The neglected rural dwellers and maternal mortality in Nigeria

The type of women most underserved by the limited government programmes and provisions available were clearly the women with low socioeconomic status, living in rural regions. They tend to be mainly helpless, due to their depth of poverty and lack of basic amenities. Also, they are more culturally oriented, more likely to place cultural practices and beliefs highly.

http://www.vanguardngr.com

More than one decade after the launch of the Safe Motherhood Initiative, the burden of maternal mortality still takes a heavier toll in the rural dwellers compared to their urban counterparts (Ugwuoke et al., 2015). This is most likely because of the reported underutilisation of skilled birth attendants during pregnancy and delivery. The rural women often seem invisible, they have limited access to infrastructural development, low education and income levels (Ugwuoke et al., 2015). The effectiveness of interventions should equally depend on the focus on the issue of the rural dwellers otherwise they may have limited effects if they don’t tender to the needs of the underserved population. 

The principal means of survival for these rural women are farming and agriculture (Fabiyi and Akande, 2015). If maternal death interventions are to be efficient, the women have to be empowered to make effective decisions especially those requiring finance (e.g., hospital registration, transport to infrastructure and healthy diets). To reduce the women’s poverty level, some states in Nigeria have implemented poverty alleviation through agriculture. Bello and Ashimolowo (2014) reported that the women who participated in the agricultural empowerment projects in Ogun State, Nigeria stated that such programs had a positive impact on their balanced emotion, income, business expansion, and access to credit facilities. Nlerum et al. (2012) reported that majority of the rural women in Eleme community (Rivers State) stated that they had no access to agricultural information and technologies (e.g., such as poultry production, snail rearing etc). But the few respondents who had access to information reported that this raised their farm productivity level (Nlerum et al., 2012). Implications of this are that using less expensive empowerment techniques such as transferring agricultural technology knowledge may potentially increase the Rivers State women productivity rate, thereby, placing them in a better position financially to support proper health care decision-making.

Education and residential area were other influencing factors in the women’s choice of health care provider, their choice on the decision to self-medicate or not, the fear of caesarean section and their general health care seeking behaviour. Studies have shown that women’s formal educational is the most potent tool for the reduction of the Nigerian maternal mortality rate (Igberase, 2009; Moore et al., 2011; British Council, 2012). Unfortunately, some studies have also reported that the Nigerian economy since its independence in 1960 has marginalised the benefits of education (Ikeako et al., 2006). Since most women with low socio-economic backgrounds can not afford to get a proper education, the potential key is in the stimulation of these women to attend health facilities by relaying critical risk communication and using effective communication strategies. Importantly, if communication is successful, to ensure that these women continue proper health care practices, the services and facilities should be made equally services accessible and affordable (Wasabi, 2013).

Please feel free to discuss and comment. 

Video of the week: reducing maternal deaths in developing countries

The highlighted videos of this week show some discussions from the year 2008 concerning maternal health in developing countries. The major role of the meeting was to emphasise on the importance of research in catalysing the progress of the fight against maternal deaths. Sadly, maternal mortality is still an ongoing issue in the world, especially in the developing regions. It is important to note that giant strides has been made to reduce maternal death in some countries (for example: Rwanda), however many countries (e.g. Nigeria) still struggle with getting on track with cutting the maternal mortality ratios.

Each day, more than 830 women in the world die during pregnancy or childbirth. One in 16 women in Africa and 1 in 43 women in Asia will die of maternal causes this year, compared to 1 in 2,500 in the United States.Although this is a relatively old video, but the discussions still resonates with the issues currently being faced by the developing countries , and the strategies needed. 

The event speakers: Sophie Witter, Cynthia Stanton, Dr. Julia Hussein, Wendy Graham 

Please feel free to leave your comments on the discussions.

Article gems : Socio-economic inequalities in access to maternal and child healthcare in Nigeria

This paper examines socio-economic inequalities in maternal and child health care in Nigeria over an 18-year period. Studies demonstrate that maternal and child mortality is much higher amongst the poor in low-income countries, with access to health care concentrated among the wealthiest.

Image from:teepasnow.com

Evidence suggests that in Nigeria inequalities in access to quality services continue to persist. We use data from two rounds of the Nigerian Demographic and Heath Survey (NDHS) conducted in 1990 and 2008 and measure inequalities in maternal and child health care variables across socio-economic status using concentration curves and indices. Factors contributing to the inequalities are investigated using decomposition analysis.

The results show that in 1990, maternal access to skilled assistance during delivery had the highest levels of inequalities. It reveals that child and maternal health inequalities appear to be determined by different factors and while inequalities in child care have declined, inequalities in maternal care have increased. We discuss the findings in relation to the much greater attention paid to child health programmes. The findings of this study call for specific maternal programmes targeting the poor, less educated and rural areas in Nigeria.

This is the abstract of a paper titled : 
Socio-economic inequalities in access to maternal and child healthcare in Nigeria: changes over time and decomposition.

"Article gems" is a new series of posts on Natasha's health watch, highlighting important research public health papers. Feel free to email me if you find interesting articles that could be part of the series.

Major highlights from the Lancet’s Maternal Health Series

The series was guided by the paramount message below

“Every woman, every newborn, everywhere has the right to good quality care.”

www.maternalhealthseries.org

The adopt primarily a numerical lens to illuminate patterns and trends in outcomes but recognise that understanding of poor maternal health also warrants other perspectives, such as human rights (Graham et al., 2016). Although there has been progress observed in the reduction of maternal mortality rates across the world, there are still some countries that recorded little or no advances in the reduction of women dying as a result of pregnancy.
For example, Nigeria has one of the world’s worst indices for maternal mortality rate, with an estimated lifetime risk of maternal death being 1 in 31 compared to that of high resource countries (1 in 3700) (Agboghoroma & Gharoro, 2015; Njemanze & Okoro, 2015). The growing loss of women’s lives in Nigeria due to avoidable factors occurring under preventable conditions remains a worrisome issue.

The series highlights the major causes of maternal deaths and the critical interventions as seen in the figure below:

Universally, every woman deserves the right to good quality woman-centred maternal health care. The series informs us that there are issues in the maternal health sphere across high-middle-low income countries. On one hand, there is a growing risk of over-medicalization of healthy pregnancy and birth, while on the other hand, poor quality care that is too little, too late jeopardises the women;s health.

There is a shift seen from avoidable deaths to an increasing array of maternal morbidities, as more women survive childbirth. The diversity and divergence in the burden of poor maternal health across the world are as a result of four major transitions. These include demographic, epidemiological, socioeconomic and environmental. Contrary to popular belief that poor quality care is mostly always seen in low-income developing countries, it is an issue present in all countries. Although some women receive excellent care, a lot experience one of two extremes: too little too, too late, or too much, too soon.

Too little, too late
•    Lack of evidence-based guidelines
•    Lack of equipment, supplies and medicines
•    Inadequate numbers of skilled providers
•    Women delivering alone
•    Lack of emergency medical services and delayed inter-facility referrals

Too much, too soon
•    Unnecessary caesarean section
•    Routine induces or augmented labour
•    Routine continuous electronic fetal monitoring
•    Routine episiotomy
•    Routine antibiotics postpartum

It is recommended that particular, context-appropriate strategies and guidelines are needed to counter both extremes.

One salient point to never forget is that the burden of maternal health mortality and severe morbidity is concentrated among vulnerable population, especially those that face gender and other discrimination, have financial constraints, are affected by humanitarian crisis or live in fragile state or areas prone to natural disasters.

The series concludes with a five-point agenda for change:
•    Good quality care for every woman, every new-born, everywhere
•    Equity through Universal Health Coverage
•    Health system resilience, strength and responsiveness
•    Sustainable financing for maternal and new-born health
•    Better evidence, advocacy, and accountability for progress

As a matter of priority, widening gaps or differences in the rates of maternal deaths seen across the world, especially amongst the vulnerable population has to be addressed. There needs to be strong political will and commitment from all the stakeholders to improve equity. Progress on the issue of reducing maternal deaths will ultimately be the judge of sustainable development.

Please leave your comments, and checkout the full executive summary of the maternal health series here

Importance of preparedness and timing in public health

If we had a wish, it would be for the ability to determine the exact probabilities of a risk occurring, when and how. Where the subsequent maternal or child death will be happening. Unfortunately, none of us possesses a magic ball to fulfil that wish.

Talonsurvival.com

At this point in history, the fact is that timing plays a crucial role in stopping preventable deaths of the mother and child. Any lapse in efficient timing and the unfortunate evil (e.g. Maternal death) will find it and strike. This is why it is vital to have strong public health systems, medical professionals and decision makers.

Precrisis or prodromal signs/stage begins as a symptom of issues emerges, so if these warning signs are not recognised and attended to, the likelihood of a negative event occurring increases (Venette, 2008). For example, excessive vomiting/nausea, severe headaches, and protein in the urine are some of the symptoms that a pregnant woman is developing pre-eclampsia. These symptoms could become worse, and the woman may eventually be diagnosed with eclampsia if the woman does not take the appropriate medication. The scenario above demonstrated the importance of timing between risk and a potential crisis (maternal deaths).

Another useful example can be seen in the recommended time prescribed to pregnant women for their first visit to the hospital.The National Health Service UK has recommended that ideally, a woman should get in touch with her health care provider no later than the 10th week of pregnancy (NHS, 2016). An early meeting between the pregnant woman and her antenatal care service provider is advocated for, in an attempt to identify risk factors and prevent future complications that may arise. For example, the prenatal diagnosis of certain conditions such as Down’s syndrome is possible preferably by the 16th week and no later than 20weeks (Simpson & Walker 1980).

Several factors come into play in the probabilities of a pregnant woman and her child surviving or dying. In particular, across the developing countries, we need adequately equipped laboratories that can rapidly diagnose the cause of illness. We need an effective ambulatory system that can reach individuals with no means of getting to health centres on time. We need community based participatory interventions that will be utilised in hard to reach the rural area for the education of the people on the advantages of good health seeking practice. We need an excellently skilled health care workforce armed with not only technical knowledge but also the importance of compassionate care. We need decision and policy makers who will make the health status of the citizens a political priority in their constituencies. Until we have these things, there will be significant gaps. Ultimately limiting our ability to stop preventable deaths.

As passionate stakeholders, we cannot accept the present state of affairs; we must put our skills and expertise into work that will make our various countries a safer place. In doing this, we are closer to achieving the Sustainable development Goals by 2030.

Please leave your comments below.

Video of the week: Why did Mrs X die, retold

"Why Did Mrs X Die, Retold" is a remake of the World Health Organization 1980's film "Why Did Mrs Die?" based on a lecture by the founder of the Safe Motherhood Movement, Prof Mahmoud Fathalla.

This is a short animated film telling the story of one unfortunate woman's journey through pregnancy and childbirth. In doing so, the film paints an accurate picture of the dangers women are facing across the world, and our need to help them. 


The video highlights some issues concerning: 

•   Importance of skilled birth attendants at birth.

•   Early marriage.

•   Gender inequality.

•   Tradition and lack of knowledge.

•   Out of pocket payment and bribes. 

•   Anaemia and clinical complications.

•   Inadequate referral system.

•   Lack of hospitals equipped with comprehensive medical services.

•   lack of basic amenities e.g transport.

•   Social injustice .

•   Lack of family planning services.

•   Lack of education.


Produced by Hands On for Mothers and Babies, an organization making educational tools for women in poor areas of the world. www.handsonformothersandbabies.org 

Mrs X could be any woman, our mothers, sisters or even ourselves. We as health care professionals, policy and decision makers, any one who believe in the dream of safe motherhood for all should continue to join forces in making safe pregnancy and childbirth a basic human right and not a tragedy.