Maternal health in Northern Nigeria—a far cry from ideal
Dr H Galadanci, Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, PMB 3452 Kano, Nigeria. Email email@example.com
Objective To determine the level of maternal care in Northern Nigeria.
Design A cross-sectional descriptive study design was used.
Setting The Study was Community based and carried out in the ten states that constitute UNICEF D zone in northeast Nigeria.
Population Women who delivered in the 11 months preceding the survey and resident in the study area.
Methods The WHO cluster sampling methodology was used to draw a sample of 210 eligible women in each of the 10 local government areas (LGAs).
Main outcome measures Utilization of antenatal care (ANC) services, tetanous toxoid immunization, skilled attendant at delivery and postnatal care.
Results Majority of the respondents, 73.2%, were between the ages 20 and 34 years. Overall, 50% of the women attended antenatal clinics during their last pregnancy, with a range of ANC coverage by LGA of 14.0–81.0%. The proportion of women who booked in the first, second and third trimesters was 22.8, 63.0 and 14.2%, respectively. The antenatal services offered ranged from 95.7% for abdominal examination to 41.2% for urine examination. Sixty percent of the women received no tetanus toxoid in their last pregnancy, 11% had one dose and 29% had at least two doses. Home delivery was still the norm throughout the zone with 1791 (85.3%) delivering at home. Up to 80.5% of the deliveries were supervised by personnel with no verifiable training in sanitary birthing techniques. Only 11.4% (233) of those who received ANC had postnatal check-up.
Conclusions Maternal health care as evidenced above is far from the ideal. Likewise, the commitment of the 5th Millennium Development Goal is extremely far-reaching: to reduce the maternal mortality ratio by 75% by the year 2015 with this level of maternal care.
Decades after launching the Safe Motherhood Initiative in Nairobi in 1987, maternal mortality continues to be the health indicator, showing the greatest disparity between developed and developing countries.1 WHO and UNICEF estimated maternal death to be 585 000 every year, with 90% occurring in sub-Saharan Africa and Asia.2,3 Maternal mortality ratio (MMR) in the least developed countries has hardly changed over the past decade, and in 12 African countries, the MMR has actually risen since 1990.4 The tragedy of maternal death is multiplied by the consequences on the offspring, the chance of death for the children (whose mother died) younger than 5 years is as high as 50% in developing countries.5 Safe Motherhood policy is largely focused on improving skilled attendance at delivery and access to Emergency Obstetric Care (EOC) in hospitals, but many countries are far from achieving the skilled attendance goal.6 It is estimated that 45 million pregnant women do not receive any antenatal care (ANC), 60 million women give birth every year without the assistance of a skilled attendant and 90–100 million women do not receive any postpartum care within medical establishment in the developing countries.7 In Nigeria, 60% of women attended ANC during pregnancy,8 58% of women deliver at home and only 12% of women are attended by skilled attendant at delivery.9
UNICEF, a development partner supporting the Safe Motherhood Initiative and Child Health services, conducted a community-based survey in the zone D in North East Nigeria to obtain accurate data for planning and evaluation of her 5-year programme cycle. The objectives of the study were to assess maternal healthcare services including the level of utilisation of ANC services, tetanus toxoid (TT) immunisation, skilled attendant at delivery and postnatal care.
In Nigeria, the UNICEF Zone D comprises ten states that make up one of the four primary healthcare zones in the country, namely, Borno, Yobe, Adamawa, Taraba, Gombe, Bauchi, Nasarawa, Plateau, Jigawa and Kano States. It has a total of 213 local government areas (LGAs). The zone has the largest landmass in the country and is comparatively the least densely populated. The inhabitants of the zone are mainly agrarian and nomadic by occupation. There are many ethnic groups in the zone, with Kanuri and Fulani predominating towards the northeastern end of the zone and increasingly diverse ethnic groups as one moves southwards. Islam is the main religion practiced in the more northern states, while Christianity tends to predominate as one moves southwards.
Two hundred and ten mothers of infants aged 0–11 months were sampled in ten LGAs using the 30 by 7 WHO cluster sampling methodology, in which the primary samples were selected based on probability proportionate to size. A listing of all the settlements in the LGA and their populations was obtained, a cumulative population for the listed settlements was computed and a systematic sampling was performed to obtain 30 clusters from the cumulative population listing. The settlement where a cluster fell constituted one of the sampled settlements. In each of the sampled settlements, the centre of the settlement was located by balloting performed to determine the direction to start the secondary sampling. In the direction chosen, all the houses in that direction were counted, and the first house to be sampled was selected by balloting. Subsequently, all consecutive houses were entered to identify the presence of mothers of infants aged 0–11 months. Seven eligible mothers were then sampled per cluster and interviewed. Data were collected using the maternal care questionnaire, which had detailed inquiries into ANC utilisation, deliveries, postnatal care services and TT administration. The Federal Office of Statistics in the zone, the partners used by UNICEF, provided the personnel who served as supervisors and interviewers for the survey. The supervisors, one per surveyed LGA, and their zonal coordinators underwent a 2-day training to acquaint them with the purpose and methodology of the survey and their roles during the survey. Data collection across the zone took place over 2 weeks.
The Epi Info™ version 6 (CDC, Atlanta, GA, USA) statistical software was used for data entry, validation and analysis. The Epi Info™ questionnaire and a check file were developed centrally to ensure that only legal entries in prespecified ranges could be entered.
Ethical approval was obtained from Aminu Kano Teaching Hospital Ethical Committee. While, in each location visited, the team first visited the community leaders to whom a full explanation of the goals and methods of the survey was rendered and their permission obtained. Furthermore, feedback was provided to these leaders immediately after the survey. In each household, the same procedure was followed. Each house head was informed that participation was voluntary and that no adverse action of any sort will result from their refusal to participate. The consent of the husbands and wives (respondents) were obtained before commencement of each interview.
Information was collected from a total of 2101 women who had delivered within 11 months from the survey period.
Majority of the respondents, 72.9%, were between the ages of 20 and 34 years, and 11.8% of the respondents were adolescents, with 12 (0.6%) of them younger than 15 years, indicating that early marriage is still practiced in the zone.
The mean number of pregnancies the women have had was 6.7, while the mean number of live births was 5.7. On average, a woman had given birth to one child by the age of 19 years, three children in her 20s, four in her early 30s and six by her late 40s. More than 50% of the women had eight or more children in their late 40s.
Overall, 50% of the women interviewed across the zone indicated that they attended antenatal clinics during their last pregnancy. The ANC coverage ranged from 14.0% in Machina LGA, Yobe State, to 81.0% in Mubi South LGA, Adamawa State, as shown in Table 1.
Table 1. Maternal care service utilisation across the UNICEF focus LGAs in Zone D
|Place of delivery of mothers in UNICEF focus LGA in Zone D|
|Primary healthcare facility||3.8||1.0||5.7||5.7||9.5||11.4||5.7||12.0||—||2.4||5.8|
Sources of ANC
Government Primary Health Centers were the main sources of ANC used by 51.4% of the 1052 women who received ANC. Government hospitals and private clinics were used by 32.9 and 14.5% of the antenatal clinic attendees, respectively. Twelve others (1.1%) used other service outlets.
Number and timing of ANC
The median age of the last pregnancy at booking for the 1051 women who received ANC was 5 months. Only 22.8% of the women who received ANC booked in the first trimester, 63.0% of the women booked in the second trimester and 14.2% did not start attending antenatal clinics until they were in their last trimester.
Of the women who received ANC, 56.6% attended at least four antenatal visits. However, overall, only 28.3% of all the respondents received ANC with a minimum of four visits.
Quality of ANC
For the 1052 who indicated that they attended antenatal clinics during their last pregnancy, they were asked whether they received the following specified items of care, at least once, during the course of the antenatal visits: abdominal examination to assess fetal growth, weight measurement, blood pressure measurement, blood examination, examination of urine, haematinics and TT injection. The care given ranged from 95.7% for abdominal examination to 41.2% for urine examination. Only 34.1% of the women who attended antenatal clinics and 17.1% of the total 2101 women interviewed had abdominal examination to assess fetal growth, weight measurement, blood pressure measurement, blood examination and urine examination.
In addition, only 17.1% of the women who received ANC and 13.9% of the overall women had haematinics, and TT in addition to the above services. Hawul LGA had the best indicators, while Machina LGA recorded the worst rates.
Sixty percent of the women in the zone received no TT in their last pregnancy, 11% had one dose and 29% had at least two doses. The rates of having at least two doses of TT varied across the LGAs with Donga having the lowest coverage of 5.2% to Mubi South with the highest coverage of 60.5% as shown in Table 1. Of the 1052 women who received ANC in the preceding pregnancy, 206 did not receive even a single dose of TT. Nonavailability of the vaccine and lack of awareness of the need for the vaccine were the major reasons cited by 44.2 and 40.3% of the women, respectively, for nonreceipt of the vaccines. Other reasons were fear of adverse effects and lack of faith in the vaccines.
Place of delivery
Home delivery was still the norm throughout the zone, with 1791 (85.3%) delivering at home. Health facilities including public, not for profit and private, took 14.7% of deliveries. These general proportions were reproduced across the zone as shown in Table 1, with the lowest proportion of home deliveries in Donga LGA of Taraba State (74.7%) and the highest in Takai LGA of Kano State (95.2%).
Assistance at delivery
As most deliveries took place outside the health system, most were not attended by trained personnel. A total of 80.5% of the deliveries were attended by personnel with no verifiable training in sanitary birthing techniques. These included traditional birth attendants (TBAs) and village health workers, parents, in laws, neighbours and other relations who happened by at the critical moment. Only 19.5% were attended by personnel with medical training although the exact nature of their qualifications is not directly derivable from the responses since terms like doctor or nurse carry cultural connotations that differ from the orthodox definitions.
As expected, medical personnel attended 86.4% of health facility deliveries compared with 5.1% of home deliveries. However, nonmedically trained personnel attended 3.4% of health facility deliveries. This is distressing, and needs to be further investigated.
Complications of delivery
Despite the large proportions of home deliveries, only few women reported complications. Overall, 354 (16.9%) reported at least one form of complication. This ranged from 10% in Machina and Maigatari LGAs to 23.8% in Shongom LGA. Donga, which has a relatively high proportion of health facility deliveries, had the second highest rate of complications (23%).
Most of the 354 women reporting complications had prolonged labour (33.9%), abnormal bleeding (26%) or postpartum fever (22%). The complications of delivery occurred in all the locations, with high proportions in health facilities (28.3% in private and 25.8% in general hospitals).
Only 11.4% (233) of those who received ANC returned for a postnatal check after 6 weeks. Table 1 also shows the rates of postnatal check across the zone ranging from 2.4% in Machina LGA to 18.9% in Darazo.
The key findings in this study include a low utilisation of ANC (50%), delivery services (14.7%) and postnatal care (11.4%) among women in Northern Nigeria. In addition, only 29% of women attending ANC were given at least two doses of TT immunisation during their last pregnancy.
The percentage of antenatal attendance in the last pregnancy was 50% in this study. This figure is higher than the 40.3% antenatal clinic attendance recorded for the zone in the 1999 Nigerian Demographic and Health Survey (NDHS)9 but lower than the national antenatal attendance of 60%.8 Machina, Maigatari, Takai, Langtang South and Darazo LGAs recorded coverage levels below the zonal average. While Machina and Maigatari LGAs appear to be hard to reach and very disadvantaged LGAs and Langtang South have been paralysed by communal clashes, there does not appear to be any obvious reasons for the poor coverage in Takai and Darazo LGAs.
The effectiveness of ANC in improving pregnancy outcome is in part determined by the age at booking and the number of antenatal visits. It is recommended that pregnant women book in antenatal clinics as soon as they know that they are pregnant and optimally should have at least four antenatal visits during the course of the pregnancy based on the focused ANC package.10 Of the women who had ANC, 56.6% attended at least four antenatal visits. This means that only approximately half of the women who had ANC were aware of the importance of regular ANC and were sufficiently motivated to avail themselves of the service. However, overall, only 28.3% of all the respondents received ANC with a minimum of four visits. This is comparable with the figure recorded during the 1999 NDHS,9 with only 27% of women attending up to four ANC visits.
In addition to attendance at antenatal clinics, the quality of care received in the clinics is another major determinant of pregnancy outcome. Only 34.1% of the women who attended antenatal clinics and 17.1% of the total 2101 women interviewed had abdominal examination to assess fetal growth, weight measurement, blood pressure measurement, blood examination and urine examination. Likewise, in the 2003 NDHS,8 58% of pregnant women received iron supplement and 39% received drugs to prevent malaria as part of their ANC. Studies in Zimbabwe showed that the nonutilisation of maternity services is associated with poor fetal and maternal outcomes11 and that the pattern of utilisation of maternity services by rural women was based on rational decision making, which took into account not only the distance to a service but also whether the care provided was seen to be good.12 Hence, the low quality of care offered in our antenatal clinics contributes to the low utilisation of the service.
With the low utilisation of antenatal services, women in Northern Nigeria are unlikely to use healthcare services such as EOC services when the need arises. Although focusing on prenatal care inclusive of training TBAs have been shown to provide limited impact on maternal mortality unless emergency obstetric services are available.13 Other studies have also shown that women seeking ANC may be more likely to seek professional care during delivery.14
TT immunisation is given during pregnancy to prevent neonatal and puerperal tetanus. The old national policy stipulated that a pregnant woman gets two doses of TT during pregnancy. However, the current policy recommends that women receive a total of five doses of TT at specified intervals, beginning as soon as they attain the reproductive age. Difficulties in accessing women while not pregnant have hampered the implementation of the revised policy. Consequently, healthcare providers continue to implement the old policy. Only 11% of women had one dose of TT and 29% had two doses. This is not different from the 24% record of women receiving two or more TT injection in the 1999 NDHS.9
The WHO estimates that 60% of births in the developing world still occur outside a health facility with 47% either unassisted or assisted only by TBA.15 This is clearly demonstrated in this study with 1791 (85.3%) women delivering at home and 80.5% of women delivering in the presence of an unskilled attendant. Home delivery is still the norm throughout the zone. This figure is higher than the national figure of 58% of women delivering at home (NDHS 2003).8 This is true of other African countries as illustrated in South Africa where their women describe preferring to stay away from formal care structures for their deliveries.16 TBAs are also likely to remain as delivery care attendants for sometime because of difficulties experienced in posting trained professionals to rural areas in many developing countries. This is unfortunate, given that greater use of services (‘skilled attendant at birth’) is a key step in reducing the half million maternal deaths in developing countries each year.17 Training of TBAs is a controversial issue with many training programmes being abandoned in the 1990s based on the advice of WHO. However, recent meta-analysis of 60 studies showed training of TBAs to be associated with increase in ANC attendance rates by 38%18 and significant improvement in performance and perinatal mortality but no improvement in maternal mortality.19 In regions with very high maternal mortality and very high coverage of delivery by TBAs, it is plausible that training of well-selected TBAs in a culturally appropriate approach in delivery hygiene and prompt referral for complications might have an impact in reducing maternal mortality. However, increasing the proportion of deliveries with skilled attendance is regarded as a crucial intervention strategy and is widely advocated by international agencies.20
Postnatal care services are the least of all maternal care services being used, only 2.4–18.9% of women return to the clinic for postnatal check-up in the zone. This needs to be addressed as more than 60% of maternal deaths occur in the postnatal period,21 and a survey of women delivering in rural homes identified a 43% rate of postpartum morbidity.22
The complications of delivery occurred in all the locations, and the high proportions in health facilities (28.3% in private and 25.8% in government) might merely be the result of selection bias, as women in labour tend to present in hospital only when difficulties arise.
Although our study had certain limitations, namely, reliance on respondent’s recall and self-evaluation and low literacy level among the study population, these effects were reduced by restricting respondents to those who delivered within the preceding year and using local language in administering the questionnaire. Furthermore, the validity of self-evaluation has in many studies proved to be realistic.23 Therefore, some results may only be indicative of the situation.
Maternal health care as evidenced above is far from the ideal. Likewise, the attainment of the 5th Millennium Development Goal (MDG5) is extremely far-reaching: to reduce the MMR by 75% by the year 2015 with this level of maternal care. Of all MDGs, this goal is the one least likely to be attained. The continuing high maternal mortality in low-resource countries calls for an urgent need to identify and implement those strategies that are most effective in these low-resource countries in the reduction of maternal mortality.24
This study resulted from a large collaborative effort, led by UNICEF D field office and Federal Office Statistics (FOS). We wish to thank Dr Brando Co and Dr Susan Saba-Ojomo of the UNICEF Country Office and UNICEF D Field Office for giving us the opportunity to assess maternal healthcare service utilisation in the Zone D. Likewise, we appreciate the efforts and cooperation of FOS throughout the conduct of the survey.