Cases of post natal mortality, despite advancement in medicine in this part of the world, is not on the decline. SADE OGUNTOLA reports that socio-economic and socio-cultural factors in Nigeria are major causes and the situation may not change too soon.
JUDAH Adekola lost his wife in 2007, three days after their son was born. It was the easiest birth out of the three his wife had had. According to Judah, his wife was deemed to have fully recovered by the doctor which prompted her being discharged from hospital the second day after giving birth.
However, at dinner after she arrived home, Judah recalled that Hannah (his wife) began to feel some pressure in her diaphragm and chest area. Within one hour, the pain had become so bad that she asked to be taken to hospital. But she lost consciousness on the way to the hospital and died later that evening reportedly due to severe internal bleeding.
Sadly, the case of Hannah Adekola is all too familiar in Nigeria, where, in spite of advances in medical care, maternal mortality arising from pregnancy or birth is still very common. Though, maternal mortality worldwide has decreased by nearly half in the last decade and a half, Nigeria still faces a heavy burden of being the world leader in the total number of maternal deaths per year.
According to the United Nations Population Fund (UNPFA), Nigeria is responsible for 10 per cent of the global burden of maternal mortality. It is estimated that 111 Nigerian women die during childbirth daily.
The cause of death varies from woman to woman. Some result from infection, some hypertension, some excessive blood loss, and some “psychosocial distress”. Psychosocial distress is a broad term that covers depression, stress and dissatisfaction with life.
The period following birth in Africa is often marked by cultural practices. Many communities throughout Africa observe practices that keep mothers and babies indoors for the first month after birth – a period of seclusion.
If mothers or babies become ill during the period of seclusion, seeking formal health care is often delayed. Yet, delay in seeking appropriate medicare may result in death or disability, as well as missed opportunities to promote healthy behaviours affecting women, newborns, and children.
According to medical experts, half of all postnatal maternal deaths occur during the first week after the baby is born, and the majority of these occur during the first 24 hours after childbirth.
“Quite a number of things that cause these deaths are related to events during pregnancy and childbirth. For instance, a woman that has hypertension in pregnancy, known medically as preeclampsia, stands a higher risk of death if this is not managed adequately,” said Professor Adetunji Adeniji, a consultant obstetric and gynaecologist, at Ladoke Akintola University of Technology Teaching Hospital Ogbomoso, Oyo State. Professor Adeniji explained further that severe bleeding after childbirth is a major killer of women in the first week after the baby is born but “many a times, patients come in and there is no blood to use. If the bleeding lingers, the woman may die.”
Apart from this, infection, according to Adeniji, causes another 10 per cent of maternal deaths, mostly during the postnatal period. “The conditions under which many women deliver are not optimal in many hospitals. Some (hospitals) do vaginal examination for women in labour using unsterilsed gloves, thus heightening the risk of infection,” he added.
Unfortunately, when signs of these complications are not picked or discovered early the patients, who should be promptly referred for specialist care, for example, at a teaching hospital, they end up with severe ill health that could end up in stroke; some may not even be able to get pregnant years after.
Despite increasing awareness among pregnant women in Nigeria concerning their health status, Professor Adeniji believes that money is another major constraint most Nigerian families face. As most women “are financially constrained,” he explained, “they resort to alternatives such as, birth attendants (TBA), a group trained to give some basic care in terms of childbirth. Unfortunately, some TBAs because of monetary or economic gains tend not to refer these women (to hospitals) until complications stare them in the face, by which time it may even be too late for an expert to intervene.”
Certainly, the frequency of deaths in women days after child birth varies from one community to another. In Northern Nigeria, where six to seven of every 10 women still deliver their babies at home and only come to the hospital if there is a problem, many deaths are recorded, says Dr Lamaran Dattigo, a consultant obstetric and gynaecologist, at Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Bauchi State.
Giving a new mother a hot bath and intake of pap that contains potash, a cultural practice that is common among the uneducated rural dwellers, Dr Dattigo said, had also accounted for some women developing heart failure which might result in death later.
While noting that “pregnancies that are too often, too close and too many, increase the chances of a woman dying from pregnancy-related problems,” Dattigo stated that “excessive bleeding after delivery, a major cause of death pregnant women and childbirth is common among women that have delivered many babies.
“Once a woman has five, six children, she has a higher risk of developing complications during childbirth and after, compared to another woman who has maybe one or two kids and who are properly spaced.
“In Northern Nigeria, we have a lot of women that have delivered more than five children. Some have had nine; some 10 and that really predispose them to a lot of complications that can lead to death after delivery.”
Dr Dattigo believes that all these are conditioned by the environment, educational background and orientation of the majority of the people in the northern region.
“But the main issue has to do with girl-child education because most of these things usually do not occur with educated women regardless of where she leaves, where she comes from, which language or religion she practices,” he said.
Dr Monday Famakin, Chairman, Family Planning Provider Network of Oyo State and Medical Officer of Health Department, Ibadan North Local Government Council is in sync with Dr Dattigo. He is of the opinion that family planning could actually alleviate the problem.
According to him, “from studies, it is shown that family planning alone could reduce the incidence of women dying from pregnancy and childbirth-related causes. Situations where women continue to give birth to too many children, too frequently and without spacing, fuel maternal mortality.”
Alhaji Abdullahi Kabiru, a sociologist and the Kaduna State team leader of Nigerian Urban Reproductive Health Initiative (NURHI), sees a linkage between maternal death and Nigeria’s low contraceptive prevalence rate. According to him, availability of skilled birth attendants and quality hospital facilities, most especially in Northern Nigeria, have also contributed to the rising cases of death. He noted that “only about 36 per cent of women have access to skilled birth attendants, which gives an indication of why we have a crisis of high maternal mortality.”
The way out…
What then is the way out? Alhaji Kabiru is of the opinion that working with traditional and religious leaders, being custodians of social norms in the society, husbands of pregnant women and others could go a long way to help solve the problem and reduce deaths.
“When men are involved right from the beginning, they can improve the understanding and support for their women, as well as ensure that they can support their women to access services, particularly services around birth spacing, that is able to reduce maternal mortality by 40 per cent.”
Dr Sesan Ani, an health insurance consultant, in an interview with Sunday Tribune said interventions like the NHIS-MDGs-MCH initiatives that ensure pregnant women and children below five years have increased access to health have proved that deaths due to pregnancy and childbirth are largely preventable.
“It is a programme that encourages pregnant women to come and register as soon as they are pregnant. It is virtually free and it takes care of their health-care needs, including caesarean delivery, to ensure safe delivery.
“If there is any need to see a specialist, all these would have been done so that it is not at the critical stage of delivery that something will be discovered.
“For instance, over 70,000 pregnant women in Oyo State took part in the programme; they had the opportunity of being treated free. Over 80 per cent of them could have had one issue or the other that may have led to a problem,” he said.
National President, Association of Community Birth Attendants, Mrs Comfort Adedeji, however, disagreed with the claim that maternal mortality is increasing, declaring that death from such cases has reduced greatly. According to her, in many states in Nigeria, training is now being carried out continuously for traditional birth attendants (TBAs) to know the danger signs in pregnancy to look out for, as well as refer such pregnancies promptly when needed.
“All TBAs are attached to private hospitals that have ambulances, so that these hospitals can support and come in to intervene quickly where necessary. Once we call to say a pregnant woman needs to be referred, they come with their ambulance to pick the woman up to prevent delay in the woman’s care,” she stated.
Post natal care
It is essential for mother and baby to be in good hands to prevent post partum mortality. In some parts of the world some community-based projects have proved to be effective especially in Nepal. In Mali, grand-mothers are employed to educate communities about making simple changes to protect the health of mother and child. The grand-mothers discuss better nutrition, preventing and treating infections breast feeding and keeping newborns warm and dry.
Avoidance of harmful practices such as high work load for pregnant women, bathing within six hours after birth, application of cocoa butter on baby’s umbilical cord and giving coffee to newborns have all led to lower post partum deaths.
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