Maternal
mortality is defined as "the death of a woman while pregnant or within 42
days of termination of pregnancy, irrespective of the duration and site of the
pregnancy, from any cause related to or aggravated by the pregnancy or its
management but not from accidental or incidental causes"[1].
Of the approximately 328,000 females who died
from pregnancy related causes in 2008, 99% were from developing countries [2].
Haemorrhage, infections, pre-eclampsia/eclampsia,
obstructed labour and unsafe abortion constitute almost 80% of all these
maternal losses [2],
while the remainder of the mortalities occur indirectly when pregnant
women have existing co-morbidities like malaria, anaemia and HIV/AIDS during
pregnancy [2].
This paper will critically analyse the actions and outcomes
of the maternal mortality response in Lagos State [3] and compare with best practices and evidence based
interventions from other developing countries.
The state is situated in the South-western part of the country, bordered
by the Atlantic Ocean to the south, an international corridor to Benin Republic
on the west, Ogun state to the north and east [4] (See Appendix). The 2006 national population census puts the
population of Lagos at 9, 013,534 [5],
but this value has been widely disputed [6],as
the State Government claims that a more reliable figure is 17,553,924, with
women making up 8,437,901
[7]. 85% of the population live in metropolitan
Lagos, which makes up only 37% of the land mass [7]. This large
population may pose a big challenge in coping with the maternal health needs.
The maternal mortality rate of Lagos state was 400/100,000
live births, as estimated by UNFPA in 2009 [8]
, while the State Ministry of Health (SMOH), provides a higher estimate of
650/100,000 live births [9]. This disparity in baseline data in itself
poses a big challenge in benchmarking progress, even though both estimations
are lower compared to the national average of 840/100,000 live births [10]. This essay argues that efforts of the government
are not concerted, not encompassing and are not “need focused”.
To delve into this issue profoundly, the conceptual model
designed by McCarthy and Maine (1992) to classify determinants of maternal
mortality will be used. They grouped
these determinants as: distant factors such as socio-economic status including
the women’s status in the family and community (education, occupation, wealth,
social and legal autonomy); intermediate factors such as reproductive status
(age, parity, family planning), health care behaviour (belief in and use of
modern health practices), health status of the woman, access to health services
and unknown and unpredicted factors; and outcomes, for example pregnancy,
complications, death or disability have proved essential over the years in
analysing policies geared towards tackling the problem [11]. This framework has since been modified by
UNICEF as a basis to design more recent programme strategies [12].
As regards the women in Lagos, they have very high literacy
rates of 90% compared with a national average of 54%, most living in the urban
areas while 6% who have no formal education live in the rural areas [8,13]. This high figure means that Lagos women are
more inclined to making informed choices, but not in the rural areas, where
women may not be adequately educated. This
high literacy rate may however be the reason for the state having the lowest
fertility rate in Nigeria of 4 births/woman, with only 18% having been pregnant
twice within 2 years prior to a 2008 survey [13]. 28% of women
within the reproductive age group use modern family planning methods. Teenage pregnancy is also relatively low at
5.3% compared to the national average of 23% [13]. 38% of women
have comprehensive knowledge of prevention of HIV/AIDS [13], which is decision making on high
sex risk behaviours, that predisposes them to the disease, which may affect
pregnancy outcomes.
Pregnant women subsequently need to be able to access
services, but some factors may prevent them.
Maine and Thaddeus (1994) previously identified three phases of delay
for women who need to utilize maternal health services. Phase I is delay in deciding to seek care,
phase II is delay in identifying and getting to health facility and phase III
is delay in receiving satisfactory and suitable treatment [14].
SOGON reported in a 2004 health needs assessment that women who did not
access services because of delay in deciding to seek care was 41.6%, while
those who did not because of difficulty in transportation was 18.6% [15], though this may be attributed to
the riverine nature of most of Lagos.
Delay from receiving satisfactory and suitable treatment on reaching the
health facility was seen in 14% of cases [15],
which shows that there is still a gap service provision in existing facilities. In Lagos, 88% of women received ante-natal
services from skilled attendants in the five years prior to the NDHS, which is
a significant increase from the 43% that received professional care in 2004 [13].
This improvement may be attributed to the free ante-natal care
instituted by the government, even though spontaneous vaginal delivery and
operative delivery have service charges of N12,000
(£47.24) and N50,000 (£196.85) attached
to them, which I reckon is still relatively expensive, as 39.7% of Lagos women could not access care
because they lacked funds [13]. 83% of women, who accessed care, were
subsequently delivered by skilled providers [13]. The major cause
of maternal deaths amongst Lagos women over recent years has switched from
pre-eclampsia/eclampsia to haemorrhage probably because Magnesium sulphate
gained grounds in the Lagos urban health facilities [8,15].
This essay argues
that government response is not adequate, as it is not based on any defined policy
document focused on strategies to reducing maternal mortality, short of the
government providing free ante-natal services in public hospitals [8], and this in itself does not aid
strategic planning. The State tailored
her response to training skilled health workers, provision of proper equipment
and construction of referral centres in case of complications. Capacity building for health staff working in
the various obstetrics and gynaecology departments across the state were carried
out with a focus on emergency obstetric care [16]. Topics covered
epidemiologically significant causes of death in obstetrics and by May 2011, 1,103
medical personnel had been trained, including 319 doctors and 784 nurses [17].
For referral centres, six 110 bed capacity maternal and child centres
(MCC) were constructed to collectively provide an
additional 66% capacity to the available state maternal health specialist
facilities [16]. Training on
community engagement to bolster staff relationship with pregnant women and to
improve reaching out to women not accessing care in the rural community has not
been done, even though this cohort are the most deprived.
The 1992
McCarthy and Maine approach is proposed as baseline in this essay. They argue that interventions to tackle
maternal mortality must focus on achieving three intermediate outcomes, which are:
reducing chances that a woman gets pregnant; reducing the tendency of a
pregnant woman experiencing any serious pregnancy or delivery complication; and
improving outcomes for women with complications [11]. Furthermore, the 1994 mother-baby package
identified four crucial safe motherhood strategies as pillars which mould
program design - family planning; antenatal care; clean/safe delivery and
essential obstetric care, all resting on foundations of equity for women,
primary health care and basic maternity care [18]. Whilst these packages seem well grounded and all of their
components are crucial in improving maternal health, they do not consider
cross-cutting issues such as HIV/AIDS that may occur in pregnant women, poverty,
gender based violence and so on. More
recently, the
WHO in 2009
recommended
the Integrated Management of pregnancy and childbirth as the complete package
for dealing with maternal mortality.
This package has three core focuses: the health workers, health systems
and health promotions [19]. The framework details routine, additional and
specialised care for pregnant women at pregnancy, childbirth and postpartum;
outlines place of care, providers, interventions and commodities that should be
available for each type of care; home care, family, community and workplace
support for the woman during pregnancy and childbirth; care for the woman
before and between pregnancies, especially in adolescent period; and suggests
policies for pregnant women who do not want the child (safe abortion and
post-abortion care) [19]. I reckon that this is the way forward.
Some evidence based
interventions that may prove useful in Lagos would now be discussed. Focused ante-natal care, as evidenced in a
multinational study, recommends that four visits is satisfactory for low-risk
pregnancy and may reduce number of attendees [20]. This would
ensure that women who need attention the most receive it and reduce cost of
intervention, especially in a low resource setting like Lagos. Post-delivery care is crucial, yet often
neglected, even though a sizeable proportion of maternal deaths happen at this
stage [21]. The advent of the abortifacient, misoprostol
has however improved abortion outcomes in many developing countries [22], and needs to be scaled up to reach
rural health facilities of Lagos. “Task
shifting - a process of delegation, whereby tasks are moved where appropriate,
to less specialized health worker” [23] -
may also be useful in Lagos, as it has worked in districts in Senegal [24] to tackle the problem of dearth and
mal-distribution of Lagos medically trained skilled health care professionals [25], who prefer the luxury of urban life
to the simplicity of rural living. This
would reduce the dependence on the expensively trained medical doctors, and
allow wider coverage of services. For
interventions focused on maternal nutrition, vitamin A and iron supplementation
have been shown to reduce incidence of anaemia.
This is evidenced by results in Nepal where there was a 40 % reduction
of MMR with the intervention [26]. Iron supplementation is also important in
reducing maternal anaemia [27].
Less anaemia means lowered risk of death
from post-partum haemorrhage, which was previously acknowledged as a major cause
of maternal deaths. Preventing
haemorrhage rather than treating it may reduce the proportions of women dying
from the condition. Malaria also
predisposes a pregnant woman to anaemia, therefore prevention, with long
lasting insecticide treated nets and sulphadoxine-pyrimethamine twice during
pregnancy [28] - which is only
given free to Lagos women who deliver in public facilities - [8] should be scaled up to include
private hospitals, thereby expanding coverage, and reducing the impact of the
disease. As regards the cross-cutting
issue of HIV/AIDS, collaboration between existing HIV/AIDS and maternal
mortality rate (MMR) reduction strategies will be crucial in ensuring that
specialised care required by pregnant women living with HIV/AIDS is provided
for [29]. Furthermore, laws protecting women against
gender based violence also need to be instituted, as violence during pregnancy usual
perpetuated by male partners may lead to sepsis, suicide, homicide spontaneous
and induced abortions [30]. Government subsidy on normal and operational
delivery may also encourage service uptake.
Access may also be improved, especially in riverine areas, by
establishing functional transport networks to commute pregnant women to
facilities when needed.
In this “New Public Health”
era in which the field operates now, the Ottawa charter (1986) forms the action
framework on which the paradigm is structured, building healthy public health
policy, creating supporting environment, developing personal skills,
reorienting health services and strengthening community action are crucial in
health promotion [31,32], in
this case targeted at pregnant mothers. Based
on this, Lagos has made progress in reorienting health services and creating
enabling environment, but without developing personal skills and strengthening
community action through education, empowerment and engagement of the pregnant
mothers themselves; and developing sustainable health policy focused on
tackling maternal mortality and a framework on which to mark progress -
especially towards targets set locally and towards global targets as set in the
Millennium Development goals, which targets reducing maternal mortality ratio by
three-quarters between 1990 and 2015 [33]
-, the maternal mortality problem will not be solved. Nigeria, as a whole reduced maternal
mortality from 1,000 to 545 deaths/100,000 live births from 1990 to 2008, but
is presently unlikely to meet its target of 250 deaths/100,000 live births [34]. Lagos with all the resources available at her
disposal and as the centre for excellence in the country can make a valiant
effort towards meeting this audacious target.
Attention should not only be given to the women who are attending and
receiving maternal health services, but also to those women who are not
accessing care and the socio-cultural factors limiting their access. Cross-cutting issues including poverty, gender
inequality and HIV/AIDS stigma still need to be addressed. Reducing maternal mortality in Lagos would
require a plethora of highly interconnected measures managed by different ministries, departments, agencies
and development partners that would include periods long before the woman gets
pregnant, during and after the pregnancy; and would also involve community
engagement and unflinching government commitment.
In conclusion, based on the
above discussion, the response of Lagos state to maternal mortality is not
adequate for the problem at hand. No
policy for baseline, no dependable data, no dedicated monitoring of programs,
no analysis of impact and no dedicated attention to the root cause of the
problem. Indeed, no woman deserves to
die because she is carrying out her sociological role as a wife and her physiological
responsibility as a mother.
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