A FIVE–YEAR REVIEW OF MATERNAL MORTALITY AT THE FEDERAL TEACHING HOSPITAL, ABAKALIKI, EBONYI STATE.
Background to the Study
Maternal mortality remains a major challenge to health systems worldwide (Margaret, Moshen et al; 2010). Of the eight United Nations Millennium Development Goals (MDGs), that of reducing maternal mortality (5th MDG) remains the furthest from reaching its target (MDG report, 2011; Lozano, Wang, et al; 2011). Maternal death is a tragedy for the woman, the child, the families and the communities. The tragedy is that these deaths are largely preventable.
Worldwide, maternal mortality is the health index that shows the greatest disparity between developing and developed countries (Fathalla, 2006: Neilson, 2005). It is an important indicator of women’s health, social and economic status in both developing and developed countries. It is also an indicator of an access to antenatal care and delivery services, and of the quality of these health care systems overall (Fathalla, 2006: Hoj, Dasilva, et al., 2003).
Every day, approximately 800 women die from preventable causes related to pregnancy and childbirth (WHO/UNICEF, 2007). Of these, an estimated 98% occurred in developing countries (WHO/UNICEF, 2007). These high figures occurred despite the Safe Motherhood Initiative (SMI) launched in Kenya in 1987 and Nigeria in 1990, aimed at reducing maternal mortality in Africa.
An estimated 289,000 women suffered maternal mortality in 2013 (Anne, 2014). This represents a fall of 45% since 1990 where there were 529,000 deaths annually (WHO/UNICEF, 2007). This decline was mainly observed in developed countries. Nearly a third of deaths occurred just in two countries: India with 17% (50,000 deaths in 2013) and Nigeria with 17% (40, 000) of maternal deaths (Anne, 2014; WHO/UNICEF/UNFPA, 2014).
Sub-Saharan Africa is the region with the highest MMR (510 maternal deaths per 100,000 live births) accounting for 62% (179,000) of global maternal deaths (Anne, 2014, WHO/UNICEF/UNFPA, 2014), whereas it accounts for only 10% of all women of reproductive age (15 – 49 years) in the world. South Asia and sub-Saharan Africa together accounted for 86% of maternal deaths globally, though they accounted for 22% of all women of reproductive age. These figures when compared with MMR of 9/100,000 and the life time risk of maternal deaths of I in 7300 for the developed regions indicate that pregnancy related deaths in Sub-Saharan Africa is exceedingly high (WHO UNICEF, UNFPA 2007). The cumulative lifetime risk of maternal death is 332 times higher for women in Sub-Saharan Africa (where lifetime risk of maternal death is 1:22) compared to the developed regions (7300/22=332). Perhaps, there is no other health indicator that shows such a high degree of inequality.
In additions for every maternal death, there are at least 30 women who suffer short or long-term disabilities (genital fistula, genital prolapsed, infertility, anemia, chronic pelvic pain). Hence, motherhood can be considered one of the most dangerous occupation (or business) especially in Sub-Saharan Africa, Nigeria inclusive.
Nigeria still has one of the highest maternal mortality ratio (MMR) in the world currently accounting for about 12 – 17% of global maternal deaths as compared with her 2% contribution to global population (WHO/UNICEF/UNFPA,2014). In 2013, about 40,000 maternal deaths occurred in Nigeria and this figure is second only to India which recorded 50,000 deaths (WHO/UNICEF/UNFPA, 2014).
A global analysis of maternal mortality by the WHO showed a MMR of 11 per 100,000 live births for North America and 17 per 100, 000 live births for Europe (WHO, 2005). In developing countries, the figures are higher, influenced perhaps by the quality of obstetric care in the countries. In Cuba, India and Egypt, the MMRs were 45 per 100,000, 450 per 100,000 and 130, per 100,000 live births respectively (WHO, 2005). In Sub-Saharan Africa, the figures ranged from 650 per 100,000 for Ghana and 950 per 100,000 for Burundi (WHO, 2005).
Maternal Mortality remains at unacceptably high levels in Sub-Saharan Africa. Over half of all maternal deaths are found in seven countries. Among these, two countries, India and Nigeria, account for the major percentage of all maternal deaths worldwide. The 10 countries with the worst maternal mortality ratios are all in Sub-Saharan Africa: Sierra Leone (1,100 per 100,000 live births), Chad (980), Central African Republic (880), Somalia (850), Burundi (740), Democratic Republic of the Congo (730), South Sudan (730), Côte d’Ivoire (720), Guinea (650) and Liberia (640)(WHO, UNICEF, UNFPA and The World Bank, 2013).
In Nigeria, reports from the Federal Ministry Health indicate a gradual reduction in MMR – 1,100 per 100,000 in 2005 (WHO, 2005) 800 per 100, 000 in 2007 (NDHS, 2007) and 540 per 100,000 in 2009 (NDHS, 2009). The yearly average of MMR in Nigeria is currently estimated to be 560 maternal deaths per 100,000 live births and an appalling life time risk of one in 41 in 2013 (WHO/UNICEF/UNFPPA, 2014). Although Nigeria’s average MMR has partly declined between 1990 and 2013, it is yet to reach the reduction rates as recommended by the MDGs with less than one year to the target.
It is however worrisome that available evidence suggests conflicting institutional figures of MMR and these figures vary according to the geopolitical zones of the country. In Sokoto, northwest Nigeria – 2,151 per 100, 000 (Audu & Ekele 2003), 2,735 per 100,000 in Port Harcourt, south east Nigeria (Uzoigwe and John, 2004), 740 per 100, 000 in Jos, North central Nigeria (Uja, Aisien et al., 2005) 2,989 per 100,000 in Shagamu, southwest Nigeria (Oladapo and Odusoga, 2006), 772 per 100,000 in Enugu, South east Nigeria (Onah, Okaro, et al, 2005), 906 per 100,000 in Abakaliki, South east Nigeria (Onoh, Umeora et al, 2007).
The shocking reality of this high maternal mortality burden has led to renewed vigour in seeking solutions. Although Nigeria’s average MMR has partly declined between 1990 and 2013, it is yet to reach the reduction rates recommended by the MDGs with less than one year to the target. MDG 5 targets 75% reduction of the maternal mortality ratio between 1990 and 2015, requiring an average annual reduction of 5.5%. In the African region, the annual average reduction from 1990 – 2010 was 2.7% (Anne, 2014).
Much work has been done on maternal mortality but it still remains a focal issue as we approach the deadline of the target of MDG5. The latest study on maternal mortality at the Federal Teaching Hospital, Abakaliki was in 2005 when a MMR of 906 per 100,000 live births was obtained (Onoh, Umeora, 2007). Since then, several positive changes have taken place both in human resource for health and infrastructure. These were mainly aimed at reducing maternal deaths and improving maternal health. The extent to which these changes affected maternal mortality will be evaluated in this study.
Statement of the Problem
Pregnancy and childbirth are physiological events and hence supposed to be a pleasurable experience. Unfortunately, deaths as a result of pregnancy and childbirth are alarming and worrisome as approximately 800 women die every day from preventable causes related pregnancy and childbirth (WHO/UNICEF 2007). Ninety-eight percent of these deaths occur in developing countries. Nigeria currently has one of the highest MMR in the world. Unfortunately also no comparable sense of urgency has been deemed fit for the millions of our young women on this steep and dangerous road of maternal death in most countries of Sub-Saharan Africa.
Maternal deaths decimate the reproductive age group of our women, truncate family ties, debase the social and economic status of women and eventually lead to developmental backwardness. For every woman who dies, approximately 30 more suffer severe long term complications (genital fistula, genital prolapsed, infertility, anemia). Moreover, maternal deaths are usually associated with collateral damages like fetal demise and early neonatal deaths. Millions of other children are left motherless with the risk of death of children under five years of age doubling if their mother dies in childbirth (UNICEF, 2001). Hence, maternal mortality is not just a health disadvantage; it represents a huge socio economic loss to the family, community, governments and nations (Khan, Wojdyla and Say, 2006).
As the deadline for achieving the target of the Millennium Development Goal 5 approaches, it becomes pertinent to review maternal mortality trend to establish the extent of compliance. The last study on this subject in this centre was in 2007, to the best of the researcher’s knowledge (Onoh, Umeora. 2007). Since then, several efforts were made to improve obstetric services. These included, reduction in fees for obstetric services, improvement in blood banking services, provision of more facilities for emergency obstetrics and man power development. The extent to which these have reflected on the maternal mortality ratio will be evaluated in this study.
Purpose of the Study
The purpose of the study is to review maternal mortality for five years at the Federal Teaching Hospital, Abakaliki. This has become necessary because of the structures that were put in place since the last study was conducted. These structures were aimed at improving women’s health and making motherhood safer.
Objective of the Study
Specific objectives of the study are to:
- Determine the maternal mortality ratio (MMR) at the Federal Teaching Hospital, Abakaliki over a five-year period (1st January 2010– 31st December 2014).
- Establish the trend of maternal death over a five-year period at the Federal Teaching Hospital, Abakaliki.
- Identify the causes of maternal deaths at the Federal Teaching Hospital, Abakaliki (FETHA) over a five-year period (1st January 2010– 31st December 2014).
- Establish association between occupation and causes of maternal mortality at FETHA.
- What is the maternal mortality ratio at the Federal Teaching Hospital, Abakaliki?
2. What is the trend of maternal deaths over a five year