Introduction — To be invited to share this platform with some of the best minds, past and present, in the Nigerian intellectual firmament, selected as they were, from diverse backgrounds and cosmopolitan origins, which had delivered the O.K. Ogan Memorial Lecture, is a great privilege and honour. I thank the Head, all staff and students of the Department of Obstetrics and Gynaecology of the University of Nigeria, as well as the leaders of the various institutions that house the department – the Chief Medical Director of the Teaching Hospital, the Provost of the College of Medicine and the Vice Chancellor of the University, for finding me worthy of this honour and privilege and for approving of my presence here today.
The sundry nature of the previous lectures, some of which ranged from Medical Education in Developing Countries to the Economics of Health Care Delivery, and from Medical Insurance to Fertility Regulation, portray the versatility and multiplicity of the contributions of the late O.K. Ogan, who has been aptly described as “a citizen of the world”1 and in whose memory we are all gathered today, to the improvement in the quality of life of ordinary Nigerians when he was alive. For be it in his days as a student at King’s College Lagos, where he was in the first team of the college’s football, cricket and hockey squads, to his time at the Federal Public Service Commission, as its Chairman, social justice and equity were his abiding philosophy. And it is on these values that today’s lecture is predicated as indeed high maternal mortality which affects mainly the poor and deprived in the society, is iniquitous and a social injustice. For I am persuaded that should the late O.K. Ogan communicate with us, his protégée, today, he will demand to know “Why do many women still die in childbearing in Nigeria”? Judging from how relentlessly he strived to improve the lot of women and children.
In responding to this question, I shall first confirm that maternal deaths are truly far too many in Nigeria, even by the standards of developing countries. Then I will give a simple answer as to why this is so: the medical causes of maternal deaths. Next, I will indicate that because the stated causes of death are preventable or easily treatable in ideal environments, it is not they alone, but also, the underlying mass poverty, ignorance, deprivation, illiteracy and general lack of development with which these deaths are associated, that should be tackled as the real bases for the many maternal deaths in the country. In the subsequent sections I will review Nigeria’s development efforts over the years and conclude that it is in these efforts that the key for the large scale reduction in the number of women who die in childbearing, resides.
The Magnitude and Complexity of the Problem
The Joint News Release that was made by the WHO/UNICEF/UNFPA/World Bank in October 2007 estimated that 59,000 women died in 2005 while pregnant or within 42 days of the termination of a pregnancy in Nigeria.2 Thus, although Nigeria, which, with a population of about 140 million, accounted for about 2% of the world’s population, it contributed about 11% of the global estimates of 536,000 maternal deaths in that year. The only other country that had a higher absolute number of maternal deaths for 2005 was India, the second most populous nation in the world, with a population of about one billion and estimated maternal deaths of 117,000.3,4,5
Even at this, the quoted number of maternal deaths in Nigeria is regarded by many as underestimates as there are no reliable records of deaths across the country – such information being gleaned from poorly kept records in various health institutions and often times, from verbal accounts from relations of the dead. This was the core finding of a number of important surveys in the country, giving the Nigerian woman one of the highest risks of dying in pregnancy – 1 in 18 (some say 1 in 16), and the country, a maternal mortality ratio (number of maternal deaths per thousand live births) in excess of 1,000 per 100,000 live births in some instances. These surveys include the Zaria Maternity Survey6, the Nigeria Demographic and Health Survey7, the Status of Emergency Obstetric Services in Six States of Nigeria8 and the Annual Reports of the Obstetrics and Gynaecology Department of the University of Port Harcourt Teaching Hospital9.
Furthermore, estimates of maternal deaths in Nigeria are too high even by the standards of developing countries – including many sub-Saharan African countries, where over 50% of the global maternal deaths occur. A review of the League Table of Maternal Deaths indicate that countries like Mauritius, South Africa, Cameroon, Kenya, Ghana and Tanzania all have lower maternal mortality ratios than Nigeria which finds itself jostling for bottom positions in the League Table with countries like Mali, Ethiopia, Eritrea and Niger that are far less endowed than it in human and material resources. Additionally, the evidence available shows that the maternal mortality ratios in Nigeria have not fallen appreciably in the past three decades, hovering around a national average of about 800 per 100,000 live births10; by some accounts they have increased.7,9
However, the point must be made that variations exist in the distribution of these deaths in the various parts of the country – they were least in parts of the South/West and South/East and highest in those of the North/East and North/West7.
As for those who died, the reports showed that they were mainly young or teenage girls under the age of 20 while having their first pregnancies, or women over 35 who were persisting with large number of deliveries, not uncommonly, in rural settings. Maternal deaths, it was found, occurred more frequently in persons that were illiterate or with a modicum of education. More often than not, such persons were poor, deprived and socially, heavily dependent.
Medical Causes of Maternal Deaths
Regarding the direct causes of death, it is known that more than 70% of all maternal deaths in Nigeria are due to five major complications of pregnancies:
In most instances these conditions are preventable and treatable through expert prenatal care and prompt and efficient intervention when things go wrong during the course of pregnancy or delivery thus reaffirming the position of the Director-General of WHO, who in 1998 stated that
“the interventions that make motherhood safe are known and the resources needed
are obtainable; the necessary services are neither sophisticated nor very expensive,
and reducing maternal mortality is one of the most cost-effective strategies available
in the area of public health”.
.
In parts of the world where maternal deaths are high therefore, it must be that these inexpensive interventions are not being effectively applied or there exist other factors which promote death in such large numbers.
In Nigeria, several factors – medical and development issues – act together to ensure high maternal death rates including:
Maternal Deaths as a Development Issue
The Human Development Index (HDI) is the development indicator that is currently in vogue for measuring the development of nations and the well-being of their citizens. Propounded in 1990 by a group of academics and popularized by the United Nations Development Programme (UNDP) through its annual ranking of countries by levels of human development, HDI has been used to categorise countries into developed, developing and underdeveloped.
The indicator combines three basic elements:
Using these three factors, UNDP calculates HDI for various countries which under optimal development conditions amount to 1. HDI below 0.5 is considered to represent low development while HDI of 0.8 or more is considered to represent high development. Most of the countries with HDI of below 0.5 are located in Africa while countries in North America and Western Europe all have HDI of 0.8 or more.
Nothing confirms the fact that high maternal mortality ratios depict underdevelopment as the wide disparity that exits in these ratios as well as the lifetime risk for a woman to die because of pregnancy and childbirth between developed and underdeveloped countries. Furthermore, even in the developed countries, maternal mortality rates are higher among the most disadvantaged groups of that society.14
Globally, 99% of all maternal deaths occur in underdeveloped countries – mainly in South East Asia and sub Saharan Africa. Of the 530,000 estimated maternal deaths per 100,000 live births that occur worldwide, the estimated ratios are 480 for underdeveloped countries and 27 for the developed countries. The highest maternal mortality levels are found in parts of India, eastern and western Africa (all with HDI < 0.5) with some of the least developed countries of the world (800-1,000 per 100,000 live births in Nigeria); the lowest levels occur in northern Europe (all with HDI > 0.8) with some of the best developed countries of the world (<4 per 100,000 live births in Finland).
These ratios can be translated into women’s lifetime risks of dying from pregnancy/pregnancy-related causes as follows: 1 chance in 48 in the underdeveloped countries (in several countries it may even be one in ten) contrasted with 1 chance in 1,800 (in several countries the risk may even be less than 1 in 5,000) in developed ones.12
It is in a desire to bridge this gap in development which underscores maternal mortality and its related issues of poor women as well as inadequate child health that the matter has recurred in many major international development conferences that have been supported by the big global funding agencies – World Bank, UNDP, UNICEF, WHO, Ford Foundation since the commencement of the Safe Motherhood programme in 1987.
Furthermore, as if any doubt still existed, at the turn of the millennium, the relationship between Women’s Health, Maternal Deaths and Development was given a stamp of confirmation by the United Nations when a 50% reduction in maternal deaths by the year 2015, was stipulated as a development target (MDG5) in a set of development priorities that are expected to improve the quality of life for all mankind. These development priorities were identified by 189 Heads of States and Governments in 2000 and christened the Millennium Development Goals (MDGs).
It was for this reason that obstetricians across the globe, at the instance of the Royal College of Obstetricians and Gynaecologists, London, advocated and ensured that Maternal Mortality was at the top of the agenda when Heads of State met in September 2008 to review progress on the MDGs. The purpose was to get the Heads of State to make a serious political and financial commitment to reduce maternal mortality. Happily, at the meeting on the 25th of September, 2008, the United Nations teamed up with world leaders to launch a new initiative to strengthen health systems in an effort to reduce the number of women who die in pregnancy and childbirth. The task force on maternal mortality, which will be co-chaired by British Prime Minister Gordon Brown and World Bank President Robert Zoellick, will focus on innovative financing to strengthen health care systems and pay for health care workers. If this plan comes to fruition, Nigeria will be a major beneficiary since the country, apart from India, produces the largest number of women who die from pregnancy and childbirth in the world.
To buttress the matter further, in June 2008, even before the prompting by the Royal College, a coalition between NGOs in Nigeria and the United Nations Committee on Convention to Eliminate All Forms of Discriminations Against Women (CEDAW) reported its concern to the 41st Session of the United Nations, of the very high maternal mortality rate in Nigeria and its regret that there has not been much progress in reducing these deaths in the country.
It is in the light of this association between high maternal deaths and underdevelopment, that the Maternal Death Road (Figure 1) which Mahmoud Fathalla described at his MacArthur Foundation lecture,12 could really be seen as the Path to Underdevelopment. For unlike the “detours and shortcuts” which Deborah Maine rightly condemned in a recent article15, advancement of the status of women, community based prenatal services for pregnant women as well as the other parameters which were cited by Fathalla as being factors that could lead one away from the risky path of maternal death, are, in reality, development issues.
It is therefore not surprising to note that maternal mortality ratios in Nigeria are not uniform in the different parts of the country. They are least in South-West Nigeria where literacy rates are highest and health facilities are more and better organized than is the case in the other parts of the country.7
Many Nigerians believe that this comparative advantage which the western part of the country has acquired is a product of the free and compulsory primary school education which the visionary leaders of that part of the country instituted in the 1960s well in advance of the other sections of the country. Nigeria’s rural communities, where infrastructure is poor, health facilities inadequate and badly run and literacy rates low, constitutes the home for the majority of the deaths.
Nigeria’s Development Efforts
Since such a close relationship exists between high maternal death rates and national underdevelopment, it will be pertinent at this point to review, briefly, Nigeria’s development efforts since it acquired independence from its British colonial rulers in 1960.
Nigeria’s earliest post-independence efforts at development, designed to change the conditions of its citizens for the better, were through Five Year National Development Plans: 1962-1968(first), 1970-1974(second), 1975-1980 (third), 1981-1985 (fourth), and 1988-1992 (fifth). Buoyed by massive influx of funds mainly from the sale of the nation’s crude oil in international markets, these periods of development initially supported a post fratricidal war (1967-1970) reconstruction with a GDP growth of 12.3 per cent per annum (what was envisaged was 6.2) and were envisioned to bear a 12 fold increase in annual public capital expenditure with enormous expansions in agriculture, industry, transport, housing, water supply, health facilities, education, and rural electrification. A superfluous Festival of African Arts and Culture (FESTAC) with global participation and huge financial outflow was undertaken during the period.
Regarding the health sector, it was stated, among others, “all Nigerians shall have easy access not only to primary health care facilities but also the secondary and tertiary levels as required. Particular attention shall be placed on the needs of the remote and isolated communities, which have special logistic problems in providing access to the referral system” (3rd National Development Plan).
However, on account of lack of adequate planning, profligacy, corruption and unanticipated fall in returns from the sale of crude oil, among others, total inflow of funds into the economy dropped substantially. The rate of development of the nation at the anticipated pace became unsustainable and abandoned developmental projects dotted the country’s landscape, including university teaching hospitals which were expected to serve as the nation’s apex health institutions.
So, when in 1989 the Ibrahim Babanginda’s military regime decided to abandon the concept of fixed five year plans, and to replace them with a three year “Rolling Plan”, Nigeria, as a nation, was in steep decline. Sadly, the Structural Adjustment Progamme (SAP) which the country was railroaded to adopt by the International Monetary Fund (IMF), as a means of stemming and reversing this decline, only aggravated the situation as the country’s currency was drastically devalued thus putting the essentials of everyday life beyond the reach of many of its citizens. Poverty deepened and all its attendant consequences became manifest in their harshest forms, including sustained social unrest in parts of the country.
Dithering then, as it were, on the precipice of a failed state, Nigeria elected a democratic government into power in May 1999 which was led by Chief Olusegun Obasanjo in contrast to the repeated military dictatorship of the previous years. That government, using a number of fiscal and social engineering instruments – National Economic and Development Strategy (NEEDS), Bank Consolidation, Due Process, Poverty alleviation, Debt Reprieve, Fight against Corruption, among others, succeeded, to some extent, in pulling the country from the precipice. The GDP growth which had dipped to 3.5% annually is now 6.9% with inflation rate remaining in the single digit. Nigeria is becoming a major player in the global banking sector and spectacularly so in Africa. A respectable foreign currency reserve of 63 billion US dollars (as at October 2008) has been built up by the country from the paltry one of 4.7 billion dollars (as at January 1999). Furthermore, there is an inflow of foreign investment which has remained strong at about $8.5 billion by the end of August 2008, compared to $5.8 billion for the corresponding period of 2007. Many, however, are expressing anxiety about the safety of this foreign reserve in the wake of the current turmoil in the American financial market where a sum of $1.2 trillion was lost from the stock market in one single day! And again others have argued that this increase in the nation’s wealth has not been seen to improve the living conditions of its citizens.
The present administration of Umaru Musa Yar’Adua (elected into office in May, 2007) wishes to consolidate the gains of the previous one through insisting on the Rule of Law and a Seven Point Agenda Plus Two Special Issues which are aimed at transforming Nigeria into one of the world’s 20 largest economies by the year 2020: Power and Energy; Food Security and Agriculture; Wealth Creation and Employment; Mass Transportation; Land Reform; Security; Qualitative and Functional Education; Plus Two Special Interest Issues…. Niger Delta and Disadvantaged Groups.
Even with all this, Nigeria currently remains an underdeveloped and poor country which had frittered away several opportunities to have bettered the lot of its citizens. According to UNDP publications, the country, with an HDI of 0.470, occupies the 158th position in the HDI list of 177 countries. Since 1975, Nigeria’s HDI has been consistently lower than the sub- Saharan average. The probability of its citizens surviving beyond the age of 40 years is 39.0%. Twenty nine per cent of its children (0-5years) are underweight and with an under five mortality rate of 190 per 1,000, the country is rated as one of the world’s worst country for child survival. Adult literacy (% of ages 15 and above) rate is 30.9% and only 52% of its citizens have access to improved water supply. With 60% of the people living below the poverty line of USD 2 per day, more Nigerians live below than above the poverty line and only recently, a publication in the Guardian Newspaper (Friday, September 12, 2008) quoted Dr. Magnus Kpakol, the country’s National co-ordinator for the National Poverty Eradication Programme (NAPEP), as saying that 70 million Nigerians live below 65 naira (the nation’s currency) a day. This amount, it was observed, is about 48 cents below the $1 dollar mark for the poorest countries around the world. .
It is this state of poverty and underdevelopment with “infrastructural deficit” that is blindingly obvious, that constitutes the Real Issue16 as far as the huge number of women who loose their lives in childbearing in Nigeria is concerned. For, it ensures that priority attention is not given to the health delivery system; that the system is poorly funded, inadequately staffed and functions inefficiently. It is responsible for the large number of illiterate and ignorant persons in the country who are unable to take some responsibility for their own health and so do not utilize the existing health services, such as there are, even when things go wrong in childbearing. It explains the large number of poor persons (those who live on < two US dollars per day) in the country that is unable to pay for medical care and so do not have prenatal care or delivery by skilled attendants in health institutions. It assures the absence of essential drugs in some health institutions and also the absence of cheap and reliable means of transportation with which women can be quickly transferred to better equipped centres for expert care when life-threatening complications arise in the course of pregnancy and labour. It adds on to the type three delay which contributes significantly to maternal deaths even in major hospitals in the country where due to epileptic electric power supply and absence of clean water for washing of hands and scrubbing, life saving emergency operations, are postponed for several hours because the intersectoral collaboration (steady power supply, accessible roads, clean environment, potable water) which should support the health care delivery system practically do not function17.
Successful Models in Maternal Mortality Reduction
While the main theme of this lecture is not directed at suggesting ways by which the large number of maternal deaths in Nigeria could be reduced, it will be remiss not to indicate that high maternal mortality is not an insurmountable problem and that many countries have succeeded in bringing down high maternal deaths over the years. A few examples will suffice.
The United Kingdom and Nigeria share close ties (Britain, as part of the UK, served as Nigeria’s colonial masters in pre-independent years and many Nigerians live in or travel there frequently for various reasons); it will be appropriate to commence by examining how that country effected a large scale reduction in its number of maternal deaths.
Available evidence indicates that Reports of National Enquires into Maternal Deaths in England and Wales have been published since 1915.14 These reports point out that Maternal Mortality Ratios were high in England and Wales and did not fall substantially until 1930 when they cascaded chiefly in response to the introduction of sulphonamides for the treatment of puerperal sepsis which was a major cause of death then.
The death rates further fell in the aftermath of the Second World War when the Government of the UK created the National Health Service (NHS) as part of the “cradle to grave” welfare reforms for its citizens. Aneurin Bevan, then Secretary of State for Health, introduced the service which was committed to providing quality care that met the needs of everyone, free at the point of need, based on patient’s clinical need and not ability to pay. Every member of every community signed up with a specific General Practitioner as a way of entry into the system. From that point on, any resident of the UK would have access to any kind of treatment they needed without having to pay for it.14
So, it was a combination of social reforms which advanced the quality of life, free and improved medical services for all which guaranteed the inclusion of the poor, and upgrading in the organization of maternity services as recommended by the Reports of the National Enquires into Maternal Deaths which resulted in widespread use of antenatal care, that drastically reduced maternal deaths in the UK to their current ratio of 8 per 100,000 live births and a life time risk of dying of 1 in 8,200.
If the UK example is considered as inappropriate in comparison with Nigeria, the former being rich and developed and the later, poor and underdeveloped, examples of the state of Kerala in India, and Cuba, both poor-resourced environments, show that even in such circumstances, massive reduction in maternal deaths could be achieved.
Kerala, one of the twenty eight (excluding the capital city of Delhi) States (population about 32million) in the Indian Union, is located in the south western part of the Indian peninsula. The State is poor – income per capita per year is USD 320 compared to the USD 770 for the country. But here, social (wealth, especially land redistribution) and educational reforms that were enacted in the late 19th century were expanded upon by post independent governments (free primary and secondary education) making the state one of the most literate (literacy rate of almost 100%), healthiest (infant mortality of 10 per 1,000 live births) and gender equitable states in India. Thus, the essential demographic transition which was required to reduce high maternal deaths (currently 90 per 100,000 live births) was achieved through high female literacy, low fertility at replacement rate, a social structure that is uniquely favourable to female emancipation (matrilineal inheritance) and easily accessible free family planning services. Kerala, with HDI of 0.602, ranks first among all the States of India in the Human Development Index and is now a key player in the emerging global health tourism industry.
The paradigm from Cuba, another developing country which has also made good its maternal mortality indices is similar. In that country, good health is considered as a fundamental right of all its 11.4million citizens and so health care is regarded as a national priority. Accordingly, the National Health System assumes complete fiscal and administrative responsibilities for the health of the people; there are no private health care delivery institutions. Literacy rate is 96.4%; infant mortality, 7.2 per 1000; maternal mortality ratio, 24.1 per 100,000; physicians per 10,000 individuals, 582.18
The lessons that emanate from these three examples are easy to comprehend. For large-scale reductions in the number of maternal deaths in developing countries, Nigeria inclusive, the following are minimum imperatives:
Other than the examples given, many other countries like Malaysia, Singapore and Sri Lanka also have their success stories to tell. Indeed a World Bank study carried out in 2003 concluded that using the approaches that have been described, maternal mortality could be halved in developing countries every 7-10years.20
Concluding Remarks
Let me now conclude by appreciating this department for keeping the memory of such a great man alive. My understanding is that your collective will to do so is predicated on those sterling qualities you identified in the cerebral Okoronkwo Ogan when he was alive – qualities which many would wish they had but which unfortunately are found in few, select individuals:
And so your action of keeping his name and memory evergreen must transcend an annual ritual of public lectures, however academically stimulating and professionally instructive. Keeping an effigy of O.k. at the entrance to the Labour Ward as an inescapable surrogate of his mortal self is a step in the right direction but to my mind, practicing Okoronkwo Ogan in our daily lives would even be a better way of immortalizing the name of that fine gentleman. We must not forget that it was he who started this department as its Head – the department that has been able to produce a gold medalist at the British Royal College of Obstetricians and Gynaecologists examinations in London, a feat which no other department in the universities in Nigeria has so far been able to achieve. This department must, ipso facto, be adjudged the best, by any yardstick, not just in Nigeria but indeed in the whole of the continent of Africa in the quantum of its research output, the sophistication of its patient care, the rigour of its tutelage and the amity of its members; none other has had such a distinctive foundation.
The plank of my lecture today has been that behind the well-known medical causes of death from torrential genital tract haemorrhage, generalized convulsions and systemic infections, among others, that kill women in and around pregnancy, there is a less appreciated wider web of poverty, ignorance and general underdevelopment that unpin the large number of maternal deaths in Nigeria – factors which Kelsey Harrison described in a recent Commentary on Maternal Mortality in Nigeria as the “Real Issues”.16
To bring about a drastic cut in these deaths therefore, Nigeria, as a nation, must seek to develop its people in a meaningful way and take those political decisions and concrete actions that will lift the vast majority of its people out of poverty, deprivation and ignorance and in the main, afford them a better quality of life. For, as a core issue, high maternal mortality depicts underdevelopment.
In addition, a robust and functional health system, which is strongest at the community level, where it can engage in preventive and promotive measures like antenatal care as well respond swiftly to the emergencies in childbearing that so often result in death, must be put in place. Furthermore, such a system should be easily accessible by all irrespective of their ability to pay and should be backed by an effective referral system. Entry into this system at the community level should guarantee easy passage to the most advanced level of care anywhere in the country, should this become necessary.
That this has not been achieved so far despite the substantial increase in human and material resources in the health sector over the years, is a major failing of the system and denotes, among others, lack of intersectoral collaboration which is rooted in national underdevelopment.
As a department of Obstetrics and Gynaecology in one of the foremost universities in this country, you must produce men and women whose focus will now shift from disease to health, from the individual to the people, from the hospital to the community, and from tropical medicine to medicine in the tropics if I might borrow from the second O.K Ogan lecture that was most eloquently delivered by no less a person than the father of medicine himself, Chukwuedu Nwokolo.1
It is such actions that affect the downtrodden masses rather the individual, that benefit the poor than they do the rich and that promote the community in preference to the household – shelter from the elements, safety of life and property, food supply to meet daily needs at affordable costs, clean environment that promotes healthy living, potable piped water in sufficient quantity, basic heath care that is predicated mostly on preventive as well as promotive actions, in which “maternal mortality is addressed as part of a continuum of care”,21 that result, ultimately, in drastic reductions in maternal deaths. In his lifetime, Okoronkwo Ogan was a proponent of all this and more. Can we now afford to do less?
References
Why Do Many Women Still Die In Childbearing in Nigeria, by Professor Nimi D. Briggs, OON, MD, FAS at The 2008 ANNUAL O.K. OGAN Memorial Lecture of the Department of Obsterics and Gynaecology, University of Nigeria, Nsukka on Tuesday 14th October, 2008
Pro-Chancellor and Chairman of Council, Federal University, Lokoja, Nigeria. February 2016
Member, Court of Governors, College of Medicine, University of Lagos, October 2015 for four years.
Copyright © 2014 Prof Nimi Briggs. All rights reserved. Designed by Syllable Media Limited +447869717613