How to ensure no woman dies giving birth in Nigeria

*Report recommends implementation of community MPDSR to reduce maternal deaths
*FMoH plans legislation on reporting childbirths, deaths to track, account for fatalities

FATIMA lived in Bauchi State. She was on her way to having her third child. She was scheduled to give birth at home with the help of her aunties. Time passed, the labour graduated into prolonged obstructed labour and there was no means to convey her to the nearest health facility. She was taken to the traditional birth attendant’s (TBA) home and was administered locally made herbs. Fatima died after 14 hours of intense labour, losing the child also.

Ebiladei was 29 years old and had a fulfilling life ahead of her. She went into labour, which went as normal as it could have. She was being taken to a health facility at the city centre in Yenagoa, Bayelsa State, when she gave birth in the vehicle. Minutes after, she started bleeding excessively and before she could reach the health facility, Ebiladei died.

Obiageri was from Ebonyi State. She was 22. She gave birth in the primary health care facility. She was discharged two days after.One week after she was discharged, Obiageri went into convulsions. Members of her immediate family administered local herbs made from onions and palm kernel oil to stop the convulsions but to no avail. An auxiliary nurse was called in to attend to her but Obiageri died.

Auda was from Kebbi State. From dawn, she started suffering from what seemed like symptoms of high fever and that continued until 2:00 pm when her husband decided to take her to the nearest health facility. Unfortunately, it was raining heavily. They were not able to leave the village and had to employ the service of the TBA. She became unconscious and could not be revived. She died by evening. Auda was 32.

Bolanle was a cashier at a supermarket in Lagos. She was 29 years old. Bolanle was taken to the faith-based centre as soon as she went into labour. She gave birth and shortly afterwards, started bleeding profusely. There was no effort made to move her to a health facility as the attendants resorted to praying for her. She died at the faith-based centre.

Majin was 41. This was her fourth pregnancy. All of her previous pregnancies had been successfully delivered at home with the help of her aunties. She went into a prolonged obstructed labour and died after pushing for hours. Her baby also died.

Fatima, Ebiladei, Obiageri, Auda, Bolanle and Majin represent 67,000 Nigerian women that die yearly from preventable childbirth-related complications.

Recent data indicate Nigeria has an average Maternal Mortality Ratio (MMR) of 512 deaths per 100,000 of the population.Maternal mortality, according to the World Health Organisation (WHO), is the death of a woman while pregnant or within 42 days following the delivery or termination of a pregnancy. The WHO notes that Nigeria alone accounts for nearly 20 per cent of global maternal deaths. Globally, maternal mortality remains a major public health concern, especially in poorly resourced and developing countries, including Nigeria. About 295, 000 women around the world reportedly died during pregnancy and childbirth in 2017, with sub-Saharan Africa accounting for 66 per cent of the total deaths.

Why are Nigerian women still dying during childbirth? A community-informed maternal death review titled, “Why Are Women Dying While Giving Birth in Nigeria?” has provided reasons and proffered solutions.

The 18-month long programme for maternal deaths in Nigeria was launched in January 2019, under the theme: Giving Birth in Nigeria. The programme was implemented to investigate why women are dying while giving birth in communities, to create a sense of urgency and use the data and insights from the review to catalyse accountability for the death of every woman in the country.

The project, implemented by Africare, Nigeria Health Watch and EpiAFRIC, was launched at a virtual meeting on Monday, November 30, 2020.
Funding from MSD, through MSD for Mothers, the company’s $500 million initiative to help create a world where no woman dies giving life, supported this report. MSD for Mothers is an initiative of Merck & Co., Inc., Kenilworth, NJ, United States.

According to the report, in many communities across Nigeria, women such as Fatima, Ebiladei, Obiageri, Auda, Bolanle and Majin continue to face barriers in accessing safe maternal health care during pregnancy. Some of these challenges include lack of adequate health infrastructures, lack of skilled birth attendants. Consequently, pregnant women increasingly patronise TBAs during childbirth to deliver their babies. A traditional birth attendant is a person who assists pregnant women when giving birth. But traditional birth attendants are unskilled: they lack formal training, adequate health information, and proper understanding of pregnancy complications and risk factors that lead to maternal deaths. They also lack access to requisite tools for clean delivery such as medicine and equipment for obstetric care.

According to the report, some of the reasons for the continuous patronage of traditional birth attendants could be attributed to the elements of the Three Delay Model which identifies three groups of factors – delay in decision to seek health care, delay in reaching health care points and delay in receiving adequate health care – that may hinder women from accessing the maternal health care they need.

Nigeria Director, MSD’s Merck for Mothers, Iyadunni Olubode, said: “In 2017, there were 67,000 maternal deaths in Nigeria, more than any other country on earth, and 23 per cent of the global total. Nigeria has a maternal health crisis so severe as to prompt federal authorities to declare a state of emergency.

“I am a mother myself. I was fortunate to have received quality care when I gave birth to my own daughters. But too many women in Nigeria are not getting the care they need and deserve during pregnancy and childbirth.

“Most of these maternal deaths in Nigeria are preventable. 60 per cent of women in Nigeria give birth outside health facilities. The call to prevent the needless deaths of women during childbirths is a responsible one and a call we must all rise up to.”

Managing Director, Nigeria Health Watch, Vivianne Ihekweazu, said: “The essence of the community-informed review is to better understand the reasons why women die while giving birth and to listen to the stories and experiences of the women in the communities.

“Many women are giving birth at home in Nigeria. The lowest is 16 per cent in the South West. Many women give birth without assistance of health professionals.

“Giving Birth in Nigeria project is to raise awareness of the challenge women face during childbirth and proffer solutions. We found a large number of women are dying and are not recorded. Post partum haemorrhage (bleeding after delivery) accounts for the more reason why women died.

“The deaths are preventable but sadly that level of care is not available. Most of the Primary Health Care centres (PHCs) are not functional.”
Ihekweazu said the team selected one state from each geopolitical zone for the project. She said they found mental health is often a challenge. “We had a clinical psychologist who accompanied us. There was high level of anxiety among women who are due for delivery. They did not really have enough emotional support and this could lead to complications and preterm birth,” Ihekweazu said.

She said each State has its own peculiar challenges. “Culture was highlighted in Bauchi State. Bayelsa, a riverine area, access to health facility was a big issue. In Ebonyi, many women are not familiar why they should go to health facilities for antenatal care and delivery. In Kebbi, we found that access to PHC was a challenge to many women. In Lagos, many women give birth by TBAs and there were large fear for Cesarean Section (CS). In Niger, the challenge is access to health facility and so, many women were patronizing TBAs,” she said.

Ihekweazu added: “We want a Nigeria where no woman dies of childbirth. Pregnancy is not a disease.”
Keynote Speaker and Wife of Kebbi State Governor, Dr. Zainab Shinkafi-Bagudu, said funding was a major issue for women in rural areas and that informed her decision to distribute 35,000 birth kits to help them. She said she established the Pampers programme to support the indigents.

Shinkafi-Bagudu warned that COVID-19 would affect all the indices as regards maternal mortality in 2020. “The major challenges are inadequate funding, COVID-19 pandemic and poor infrastructure. Poor funding makes it impossible to sustain a programme,” she said.

She said as part of measures to reduce maternal deaths, Kebbi introduced emergency transportation system, nutrition intervention programme and engaged community leadership in government facilities.

Chief Executive Officer (CEO) of EpiAFRIC, Dr. Ifeanyi Nsofor, said: “The Giving Birth in Nigeria project was an opportunity to hear community voices on why women die during pregnancy, childbirth and 42 days after birth. This report amplifies community voices so that these preventable deaths would end.”

Officer in Charge, Africare Nigeria, Dr. Patrick Adah, said: “Health education at the community level helps to address the challenges of religious biases as well as knowledge gaps in safe motherhood and maternal health care practices. Educating community members on their roles in preventing maternal death can contribute immensely to improving pregnancy outcomes.”

Commissioner for Health, Niger State, Dr. Mohammed Mohammed Makusidi, said: “We are strengthening community reporting of maternal deaths to ensure that every death counts. We are also trying to revitalize PHCs in the state.”

Desk Officer of Safe Motherhood and Deputy Director of Reproductive Health, Federal Ministry of Health (FMoH), Abuja, Dr. Samuel Oyeniyi, said the ministry was pushing for legislation on reporting of childbirths and deaths to be able to track and be accountable to maternal deaths in Nigeria.

Commissioner for Health in Ebonyi State, Dr. Daniel Umezuruike, said unskilled birth attendants were unacceptable and major cause of maternal mortality in Nigeria. “It has to do with girl child education. The people that patronize them are uneducated women. They are causing more harm than good,” he said.

Umezuruike said what Ebonyi State had done was to introduce comprehensive health insurance scheme and one standard PHC in each ward. He said the unskilled birth attendants/TBAs should not be used at all. You can only attach them to skilled birth attendants.

But a TBA from Epe in Lagos, Alhaji Hassan Marouf, disagreed. He said TBAs in Lagos are trained and certified to take deliveries and refer to health facility when necessary. “You train them to know their limitations and to know when to refer the woman to facilities. In Lagos State Traditional Medicine Board is training TBAs and they are certified,” he said.

Meanwhile, since 2015, the WHO and United Nations Children Fund (UNICEF) have recommended the institutionalisation of Maternal Death Surveillance and Response (MDSR) to track and prevent maternal and perinatal deaths in countries around the world. The MDSR is a mechanism set up to examine the circumstances surrounding every maternal death. It is the continuous process of identifying, notifying, and reviewing maternal deaths as they occur, and implementing actions to improve maternal care and prevent future deaths. MDSR also helps track a country’s sum of maternal deaths and provide vital information such as cause of deaths, underlying contributing factors – as well as actions to address the contributing factors to prevent future preventable deaths. Thus, it plays a crucial role in reducing maternal deaths.

In Nigeria, the FMoH adopted the Maternal and Perinatal Death Surveillance and Response (MPDSR) in November 2016. However, state-level implementation of MPDSR in Nigeria is inadequate, because it is focused on facility-based maternal deaths alone and sub-national MPDSR committees are unable to effectively turn the data into action.

Consequently, this gap fueled the Giving Birth in Nigeria programme’s approach to carry out the review of maternal deaths in communities, with the involvement of family decision-makers, traditional leaders, religious influencers, health workers and government-level officers in inquiries, awareness, and dialogue.

Community MPSDR, as recommended in the “Why Are Women Dying While Giving Birth in Nigeria” report, will provide a mechanism for policymakers and other decision-makers to be well aware of the causes of maternal deaths and address these causes at all levels by creating actionable solutions that could reach women in local communities. As a framework for monitoring maternal deaths, it will ensure the timely reporting and surveillance of women dying while giving birth in communities.

Consequently, this vital information can be used to guide public health’s response and government action at all levels and prevent the occurrence of future maternal deaths in communities. Also, through community MPDSR, every maternal death at home, at a faith-based centre or with a TBA can be counted, assessed, and avoidable factors aggregated. The information generated can be used to guide the immediate implementation of solutions as well as long-term actions to reduce maternal mortality in Nigeria.

The report highlighted Nigeria’s high maternal mortality burden, particularly the high prevalence of maternal deaths in communities, where there has been no previous systematic attempt to ensure that out-of-facility deaths were integrated into any routine review or what is formally known as the Maternal and Perinatal Death Surveillance and Response (MPDSR).

Community MPDSR is key to reducing maternal deaths in Nigeria. The “Why Are Women Dying While Giving Birth in Nigeria?” report, recommended the following for reducing maternal deaths through the implementation of community MPDSR in Nigeria:
*State governments should leverage traditional and religious leaders and build upon existing socio-cultural structures to speed up accountability for maternal deaths at the community level, through community leadership, and advocacy for the adoption of safe practices in maternal care.
*Apart from working with state governments, local governments and ward councils should facilitate community MPDSR and the Federal Government of Nigeria through the Ministry of Health should implement MPDSR as a multi-stakeholder effort that will involve community influencers, community-based organisations (CBOs), religious leaders and health workers including community health extension workers.
*The government at all levels – federal, state, local – should put in place sustainable structures in local communities, so that community maternal death reviews are implemented and incorporated into state-level MPDSR efforts in health facilities, where this is currently practiced. This will ensure that comprehensive data on causes of maternal deaths at every level, are identified, addressed, policies are made, and sustainable solutions created.

The report concluded: “Every day, women die while giving birth in Nigeria. This is tragic, with devastating consequences on the family – and it is unacceptable! Maternal deaths can be prevented provided that women have access to quality maternal care throughout their pregnancies and during childbirth and that every maternal death is counted, investigated and used to create solutions to prevent further deaths.

“State and local governments need to do more to ensure that women have access to adequate health facilities in their communities. There is need for increased awareness and education on safe maternal health care practices among women and communities, as well as advocacy for effective implementation of community MPDSR in all states across Nigeria.

“Government must work with gatekeepers at the community level, including religious leaders, traditional rulers, women leaders and other community influencers to ensure that the death of every woman in the community is tracked, and solutions are established to ensure that no woman dies while giving birth.”