THE FACTORS RESPONSIBLE FOR HIGH RATE OF MATERNAL MORTALITY IN BORNO STATE

Background

Nigeria still ranks second globally in the number of maternal deaths. Most maternal death reviews in Nigeria are isolated research based reports from a single health facility. This study determined causes and contributory factors of maternal mortality in Ogun statefollowing a periodic State-widematernal and perinatal deaths surveillance and response (MPDSR) review.

Methods

We carried out a retrospective analysis of cases of maternal deaths notified (n = 77) and reviewed (n = 45) in health facilities in Ogun State from 2015 to 2016selected using total sampling method. Using the national MPDSR structured and validated data collection tools or questionnaire, collected data was extracted from existing MPDSR data base, andanalyzed using the Statistical Package for Social Sciences (SPSS) software 20.0. We obtained approval from the State Ministry of Health for this study.

Results

Average age at maternal death was 30.8 ± 5.7 years. Haemorrhageand pre-eclampsia or eclampsia account for 43.4 and 36.9% of causes respectively. Leading contributory factors ofmaternal deaths include inadequate human resource for health, delay in seeking care, inadequate equipment, lack of ambulance transportation, and delay in referrals services. 51.1%of the women had antenatal care while a significant proportion of the women were referred from Traditional Births Attendants (TBAs) and mission houses.

Conclusion

We concluded that many of the contributory factors of maternal mortality could be avoided if preventive measures were taken and adequate care available. MPDSR provides a platform for critical evidence of where the main problems lie, and can provide valuable information on strategies which maternal mortality prevention programs should focus on. The implementation and institutionalization of MPDSR programme is on course in Ogun State. MPDSR is feasible and should be institutionalized in all states of Nigeria. A commitment to act upon the findings of MPDSR is a key prerequisite for success.

The widest disparity in health statistics compiled by the World Health Organization between developed and developing countries occurred in the area of maternal mortality, with the developing countries contributing most of the figures. At the close of the Millennium Development Goals (MDGs), Nigeria like many other countries in Sub-Saharan Africa had not only failed to achieve the goals, but still hadhigh maternal and perinatal morbidity and mortality rates. Globally,thousands of women die annually from complications during pregnancy, childbirth, or postpartum period, with most deaths occurring in developing countries [1]. These trends over the past decades had been adjudged as unacceptable, as it remained a problem of public health importance necessitating the attention of all stakeholders in maternal and child health care.

According to the World Health Organization (WHO), Nigeria had the second highest number of annual maternal deaths in the world in 2010 and contributed 14% of all maternal deaths globally [2]. Nigeria has a maternal mortality ratio of about 814 per 100,000 live births as at 2015 [ 3]. Within Nigeria, Maternal Mortality Rate (MMR) figures differs between geo-political zones, with southwestern Nigeria having one of the lowest rates of preventable Maternal and Perinatal deaths according to the National Demographic and Health Survey (NDHS) data [4].

Many developing countries carry out spectrum and modeling projection analysis in order to determine levels and trends in maternal mortality, due to lack of complete and reliable data in these countries. As a result, maternal mortality ratios are generated periodically and reflect situations few years prior to the surveys. Most reviews on causes and contributory factors on maternal deaths in Nigeria are isolated research-based reports from a single health facility and which may not be generalizable on large populations. As these statistics do not present national maternal mortality ratios, reviews are needed for determining trends over a period of timeso asto develop policies for reducing maternal and perinatal mortality ratios by improving the quality of prenatal and obstetric care.

From 2009, Ogun and some other states in Nigeria have been involved in various pilot schemes to establish Maternal Death Review (MDR) processes with support from development partners. A renewed effort at a comprehensive approach that included perinatal and integrated surveillance and response components into this approach was approved by the Nigeria National Council on Health in 2013. It mandated all states to implement a comprehensive Maternal and Perinatal Death Surveillance and Response (MPDSR). By implementing MPDSR review, it is possible to obtain critical evidence of where the main problems lie, which need to be addressed to reduce maternal deaths. This study determined causes and contributory factors to maternal and perinatal mortality in Ogun state in Southwestern Nigeriafollowing a periodic State-wide MPDSR review.

Study area

The study area was Ogun State in Southwestern Nigeria. The State hasan estimatedtotal population of 6,084,327 (with 3,078,669 males and 3,005,657females) derived from projections based on a 3.3% annual growth rate of the 2006 National Population Census figure for 2016. There has been a notable rise in the population and especially that of women of Reproductive Age (WRA) to an estimated 1,366,207 [5]. We obtained approval from the State Ministry of Health for this study.

Anecdotal review and analysis of 2007 to 2009 figures for Ogun Stateshowed a State level Maternal Mortality Ratio of 179 per 100,000 live births and Infant Mortality Ratio, Perinatal Mortality Ratio and Under-5 Mortality Ratio of 69/1000, 21/1000 and 27/1000 live births respectively. Modern contraceptive prevalence rate was 21.5 and 26.0% for all methods. Though most deliveries take place at health facilities (30.7% public and 44% private), the percentage of Traditional Birth Attendants (TBA)/Home delivery is still significant (24.8%) and in most situations,cases are often referred from this source to health facilities when it is already too late.

The study population

Constitutes all cases of maternal deaths that occurred in health facilities in Ogun Statein 2015 and 2016. The inclusion criterion is that such death should have been notified by the health facility where death occurred to the State MPDSR system which is a part of the national response.

Study design and scope of reviews

The study which was retrospective in design,covered an up-to-date epidemiological and programmatic review of maternal deaths data emanating from the MPDSR State response in 2015 and 2016. Quality, consistency, completeness and availability of data, and the investments needed to improve measurement of trends were also assessed. Observed trends in the surveillance and response systems were also assessed. Other activities carried out was a comprehensive desk review of documents, policies, guidelines, and reports, related to maternal mortality in Ogun State producedtill date.

Sampling methodology

A total sampling of all the MPDSR supported health facilities was carried out. In addition, a total sampling of all deaths notified within the period was made.

Research instruments

The national MPDSR tool (semi-structured, pretested and validated data collection questionnaire) was used by all the facilities for reporting or notification of deaths, and timely review of the same by designated facility staff. The existingStatedata-base was updated and validated by visiting some of the facilities at random and checking for consistency and availability of data.

MPDSR data collection methods

The State MPDSR response team went round the supported healthfacilities to ensure that no routine notification andreview forms were left behind, and that allforms got to the State Monitoring and Evaluation unit where the MPDSR database was being regularly updated. The State MPDSR data-base was a compendium of the responses in the data collection tool per Local Government Area (LGA) and per health facility. Secondary data analysis methodology only was deployed. MPDSR implementation efforts at health facility level were also assessed. A review of presentations made by the health facilities at the annual review meeting was also done.

Study variables

These include pattern of notification and review of maternal deaths, socio-demographic characteristics and some reproductive health history of the women who died within the period, includingthe causes and contributory factors to maternal mortality.

Ethical approval

Ethical Approval was obtained from Ogun state primary health care board ethical review committee. Written informed permission was obtained from the Medical directors of selected health facilities and the Executive Secretary of the Primary Health Care Board to use data.

TABLE OF CONTENT

Title page- – – – – – – – – i
Approval page – – – – – – – -ii
Dedication – – – – – – – – -iii
Acknowledgement – – – – – – – -iv
Abstract – – – – – – – – – -v
Table of content – – – – – – – -vi

CHAPTER ONE
INTRODUCTION – – – – – – – -1
1.0 Background of the study – – – – -1
1.1 Statement of the problem – – – – -5
1.2 Purpose of the study – – – – – -6
1.3 Significance of the study – – – – -8
1.4 Research questions – – – – – -9
1.5 Scope of the study – – – – – – -10

CHAPTER TWO

LITERATURE REVIEW – – – – – – -11

CHAPTER THREE

Research methodology – – – – – – -39
Design of study – – – – – – – -40

CHAPTER FOUR

Presentation, analysis and interpretation of data – -48

CHAPTER FIVE

Summary of findings – – – – – – -60
Conclusion – – – – – – – – -61
Recommendations – – – – – – – -62
Suggestions for further research – – – – -64
References – – – – – – – – -65
Appendix I – – – – — – – – -68
Questionnaire. – – – – – – – -69

THE FACTORS RESPONSIBLE FOR HIGH RATE OF MATERNAL MORTALITY IN BORNO STATE