Emeritus Professor

Making Motherhood Safe in Nigeria: How Far Have We Gone? Keynote address presented by Nimi Briggs, OON, FAS, Emeritus Professor, University of Port Harcourt at the 46th SCIENTIFIC CONFERENCE of the SOCIETY OF GYNAECOLOGY AND OBSTETRICS OF NIGERIA(SOGON) Affiliated to the International Federation of Gynecology and Obstetrics (FIGO) ABAKALIKI, EBONYI STATE NIGERIA on 22 November, 2012

In a twenty minute talk such as this, there is little room for pleasantries. All the same, we all must pay glowing tribute and congratulations to our great society, the Society of Gynaecology and Obstetrics of Nigeria (SOGON) for its longevity, now in excess of forty years and exponential growth in membership, now in excess of 8001, despite its inauguration by a visionary few of fifty, in 19652.Long may SOGON flourish and long may its members continue to champion the course of the well-being of women in Nigeria.

A study of the themes and subthemes of the scientific conferences of this great society over these forty odd years, will reveal that concern about making motherhood safe for the generality of women in Nigeria, as is indeed the case at this year’s conference, has occupied members attention, more than any other issue. This concern is predicated on the fact that unsafe motherhood has remained the most nagging and intractable challenge which we, as obstetricians in Nigeria, have had to grapple with since the founding of our society. Maternal mortality ratio (MMR), the strongest indicator of the safety or otherwise of childbearing in a society, was estimated at 1,000 deaths per 100,000 births in the 1960s3 in Nigeria when I was a medical student in Lagos. At that time, the likes of the late Moses Majekodunmi and late Okoronkwo Ogan, whom we all venerate, were meticulously stitching together the fabrics of our great society. Today, over 40 years from then, that estimate still subsists in some parts of the country. In others, the estimates are higher4, even though the national average is said to have fallen to 487 per 100,000 births5. Thus making Nigeria, the second highest contributor, second only to India, to global maternal deaths6. Furthermore, for each mother that dies, it is estimated that many others sustain serious pregnancy and labour related complications including vesico/recto vaginal fistulae, severe genital tract infections with associated tubal occlusion and secondary ammenorhoea from severe post partum blood loss6. Thus, it is held that about 12,000 new cases of fistulae get formed yearly in Nigeria and that there is a backlog of over 200,000 unrepaired cases in the country, even though as many as 3-5,000 are repaired annually7. Described as “near-misses”, these mothers who escaped death as it were, but ended up with such horrendous morbidity, more accurately define the real extent to which motherhood remains unsafe in some parts of Nigeria to this day. Again, these figures must be looked upon against the background of the MDGs, especially MDG5, by which Nigeria along with other member states of the United Nations, signed up and committed to reducing the overall maternal deaths in the country, between 1999 and 2015, by 75%.

But does this mean that nothing has been done to make motherhood safe in Nigeria, over these years, especially when viewed against the course of events in some other countries like the United Kingdom where MMR fell by one half every ten years between 1952 and 1982? Of course, a good deal has been done but they may not have sufficiently struck at the root causes of poor pregnancy outcome in the country. The actions taken so far include the provision of expert professional care for women in pregnancy and labour as well as for those with serious complications; improvement in health infrastructure and management strategies together with a better supply of commodities; research on maternal health and publication of findings; enlightenment and advocacy for women’s well-being with policy makers, global financiers, as well as the civil society; birth control measures along with expert post abortion care and the training of professionals on the care of women, within and outside pregnancy, in collaboration with other health care providers..

In examining how far we, as Obstetricians have gone on the path of making motherhood safe in Nigeria, all that time would permit on this occasion, are a few fleeting comments on some events that have occurred at various times which I shall group as the PAST and the PRESENT There will also be some concluding remarks.

THE PAST

Outside the activities of TBAs, which, in a short address like this should receive no more than this mention, available information suggests that health personnel, working as Christian missionaries, were the first to offer expert and institutionalized health care to pregnant women in Nigeria. From 1895 with the Catholic Mission at the Sacred Heart Hospital, Abeokuta, the oldest in the country, to the 1940s, with the Christian Missionary Society (CMS), who, acting in concert with administrative officers in the locality, was able to bring about a reduction in MMR to less than 50 per 100,000 births in parts of the Diocese of the Niger, the available evidence indicates that some of the missions attained spectacular achievements in enhancing the safety of mother and child in childbearing8.In the same vein, Mary Slessor (1848-1915), a young Scottish woman of the Presbyterian Faith, was able to stop the ritual killing of twins in parts of the then Eastern Nigeria9, in the late 19th century. She also used her strong personality to advocate for women’s rights – an action that won her global recognition, including the placement of her bust on the currency of her home state of Scotland9.

This formal Maternity Care, as it were, was given a boost with the advent of the Obstetrics and Gynaecology Department at the University College Hospital, Ibadan in 1950 as part of the then Faculty of Medicine of the nascent University of Ibadan. So also was the establishment of the Island Maternity Hospital, Lagos in 1959, probably as a needed infrastructure for the soon-would-be independent nation. These properly established maternity units with competent midwives and obstetricians rendered services in most aspects of maternal care. They also had training arms where capable and professional health workers – medical students, resident doctors, and midwives – were trained, under the watchful eyes of their respective regulatory bodies – the then Nigeria Medical Council as well as the Nursing and Midwifery Council of Nigeria. These trainees joined the ranks of specialists who had trained mainly in the United Kingdom, and had returned to Nigeria to offer maternity care.

With time, several other teaching hospitals with university affiliations including those in Lagos, Zaria, Benin City, Enugu and Port Harcourt as well as several state- government- owned-hospitals with departments/units of Obstetrics and Gynaecology sprang up in many parts of the country. They swelled the number of sites at which specialised maternity care was offered and also the number of trained persons that could render such unique maternal and child health services.

Mention must be made at this stage of the establishment of two postgraduate medical colleges in the country for the training of specialist doctors in various fields, including obstetricians and gynaecologists. The Colleges are the National Postgraduate Medical College of Nigeria and the West African College of Surgeons. Professional associations, like ours and that of the midwives, with the goal of making motherhood safe in Nigeria, were also formed. In the same vein, scientific journals like our own Tropical Journal of Obstetrics and Gynaecology, that are designed to disseminate professional and scientific information in the field of maternal health were launched.

Regarding research, three, of the many that were carried out then, deserve a mention. The study of the value of the use of the Partogram to graphically record the events in labour by Philpot and his group, albeit in South Africa, the study of multiple births among the Yorubas by the late Emeritus Professor Percy Nylander of the University of Ibadan and that on Blood Volume Changes in Pregnancy by the then Drs. Kelsey Harrison and Linus Ajabor, who, as Professor Linus Ajabor, became a past President of SOGON. He and Harrison were then staff of the University of Ibadan. Whereas Philpot’s work led to the discovery of the use of the Partogram to prevent prolonged labour and eventually to the practice of Active Management of Labour, Nylander’s study provided important information on the care of pregnant women with twins and contributed to work on perinatal mortality in multiple gestations10,11. In the same vein, that by Harrison and Ajabor revealed the correct treatment of patients with severe anaemia in pregnancy. Their work showed that such patients should be given a slow transfusion of packed red blood cells directly, with the simultaneous use of a rapidly acting diuretic like ethacrynic acid and not the direct transfusion of whole blood12,13. This finding revolutionised the care of patients with severe anaemia in pregnancy globally but particularly so in the developing world, where, before then, mothers with that condition died in large numbers.

But as important as the foregoing was, it was the publication in the British Journal of Obstetrics and Gynaecology of the findings of an extensive prospective survey of the outcome of 22,774 consecutive births in Zaria in 198514 by Kelsey Harrison and his collaborators, of which the speaker was one, that served as a watershed and placed the issue of unsafe motherhood in Nigeria, and by extension, the developing world, in true perspective. Lessons learnt from the findings of that survey which were relevant then – over 25 years ago – are still so today. Overall, far too many women, as well as babies, died ( 238 maternal deaths (MMR 1,045.1 per 100,000 births) and 2,716 perinatal deaths) from pregnancy related circumstances. Many of the women that died were illiterates who had had no prenatal care and were rushed to the hospital when serious complications had arisen in the course of childbirth. Such patients either arrived too late for a salvage or the services, within and outside the hospital were not sufficiently robust to save their lives. Also, many who did not die, sustained serious complications that were to haunt them for the balance of their lives, including fistulae, blocked fallopian tubes and secondary ammenorhoea, as was found out in subsequent follow ups. The publication went on to define health and social priorities that are prerequisites to safe motherhood, including an advocacy for something to be done about the poor status that women are generally accorded in the society.

To my mind, the Zaria Maternity Survey (ZMS), as it is popularly called, taken along with other scientific works that had been done at the time, closed an important chapter of perfunctory information in our effort to make motherhood safe in Nigeria as it gave the opportunity for us, subsequently, to approach issues on safe motherhood from the stand point of hard scientific facts.

THE PRESENT

We now know that the major direct causes of maternal deaths in Nigeria are:

• bleeding from the genital tract during abortion – spontaneous or induced, in late pregnancy, during labour or thereafter
• pre-eclampsia and eclampsia arising from hypertensive disorders in pregnancy
• genital tract infection from cases of abortion, or badly handled labour or pueperium
• prolonged obstructed labour and its sequelae, mainly from cephalo-pelvic disproportion
• complications of abortions, including trauma, haemorrhage and infection
• HIV/AIDS. In recent times HIV/AIDS has joined the fray; happily, its effect is declining.

With this knowledge and seeing that most of the direct causes of death are preventable through investment in the proper upbringing of the girl child, better maternity care as provided by prenatal surveillance of pregnancy, close supervision in labour by experts in institutions that are designated for such purposes and family planning, advocacy took the front burner. Such advocacy, under the canopy of safe motherhood which has been directed mainly at policy makers and the civil society, pleads for a better appreciation of women, their peculiar health needs – within and outside pregnancy – and their unique role in society. Government and non-governmental organisations, international donor agencies, philanthropists, and professional bodies like our great society have engaged in as well as served as targets of these advocacy campaigns at the international and in-country levels. The International Safe Motherhood Conference in Nairobi in 1989, the SOGON Safe Motherhood Conference in Abuja in 1990, and even the MDGs in New York in 2000, among many others within and outside the country, are all believed to have derived from the awareness of the magnitude of the problem that was generated by the ZMS. On the whole, the advocacies have shaped policies, supported meaningful research and the introduction of life saving skills, enhanced some degree of improved funding of the health sector and instituted evidence-based management of patients.

I will give a few examples.

Political will for doing something concrete about poor pregnancy outcome in Nigeria appears to be strengthening. The Federal Government has established a policy of free maternity services in its health institutions to encourage women to visit such centres for care when pregnant15 even as the distribution of treated mosquito nets is being stepped up to reduce malaria parasite transmission to pregnant women..It has also instituted a Midwifery Service Scheme (MSS) through which the National Primary Health Care Development Agency (NPHCDA) in collaboration with the UNFPA, is facilitating an increase in the coverage of skilled birth attendants at PHCs in order to reduce maternal, newborn and child mortality. Not without some faults, the scheme has been well received in some communities and was able to win this year’s Commonwealth Association Award for Public Administration. SOGON has also expressed its wish to participate in the scheme through its Voluntary Obstetricians Scheme (VOS) by providing volunteer obstetricians who would render specialised care to reduce the manpower gap in the provision of emergency obstetric services at health centres and general hospitals where resources for maternal health is limited. As further support to the scheme, the Federal Government is planning to pay a sum of N5,000.00 to each woman who has antenatal care (at least four visits), delivers in a health facility with skilled attendants and ensures complete immunization of her baby under the MSS. The payment is seen as an encouragement as well as incentive to offset the incidental expenses women incur in visiting the health facilities16. Furthermore, President Goodluck Jonathan recently launched a plan for “Saving One Million Lives” a year which aims to scale up investment in and the performance of the health sector to save the lives of women and children. Thirteen life saving commodities, including oxytocin and misoprostol for the treatment of post partum haemorrhage and magnesium sulphate for preeclampsia and eclampsia, are to be made routinely available in health institutions. Again, as if to cut down on the 10% contribution that procured abortions make on maternal deaths and also for birth spacing, the President directed that contraceptive commodities should be supplied free of charge.

The care for pregnant women is also being extended to those with HIV/AIDS even though the number of sufferers has dropped to 4.1% from a previous 5.8% in 2001. Such women are identified and treated with antiretroviral drugs so as to Prevent Mother To Child Transmission (PMTCT)18. The outlets for such treatments have increased from 67 in 2004 to 684 in 2010, the target being that 80% of affected women should have access to treatment.

On their part, state governments are also queuing into the drive to make pregnancy safe for Nigerian women. Twenty three of the 36 states in the country as well as the Federal Capital Territory are now implementing free maternity care totally or partially17.In addition, some of them have anchored projects that involve a very close supervision of pregnant women by professionals. Rivers State Government is building 60 modern Primary Health Care Centres to serve as the bases of widespread antenatal care which would be backed by a “home based care” in which health officials would go from house to house to urge people to use the PHC centres for basic health care including antenatal care. In Ondo state, the Abiye Project19 which was established in 2009 as a Safe Motherhood Project for pregnant and nursing mothers as well as < 5 years old children, is succeeding in making pregnancy much safer in the state as the incidences of both maternal mortality and near-misses have dropped drastically. The Delta State Government has recently opened a big mother and child hospital in Oghara, while the National VVF Care Centre in Ebonyi State, which was conceived, constructed and started by the Governor’s wife, Her Excellency Chief Mrs. Josephine Elechi, has an important health education component that reaches out to the community with a message on the proper care for pregnant women, especially when in labour, as the gold standard for the prevention of obstetric fistulae. The good work that is being done by one of us, Professor Oladosu Ojengbede at this centre must be commended. Furthermore, Ebonyi State also subsidises the operations of private hospitals in the state, in a bid to improve access to proper health care by women and children.

In the area of research and capacity building, SOGON members have sustained the educational component of the work of members of the society. The Nigerian Institute of Medical Research, which is led by one of us, Professor Innocent Ujah, has for the first time, established a Reproductive Health Research Unit which is to pursue aspects of maternal health issues that require sophisticated laboratory work such as can be obtained at the Institute. Similarly, another one of us, Professor Friday Okonofua has founded an African Journal of Reproductive Health, which is generally regarded as the best scientific journal in the country on health related matters and one with a tremendously high international standing. Little wonder that he, Friday Okonofua, was elected a Fellow ad Eundem – the second Nigerian to be accorded this highly prestigious recognition ( first was the late Moses Majekodunmi) – by the Royal College of Obstetricians and Gynaecologists of the United Kingdom.

With these efforts and much more, estimates of MMR in the country have shown a downward trend – 1,000, 800, 545, and 4875 as at September 2011, all per 100, 000 births, over the years. It is true that these are estimates and that this begs reliability, but the latest estimate is still almost twice as high as the global average of 290 per 100, 000 births. Besides, over 1,000 deaths per 100, 000 births are still estimated for some parts of the country and 12, 000 mothers are still thought to acquire VVF, annually. It would appear then that current efforts alone, which depend heavily on the clinical management of individual pregnant women and complications when they arise, may not be enough to make pregnancy safe for the generality of Nigerian women. It is possible they are not striking sufficiently at the real issues that are involved in unsafe motherhood in Nigeria.

This is may not be surprising as several factors – societal, cultural, and economic – as determinants of health, contribute to the level of maternal health in a population and so, reducing maternal deaths requires functional public health infrastructure, a literate population with good quality of life in an atmosphere of political stability and economic growth20. It is for these reasons that maternal death is regarded by many as a development, human rights and social justice issue21.So, to further reduce maternal deaths and disabilities, first to global averages and then to figures obtained in developed countries of single digit deaths per 100,000 births, something has to be done about the high poverty level in the country which makes people unable to cope with the difficulties of daily living. For as we now know, majority of maternal deaths occur in poor women who live on less than 2US dollars a day. Vision20,2020 as well as the Transformation Agenda – the plank of the development agenda of the of the government in power, will all come to naught unless they are able to lift the 60% of Nigerians who live below this poverty line, out of the circle of poverty, disease and deprivation. GDP growth in the country is currently said to be 6.48%. But the inflation rate is as high as 11%, while the GDP growth has hardly been seen to improve the quality of life of the ordinary man by way of employment opportunities, life expectancy, housing, transport, potable water and access to health care. It was therefore gratifying to listen to Dr. Goodluck Ebele Jonathan, the President of the Federal Republic of Nigeria when he spoke at the recently concluded Rio+20 conference in Rio de Janiero, Brazil, on sustainable development23. He placed the eradication of poverty as one of his government’s cardinal approaches to achieving sustainable development – an action, which, if achieved, would be most welcome as poverty, especially female poverty and ignorance, is an important contributor to poor maternal health and deaths.

Next is the issue of illiteracy. From the ZMS and many other publications, we know that women who have had formal education up to the secondary school level and have antenatal care, have favourable pregnancy outcomes. Furthermore, in a country such as Nigeria, where many communities and cultures accord women an inferior social status, female education is crucial as a poverty alleviating strategy and an antidote to early marriage, which often is a precursor to teenage pregnancy, with all its attendant problems. In this respect, all efforts must be made to enforce the Child Rights Act of 2003 which prohibits the marriage of any girl below the age of 18 years. Applied properly, this Act should cut down on the cases of early marriage which often precedes teenage pregnancies with their attending high rates of mortality and morbidity in Nigeria. Eradicating illiteracy therefore stands out as one of the most important approaches to bringing about large scale reduction in maternal deaths24. Literate women tend to have antenatal care and they seek expert help early when things go wrong. Indeed statistics indicate that for each additional year of education achieved by 1,000 women, two maternal deaths will be prevented25

CONCLUDING REMARKS.

There is no doubt that as Obstetricians, we have contributed reasonably to the modest gains that the nation has made in its effort to make motherhood safe for women in Nigeria. Governments’ policies, now, more than ever before encourage women to seek expert care when pregnant even as many health institutions are constructed and equipped for such professional care. There has been massive manpower development by professional institutions even if their distribution in the country is skewed. A good deal of research work has been done, disseminated and the findings put into evidence-based care of mothers. However, much more still needs to be done to make the society a place that will care for and support the upbringing of the girl child, in an atmosphere that is free of discrimination against her, for her to grow to become a well-informed and educated, healthy and responsible woman. Such women do not only have the best outcome of pregnancy as I indicated in my Keynote address to this great society at its 7th International conference in Abuja on 22 November, 200626, but also have the ability to bring up offspring that would become responsible members of the community who would contribute to its development among many other benefits27

Furthermore, the country has to fix the infrastructural, social, economic and political disorder that is evident on a large scale. Violence and insecurity to life and properties, arising from kidnapping, armed robbery and indiscriminate bombings that are rampant in several parts of the country have to be tackled as the care, needed to make motherhood safe cannot be adequately offered in such atmospheres

Across the country, we must register all births and deaths compulsorily so as to move away from the imitations that estimates of maternal deaths really are and when deaths occur, we must institute confidential enquiries into their circumstances, to forestall further occurrences. In this respect, efforts by SOGON to review its Constitution to place it in a better position to tackle the social issues that contribute to poor maternal health in a more robust manner, are most welcome. So also are the moves to provide Protocols on the management of some major diseases that afflict women and National Guidelines on Maternal Death Reviews (MDRs). Again, education and maternity care must be made free and compulsory to extend their benefits to as many as possible. Making motherhood safe in Nigeria is not a one-off event of drama in a hospital. Rather, it is a continuum of care that commences in childhood and as such, it is everybody’s responsibility.28.

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REFERENCES

1.Chris Akpoghoroma. Secretary General, Society of Gynaecology and Obstetrics of Nigeria. Personal communication Oct. 2012

2. Constitution. Society of Gynaecology and Obstetrics of Nigeria..(Inaugurated: April 1965)

3. Lawson JB (1962) Maternal Mortality in West Africa. Ghana Medical Journal. 1, 31-36

4. Okeibunor JC, Onyeneho NG and Okonofua F.(2010) Policy and Programmes for Reducing Maternal Mortality in Enugu State, Nigeria. African Journal of Reproductive Health. Special Edition.14(3)

5 Pate AM. Safe Motherhood Day 2012 Abuja Nigeria

6.Briggs N(2009) Women’s Health. A nation’s Wealth. Valedictory Lecture. University of Port Harcourt

7.Efem IE. Programme Manager USAID Fistula Care Project in Nigeria. Statement at a media roundtable on sustainable approaches for fistula prevention in South East communities of Nigeria as published by the Guardian Newspaper 8 November, 2012, page 45, USAID repairs 65,000 fistula cases yearly.

8..Harrison Kelsey A, (2009).Transforming Health Systems to improve lives of women and newborn babies in Nigeria. Lecture delivered at the Nigerian National Health Conference. Uyo, Akwa Ibom State, Nigeria.

9. Harrison KA. Traditional Birth Attendants. Lancet 1980. 316: 43-4410.

10. Nylander PPS. The frequency of twinning in a rural community in Western Nigeria. Ann. Hum. Genet., Lond. 1969, 33, 41

11 Creinin M, Keith LG. The Yoruba contribution to our understanding of the twinning process J Reprod Med. 1989 Jun;34(6):379-87.

12. Harrison KA. Ethacrynic Acid in Blood Transfusion-Its effect on plasma volume and urine flow in severe anaemia in pregnancy. Brit.Med. J. 1968, 4,84-86

13. Harrison KA, Alabor LN, Lawson JB. Ethacrynic Acid and Direct Packed Blood Cell Transfusion in treatment of Severe Anaemia in Pregnancy. Lancet 1971,297, 11-

14.Harrison KA ed. Child bearing, Health and Social Priorities: a Survey of 22774consecutive hospital births in Zaria, Northern Nigeria. BJOG 1985.92. supplement 5.

15.Okonofua FE, Lambo E, Okeibunor J, Agholor K. Advocacy For Free Maternal and Child Health Care in Nigeria. Results and Outcomes. Health Policy 2010.

16.Pate AM. Safe Motherhood Day 2012 Abuja Nigeria.

17 Editorial. Hope for Health in Nigeria. Lancet 2011; 377

18.Bullough C. HIV Infection, AIDS and maternal deaths. Tropical Doctor 2003; 33(34) 194-196:

19.Mimiko O. Mobilizing Resources for Achieving MDG5:The Ondo State Example. Public Lecture. Abuja, Nigeria. 2011.

.21.Andrea Crisanti. Editorial. Pathogens and Global Health. Vol. 106.3.129

22. Briggs N. Why do Women Still Die in Pregnancy? 2008 Annual Okoronkwo Ogan Memmorial Lecture. University of Nigeria.

23.The Future We Want. United Nations Conference on Sustainable Development, Rio De Janeiro, Brazil, June, 2012.

24. Briggs N. Commentary. Maternal Health: Illiteracy and Maternal Health. Educate or Die. The Lancet.1993. 341: 1063-1064.

25. Harrison, Kelsey A, Maternal Mortality in Nigeria: The Real Issues. Commentary. African Journal of Reproductive Health. 1997 (1): 7-13.

26. Briggs N.MDG5. What Path leads to its Achievement in Nigeria. Guest Lecture. 7th International Conference of SOGON. Abuja. Wednesday 22 November, 2006.

27.Briggs ND. The Nigerian Child and the Health Care Delivery System. A Lecture Delivered to the participants at the Senior Executive Course. Nigerian Institute of Strategic studies, Kuru. Jos. May, 2003.

28. Briggs N. Achieving Safe Delivery through multidisciplinary Care. Guest Lecture. Second Annual Scientific Conference. League of Obstetric Anaesthetists of Nigeria. Port Harcourt. September 3, 2012.

Making Motherhood Safe in Nigeria: How Far Have We Gone? Keynote address presented by Nimi Briggs, OON, FAS, Emeritus Professor, University of Port Harcourt at the 46th SCIENTIFIC CONFERENCE of the SOCIETY OF GYNAECOLOGY AND OBSTETRICS OF NIGERIA(SOGON) Affiliated to the International Federation of Gynecology and Obstetrics (FIGO) ABAKALIKI, EBONYI STATE NIGERIA on 22 November, 2012