should be in phases as detailed in Appendix II. The engine for the successful implementation of the programme is political will, which is required for financial support and implementation at scale.
Strategies to Ensure Sustainability of The National Safe Delivery Program.
Previous laudable programmes such as the Abiye programme in Ondo State and the Midwives Service Scheme got stalled because they were not sustainable due to lack of funding. The political will that birthed these programmes was through a top-to-bottom approach, in which the visioner was the political leader himself hence the will died at the end of his tenure. Besides, in most previous programmes, there was no dedicated account backed by the Act of Parliament to fund the programme.
We, therefore, propose two strategies to engender continuous political will and sustainable funding of the NSDP:
The fund should be disbursed and managed at all tiers of government to ensure that implementation of the programme runs concurrently at all levels of health care from primary to tertiary.
CONCLUSION
Reduction of Maternal Mortality in Nigeria has been stalled because of the use of inappropriate, patchy, and poorly implemented strategies. To achieve SDG 3.1 and join the global vision of Ending Preventable Maternal Deaths we need to professionalize midwifery care, ensure accessibility and employ a National Strategy at scale to address the direct obstetric complications. A bottom-up
approach to ensure continued political will and the establishment of a Mothers Trust Fund will guarantee sustainable funding.
REFERENCES
Appendix I
National Safe Delivery Program (NSDP)
A strategy proposed for rapid reduction of maternal deaths in Nigeria. This is a health centre based intrapartum care strategy. It consists of
(1) A package of interventions that directly addresses the common causes of maternal deaths
(2) Means of Distribution - will be the health centre which is already in the health system and is therefore sustainable without the need for new capital outlay.
(3) Standby ambulance or appropriate mode of transport for prompt referral to Comprehensive Health Centre & Hospitals for management of major complications.
(4) Free Obstetric Care Service with possible monetary incentive to the mothers to facilitate mobilization of patients and encourage patronage.
(5) Targets: all pregnant women.
Appendix II
IMPLEMENTATION OF NSDP
This will involve the following phases in this order:
Phase 1
Phase 2
Advocacy via radio & TV jingles and the social media and employment of community midwives to inform and educate the community on the services available and the benefits of patronising them.
Phase 3