Maternal & PERINATAL Mortality in

Nigeria
By

Dr.J.U.E. Onakewhor
Department of Obstetrics & Gynaecology
University of Benin Teaching Hospital
Benin City, Edo State Nigeria.
Introduction

Gods word & child birth:

 I will greatly increase your pains in

childbearing; with pain you will give birth to
children
(The Holy Bible, Genesis 3 verse 16a.).

- God’s curse is pain & not death

 Maternal Mortality in Nigeria
Definition:
1. 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 itself or
its management but not from accidental or incidental causes;
(time consideration) 1, and
2. as the death of a woman from direct or indirect obstetric
causes more than 42 days but less than one year after
termination of pregnancy.2

1 . This opinion was expressed in the May 2000 edition of the Bulletin for
Health Care Professionals in the United States titled, Maternal Mortality
and Morbidity Review in Massachusetts. See details at
http://www.mass.gov/dph/ose/preg2000.pdf

2. World Health Organization Manual of the International Statistical

Classification of Diseases, Injuries, and Causes of Death, 10th revision,
Vol. 1. Geneva: WHO, 1993
 Complications can develop in pregnancy at any
time irrespective of the social class of the woman,
her geographical location and whether or not the
pregnancy is desired, planned or not
 Nearly 600,000 women die from pregnancy related
complications each year and most of these occur
in the developing countries.
 For each maternal death, a large number suffer
severe morbidity
 In spite of newer information about the
pathophysiology of MM and modern technologies
to predict and deal with them pregnancy outcome
could still be complicated even in best of
circumstances.
 In Nigeria poverty, illiteracy, Poor or lack of social
infrastructure, corruption, bad and frequent policy
changes culminate in a disastrous health system
that needs complete overhaul.
 The scale of maternal mortality
 Every minute of every day
- 380 women become pregnant
- 190 women face an unplanned or unwanted
pregnancy
- 110 women experience a pregnancy related
complication
- 40 women have unsafe abortion
- 1 woman dies.
Most of these deaths occur in poor developing countries
esp. SSA
Causes of maternal mortality :
These are classifies as Direct or Indirect Causes .
Direct Causes
- Obstetric Haemorrhage
- Obstructed labour / ruptured uterine
- Hypertensive diseases of pregnancy
- Sepsis
- Abortion
Indirect Causes
- Socio-cultural
- Environmental
- Economic
- Political
Strategies to reduce maternal mortality
- Universal antenatal care for all pregnant

women
(with 6As:Awareness, Available, Accessible,
Acceptable, Affordable, & Adequate)
- Skilled attendance at delivery( Role of
Emergency Obstetric Care)
- Post-partum care including breast
feeding;
- Contraceptive advice.
The 3 forms of delay has to be overcome.
Coverage of maternal health
services
97% 99% 90%

65%
53%

30%

Antenatal Care Skilled attendance Post-Partum care

At delivery

Developed Countries Developing Countries

Source WHO 1997
These statistics like most concerning the developing world are
steadily going from bad to worse.
 The Safe Motherhood Initiative & the role of Maternity
Services Organization(MSO) in the Prevention of
Maternal Mortality
Objective Safe Motherhood Initiative
 50% reduction in MMR by the year 2000 (Nairobi, Kenya
Feb. 1987)
Militating factors- two broad categories of MSO services:
A. Those who should not give medical advice/ manage the
women
- Every Nigerian including mother-in-laws, friends,
neighbours do
F. Those that are currently providing these services
- Primary health care centres
- Specialist and General Hospitals
- Teaching Hospitals
- TBAs
- Churches
What role for each MSO
Primary Health Care Centres.
 Health education of the community.

 Screening and identification of risk factors..

 Use of the parthogram.

 Early referral.

General and Specialist Hospitals

 All the above plus skilled, dedicated personnel and

infrastructural where with all for interventions, such

as caesarean section where and when necessary.
Tertiary Centres
 All the above plus training of suitable manpower and

research.
What role for each (contd.)

TBA
 Very controversial; But I think they should not be

encouraged . Let the tradition die off.

 TBAs are so set in their ways, mostly illiterate and the

financial involvement in training them is better utilized

to train manpower and improve infrastructure.
Churches
 Churches now rule the life of so many of our women

completely. The women must necessarily obtain

permission of their pastors before they even think.
 Antenatal care / deliveries are conducted in churches

by predominantly illiterate or unskilled persons in very

unsterile environments with devastating results.
Table 1: Some Selected Maternal
Mortality
ComparisonRatio:
with other Countries
Country MMR (maternal death/100,000 live births)

Mozambique 980
Nigeria 800
Zimbabwe 610
Botswana 480
South Africa 340
Britain 9
Sweden 7
U.S.A 12
 Table 2: Zonal Variation of MMR within
Nigeria
Zones MMR
North East 1500
North West 1000
South East 250
South West 200
Urban 350
Rural 820
National 800
 Table 3: Socio-economic and
Demographic
Total Population Data120 million
Female Population 60 million
Women of reproductive age 27 million
Maternal mortality ration 800 thousand per 100 thousand live births

Median age at first marriage 18 years

Female adult literacy rate 14%
Contraceptive prevalence rate 8.9%
Total fertility rate 5.1%
Per capital income N35,340.00 (US$310)
Access to health facilities 63.5% of population
Access o\to portable water 54.1% of population
School attendance (total) 55.1% of population
Annual growth rate 2.7%
Crude death rate 43 per 1000
Crude birth rate 16 per 1000
Infant mortality 114 per 1000 live births
Low birth weight 17%
Table 4: Under Five Mortality Rates/1000
Live (U5MR)-Nigeria and its Neighbours
Country U5MR in 1960 U5MR in 1998 Percentage Reduction
WHO Ranking
Benin 310 144 54 97
Cameroon 264 113 57 164
Ghana 216 170 21
135
Ivory coast 300 150 50 137
Niger 320 280 13 170
Nigeria 204 187 6 187
Togo 264 144 49 152
Source: WHO 2000 report and Nigeria.
Table 5: WHO’s estimate of health Personnel: Number
of Health Personnel per 100,000
population.
Country Physician Nurse Midwives Dentist

Benin 5.7 20.4 7.9 0.3

Cameroon 7.4 36.7 0.5 0.4

Ghana 6.2 72.0 53.2 0.2

Ivory Coast 9.0 31.2 15.0 N/A

Niger 3.4 22.9 5.5 0.2

Nigeria 18.5 66.1 52.4 2.6

Togo 7.6 10.4 10.4 0.7

Source: WHO 2000 Report and Nigeria

Table 6: Medical Cause of Maternal
Mortality
Post partum Haemorrhage 25%
Puerperal Sepsis 15%
Unsafe abortion 13%
Eclampsia 11%
Obstructed labour 11%

Others (ectopic pregnancy etc) 5%

Anaemia
Malaria
Anesthesia 20%
Hepatitis in pregnancy
HIV/AIDS in pregnancy
Table 7: CAUSES OF MATERNAL DEATH PER
YEAR 1996 – 2000 SPCH, Benin City
T
S/No. CAUSES 1996 1997 1998 1999 2000 TOTAL PERCENT
AGE
 .
1 Eclampsia 3 1 2 5 0 11 34.4

2 PPH o 0 2 3 1 6 18.8

3 Sepsis 1 3 2 0 0 6 18.8

4 Abortion-related 0 1 0 1 2 4 12.5
5 Ruptured uterus 1 0 0 0 0 1 3.1

6 Ruptured 0 0 0 1 0 1 3,1
Ectopic Preg.
7 APH 0 1 0 0 0 1 3.1

8 Anaesthetic 0 0 0 1 0 1 3.1
(aspiration
9 Medical Disease 0 1 0 0 0 1 3.1

TOTAL 5 7 6 11 3 32 100
Table 8: MATERNAL MORTALITY RATIO PER
YEAR, SPCH
YEAR 1996 1997 1998 1999 2000 TOTAL
 .
Total birth 1530 1516 1324 1438 1247 7055

Maternal 5 7 6 11 3 32
Death

MMR 327 462 453 765 241 454

 HISTOGRAM REPRESENTING THE FOUR COMMONEST
CAUSES OF MATERNAL DEATH SPCH, Benin City.

12

10

8
Eclampsia
Hemorrhage
6
Sepsis
Abortion
4

0
Table 9: Non-medical Causes of Maternal
Mortality
Socio-cultural early age of marriage - 10% pregnant at 15yrs of age
- 35% pregnant at 18yrs

High premium on - high fertility rate of 5.1%

child bearing - 4% still pregnant after 34yrs
- 6.9% of births are less than two years
spacing
- 24.3% of births are in grand multiple
- low contraceptive prevalence rate of 8.9%

Low status of women - high illiteracy rate of 59%

- 36% women in adult work force
- poor nutrition in childhood and
consequent poor development from childhood

Lack of decision - require male authority to access medical

making power treatment
- reason for poor maternity care
Mortality Contd.
Poor access to - high rate of non-
facility delivery
Resources hence unable - 60% of women
deliver at home
to afford cost of access to facility

Lack of knowledge - poor appreciation of

risks signs of -
pregnancy and delivery complication

Poor citing of health facility - poor road

network
- poor transportation

Poor health facilities functioning - low staff morale

capacity - low supplies of
consumables
- poorly maintained
equipments
- poor training of staff
- poor staff attitude to
Table 10: Preventing/Reducing Maternal
Mortality in Nigeria
This will be discussed as follows:

3. Previous efforts at reducing maternal mortality in Nigeria and its

Outcome viz
 Safe motherhood initiative (S.M.I)
 Prevention of maternal mortality Network (PMMN)
 Making Pregnancy safer (MPS)

8. Principal strategy for reducing/preventing Maternal Mortality and

applications in Nigeria
 Focus on Alma-Ata declaration

11. The way forward for preventing Maternal Mortality in Nigeria.

 Focus on Models of Organizing delivery care enunciated by Kobinsky et
al 2000
 Table 11: Global Efforts of Reduction of
Maternal Mortality in Developing
Countries
(a) Safe motherhood initiative conference 1987

Objective: Reduce MMR by half by year 2000

Approach: No specific approach developed or measurable action to be
taken by all.
Only advocacy call for all nations of the world for:
(a) Improved access to quality maternal health services

(b) Assist developing countries reduce the high maternal mortality

Ratio.
(cPrevention of unwanted pregnancy and address unsafe abortion
(d) Improved Education and Nutrition for women.
(e) Women empowerment
 Cont.
On indepth Analysis:

These activities though laudable lack capacity to induce a reduction in MMR

in the short term. Also the approach lacked specificity and a measureable
action in health care delivery.

In Nigeria: Safe motherhood initiative Activities were:-

(i) Sensitzation of people and Government to the High MMR through

zonal and National Safe motherhood communities who organised
conferences and seminars.

(ii) Training of TBA and presentation with delivery kits for cleanliness
while conducting deliveries. This was a major task for the Nigerians
Safe Motherhood initiative members.

- Unfortunately TBA lack the knowledge and capacity to

handle the emergency nature of causes of maternal
Cont.

 Inspite of the governmental awareness, the Nigerian government did not

accept that Safe motherhood was a vital and essential socio-economic
investment and hence .
- introduced SAP into Health care delivery including maternal Health
Services known as payment at the point of service delivery.
This pay at service point is-still in force till today.

- This SAP evoked more hardship and worsening of the MMR which today
is still rising by lips and bounds

End Result:
Approach proved incapable of reducing MMR in the chosen short term for
most areas in Africa. In Nigeria, MMR was 650 in (1980 – 85) but now 800 by
2000.

Conclusion:
SMI not so successful because of lack of focus on actual intervention that
would assist with reducing MMR.
Table : Prevention of Maternal Mortality
Network (PMMN)
PMMN is composed of multiseatogal and multidisciplinary research Team from
Carnegie Corporation of New York who executed interventions in many West Africa
Countries including Nigeria to reduce maternal mortality as model that would be
adopted for developing countries.

Object:
(i) Develop effective strategy to reduce MMR in the short term
(ii) Evolve operation research model for use in maternal mortality project.

Approach:
Evolved several models to achieve objectives

• Conceptual Model:
Intervention to reduce MMR must do one of three things
(i) Reduce the no. of pregnancies.
(ii) Reduce the no. of complication
(iii) Reduce the like likelihood that a complication will result in death
Cont.

*Best strategy to ensure short-term reduction in MMR

(e) Strategic Model:
(i) Serious complications maybe difficult to prevent or predict but with
treatment may avert death.

(ii) Strategy is to provide access for good obstetric care at the facility for all
parturients.

(iii) Once an obstetric complication occurs any barrier that prevent

access to effective medical care done increase the chances of such
complication resulting in death. Such barriers are unknown or
minimal in developed countries.

In Nigeria and other developing countries such barrier are common and comprise the
complex of socio-cultural and non medical causes and poor socio-economic in the
rural populace. They are better known as delays.
 Cont.
(c) Program Model:
Viz the three delays:
(i) Delay in deciding to seek EmOC.

(ii) Delay in reaching an EmOC facility

(iii) Delay actually receiving care at EmOC facility. Initial

Initial point to begin intervention.

All these delays will translate a complication to a maternal death any where.

(d) Evaluation Model:

Viz evolution of process indicators for accessing MMR projects.

(i) Facility utilization

(ii) Obstetric care fatality rate.

Cont.

End Result:

Program was performable and good result obtained from interventions to improve
obstetric care at facility level and reducing barrier that cause delay. In Nigeria the gain of
this project was heavily eroded by the poor economic climate which did not allow
sustenance both by the government and the community.

Conclusion:
PMMN approach is good strategy for MMR as confirmed from the result obtained from the
west Africa countries interventions.
Table 11: Making Pregnancy Safer (MPS)
(Lunched 2000 and on going)
Objective:
Reduce MMR by 50% over a ten years Period.

Approach:

To improve Condition in the Health facility to ensure quality of care generally and
especially for capacity for emergency Obstetric care at the primary health care level.

Strategy:
(a) Capacity building and adequate equipment to ensure quality delivery services and
emergency Obstetric care at PHC.

(b) Functional referral linkage with a secondary care facility with comprehensive
essential Obstetric care.
 Table 12: Principle Strategy for Reducing
Maternal Mortality in Nigeria
Preventing/Reducing Maternal Mortality any where must entail the followings:-

3. Family planning to reduce case fatality and lifetime risk of maternal death.

5. Safe abortion services to reduce the incidence of abortion related complications.

7. Emergency obstetric care to treat complications timely so as to prevent obstetric

complications resulting/translating into maternal deaths.

9. Out of these the strategy that will reduce MMR in the short term, is wide access to
emergency obstetric services by all parturient, to treat obstetric complications at all
levels of health care.

11. The efficient vehicle for bringing emergency obstetric care to the rural populace is the
primary health centre system if fully integrated into Health care delivery system as in
the Basic Health Unit (BHU) as recommended by the Alma- Ata declaration of 1978.
Table 13: Best Approach to Reducing MMR in Nigeria
(a) Establish functional Basic Health Unit as recommended by Alma-Ata declaration of 1978

and accepted by Nigeria since 1980. In each local government areas.

(i) One comprehensive Health center linked in the urban area to secondary and
tertiary centre and also in the rural areas to

(ii) Four PHC facilities, linked to

(iii) One PHC to serve 20 health post located in each local government .i.e four PHC
to serve 80 health posts.

The Basic Health unit is to provide preventive promotive curative and obstetric care to a
maximum population of 150,00 for effective Health care. Obstetric care includes Antennal,
delivery and postnatal care as Emergency obstetrics care.

(b) Such as above will ensure health care and Obstetric services at the grass root and
measures to remove the three delays can be effective.
Cont.

(c) Such will ensure improved Obstetric utilisation and decrease

Obstetric case fatality, over time to reduce MMR through provision of
intervention against the main causes of maternal death as shown in
the next table 15. Referral linkage is crucial to achieving success.

(f) The approach will help to reduce MMR in the short term over when
other Reproductive Health indices have not improved.

(e) The BHU is what has been adopted by the developed countries like
Sweden, UK, USA be ensure low MMR. The efficiency of this system
in these advanced countries in due to good road communication
network and pay for Health through Health Insurance Premium.
Hence there are no delays to accessing maternal care services when
obstetric emergencies occur.
Table 14: Definition included in
UNICEF/WHO/UNFPA Guidelines.
Obstetric Emergency
Haemorrhage (antepartum or postpartum)
Prolonged/obstructed labour
Postpartum sepsis
Abortion complications
Pre-eclampsia/eclampsia
Ectopic pregnancy; Ruptured uterus
Emergency obstetric care EmOC function
Basic EmOC (BEmOC)
1 Inject able antibiotics
2 Inject able oxytocics
3 Inject able anticonvulsants
4 Manual removal of placenta
5 Removal of retained products
6 Assisted vaginal delivery
Comprehensive EMOC (CEmOC)
All basic function 1-6 plus
Cesarean section
Blood transfusion
Table: 15: Causes of Maternal Deaths and Principal
Interventions
Required at PHC.
Causes of Maternal Deaths
Bleeding after delivery (postpartum
Haemorrhage)
Infection after delivery
Unsafe abortion
High blood pressure (hypetension)
during pregnancy: most dangerous
when severe (eclampsia)
Obstructed labour
Other direct obstetric causes
Indirect causes
% Proven Interventions
25 Treat anaemia in pregnancy.
Skilled attendant at birth: prevent/treat bleeding with
correct drugs, replace fluid loss by intravenous
drip/transfusion if severe.
15 Skilled attendant at birth: clean practices.
Antibiotics if infection arises.
13 Skilled attendant: give antibiotics, empty uterus, replace
fluids if needed, counsel, and provide family planning.
Access to safe abortion where not against the law.
12 Detect in pregnancy; after to doctor in hospital.
Treat eclampsia with appropriate anticonvulsive (magnesium
sulfate).
Refer unconscious woman for expert urgent assistance.
8 Detection in time and referral for operative delivery.
8 Refer ectopic pregnancy for operation.
19 Disease-specific interventions (malaria, HIV,etc).
Table 16: The Way Forward for Preventing

Maternal Mortality in Nigeria.

Models of Organizing delivering Care (Kobinsky et al 2000)

(c) Model 1
- Deliveries are conducted at home by untrained community
member

- This model was popular in Europe and USA some 200 yrs ago.

- It is today best illustrated by the system in which TBA are trained

to take deliveries at home. This is a non-facility based delivery
system.

- This model 1 has failed always to reduce maternal mortality to

under 100 per 100,000 live birth any where whatever the
modification. This model 1 system has been abandoned every
where in the developed economy.
 Cont.

• Model 2
- Deliveries are conducted at home by trained professionals
(Midwives & Doctors) including those in the villages.
- Backup with free ambulances (flying squad) to transfer
complicated cases to Hospital.
- Health services are free. There are good Road and
Commutations.

It was adopted in U.K 80 yrs but later abandoned for full hospital deliveries.

Malaysia adopted this model and reduce MMR to under 100 in 25 years.
Cont.

(c) Model 3

Deliveries conducted in a basic obstetric care facility/(PHC) by trained professionals.

 Backed up with referred linkage by ambulance to an emergency obstetric or
comprehensive obstetrics care facility. i.e Primary Health Centre.

 PHC access within 5km of each home

 Midwives available in all villages for deliveries. Srilanka adopted this system
and reduce MMR from 555 to 30 in 1955.

 For success of this system there must be good roads and communications
Network
 Cont.

(d) Model 4
Delivery is conducted by professionals in a comprehensive obstetrics
care facility.

• Effective referral linkages with PHC and other tiers.

• Excellent Road, transport and communications Network.

• Efficient Ambulance services.

• Appropriately manned PHC spread into the community within

1 km of each home.

• Health services payment through Health insurance premium

This is the model in UK, USA and Europe where MMR is (0 – 10) per
100,000 live birth.
Cont.

Conclusion on models of Delivery Care

(v) Model 1&2 are not workable to reduce MMR to any acceptable level because it entail non
facility based deliveries.

(vii) Model 3&4 are best to quickly reduce MMR because it entail facility based delivery system.

• Model 3&4 can best be assured through the BHU to reach the rural community and
functional referral linkage

• In the BHU system, Health post in the villages can be managed by midwives such that
deliveries occurs within (3.5) km of homes.

Upgrading Health post to conduct deliveries has been successfully done by some countries like
Srikanka, Banglodesh and cubao achieve scrbato 90% deliveries by trained staff with 3km of
homes

In Europe & USA, deliveries are at PHC and CHC with wide access via referral to the
community with out barrier or delays of any type.
Table 17: Recommendation for
Nigeria for Reducing MMR
This requires a national strategy to bring about 3 changes.

• A societal commandment to ensuring safe pregnancy.

Reducing MMR takes a long time over years. Decision makers (politically, economically
religious and house hold) must foster the perception to make pregnancy and child birth
safer. This commitment often can be sustained when the communities and decision
makers are involved in analysis of causes of maternal death and near- misses (severe
illnesses almost resulting in death).

(ii) Improvement in access to and quality Health care.

(a) This aim to make all pregnant women have access to trained personnel at the time
of delivery and for the treatment of obstetrics complication in a Health facility
with obstetrics care function with in a short distant from homes in the village.
 Cont.

(b) Appropriate national consensus guidelines for intrapartum care should be

developed to help the tontine and emergency treatment.

(c) Improve access to contraception cases and the challenge of unsafe abortion

(h) Appropriate referral linkages of all there tiers of Health care in the BHU
with good transport and communication.

(k) Free Obstetrics services from payment or at least through Health insurance
premium payments. The West African College of Surgeons can pick it this
aspect up with the government in Nigeria and the West African Region.
 Cont.

(iii) Commitment to the special needs of girl and women

throughout their lives.
This entail attention to:

- Good Nutrition

- Good Education

- Improved empowerment of women

- Partnership in decision making by which women

should be evolved

- Looking especially in Reproductive Health matters.

These later are mainly long-term measures

PERINATAL MORTALITY RATE

PMR =No. of SB+ First- week death

Occurring from 24 (Nigeria still uses 28)completed
weeks of pregnancy to 7 days after birth per 1000
live and still births.
Any infant born b4 24 weeks with sign of life but died
within 7 days is included in PMR

Other inclusions In National Perinatal statistics

 B.WT > 500g or

 22weeks completed weeks

 Crown –heel length of ≥ 25cm

For International Perinatal
statistics
 Minimum B.wt of 1000g
 Gestational Age of 28 weeks
 Crown-heel length of 35 cm

Incidence of prematurity
 8-10% in USA

 4.5- 5.5% in Nigeria;

- Fetal prematurity- 42%

PNMR in Nigeria

 PNMR 8.9/1000 in England & Wales

1991(live & still birth)
 PNMR >10/1000 in Nigeria
 NNMR 35/1000.
Factors associated with perinatal mortality

Causes- Maternal & fetal & Environmental

Fetal
•Prematurity & its complications
•IUGR
 Low birth weight b.wt,2500g

 Birth asphysia

 Birth trauma

 Neonatal infections

 NNJ

 Congenital malformation
Maternal -Medical Biosocial &Obstetrics

Maternal Biosocial
 Age

 Parity – primipirity & grand mulitparity

 Pregnancy intervals

 Education & Social class

 Medical disease

Obstetrics
 APH

 PIH/ PET/eclampsia

 Malpresentaion and abnormal lie

 Multiple pregnancy

 Unexplained
Factors associated with perinatal mortality
contd.
Environmental
 Harmful traditional practices

 Unattended delivery

 Obstetric Delays9 6As above

 Social class

Race
PMR higher in East & West Africans West Indies, Pakistan
immigrants
 Conclusion:
The core stake holders in safe motherhood are
-Obstetricians and gynecol5ogists and midwives.
- Others exist but these must be involved in whatever
organization that look after our women for maximum
effectiveness in providing a safe motherhood for our women.
- Pediatricians and good neonatal facilities (at all levels of care)
are indispensable to reducing the unacceptably high PNMR
 When sustained has potential to make Obstetric services
available to the grass root populace.
 Will present realistic basis for reducing the delays that could
translate an Obstetric complication into a Maternal mortality.
Thank you All