|Year : 2015 | Volume
| Issue : 4 | Page : 309-315
Effect of free maternal health services on maternal mortality: An experience from Niger Delta, Nigeria
Samuel O Azubuike1, Ngozi O Odagwe2
1 Department of Public Health Unit, School of Health Sciences, National Open University of Nigeria, Victoria Island, Lagos, Nigeria
2 Department of Public Health Unit, School of Health Sciences, Antenatal Clinic, Central Hospital Kwale, Delta State, Nigeria
|Date of Web Publication||18-Sep-2015|
Samuel O Azubuike
Public Health Unit, National Open University of Nigeria, 14/16 Ahmadu Bello Way, PMB 80067, Victoria Island Lagos
Source of Support: Nil., Conflict of Interest: There are no conflicts of interest.
Background: Free maternal health care was launched by Delta State Government in 2007. This development was laudable as poverty has been identified as a big hindrance to accessing health care services among mothers in rural communities. There was need, however, to ascertain the effectiveness of this program. Aim: The study aimed at determining maternal mortality rate (MMR) from 2005 to 2009, its correlates, obstetric cause of death and to evaluate the effect of free maternal care on MMR. Methodology: MMRs were computed based on all maternal deaths and live births available in summary health report of Ika South local government area from 2005 to 2009. Correlational analysis was done to determine the correlates of MMRs. Statistical Package for Social Sciences (SPSS) version 16 (USA, 2007) was used in the analysis. Results: There was a reduction in MMR from 932/100,000 in 2005 to 604/100,000 in 2009. This reduction negatively correlated (r =−;0.74, P = 0.15) with an increase in antenatal care registration within the period. The gradual increase in proportion of child delivery in health facilities from 59% in 2007 to 74.6% (2288/3065) in 2009 negatively correlated (r =−;0.5, P = 0.4) with a reduction in MMR from 836/100,000 to 604/100,000. The number of skilled staff employed increased by 36.4% (51/140) since 2005 and negatively correlated (r =−;0.34, P = 0.56) with MMR reduction of 328/100,000 since that period, with the employment of nurses being the stronger correlate (r =−;0.48, P = 0.41). Hemorrhage (44%) was the leading obstetric cause of death. Conclusion: The study showed that MMR has been on a gradual downward trend since the introduction of free maternal health services in Delta State, Nigeria.
Keywords: Antenatal care, maternal mortality, Niger Delta, Nigeria, obstetric death
|How to cite this article:|
Azubuike SO, Odagwe NO. Effect of free maternal health services on maternal mortality: An experience from Niger Delta, Nigeria. CHRISMED J Health Res 2015;2:309-15
|How to cite this URL:|
Azubuike SO, Odagwe NO. Effect of free maternal health services on maternal mortality: An experience from Niger Delta, Nigeria. CHRISMED J Health Res [serial online] 2015 [cited 2019 Jan 18];2:309-15. Available from: http://www.cjhr.org/text.asp?2015/2/4/309/165738
| Introduction|| |
Maternal mortality has been defined as "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy or its management, but not from accidental or incidental causes. Every minute a woman dies of complications related to childbirth especially in developing worlds,, mostly attributed to hemorrhage, infection, unsafe abortion, eclampsia, obstructed labor, and other direct causes.
According to United Nations Children Emergency fund, the lifetime chance of maternal death in the developing world is about 1 in 76 live births compared to 1 in 8000 in the industrialized world. Reduction of maternal mortality is one of the key goals of millennium declarations, as well as the consensus documents emanating from international conferences, including World Summit for Children in1990, the International Conference on Population and Development in 1994, the Fourth World Conference on Women in 1995, the Millennium Summit in 2000 and the United Nations General Assembly special session on Children in 2002. An estimated 358,000 maternal deaths occurred worldwide in 2008, 34% decline from the levels of 1990. Despite this decline, however, developing countries continued to account for 99% (355,000) of the deaths. Sub-Saharan Africa and South Asia accounted for 87% (313,000) of this global maternal deaths. The experience is pathetic particularly in Sub-Saharan Africa where the lifetime chance of maternal death is 1 in 31 pregnancies.
Nigeria as a nation has one of the highest incidences of maternal mortality rate (MMR) in the world,,,, accounting for 1.7% of the world population but contributing 10% of the global burden of maternal death., The lifetime risk of maternal death is 1 in 18, and MMR ranging from 545 to 840/100,000 live births., Maternal mortality has therefore become a public health problem requiring urgent attention and effective intervention at various levels of the society.
In the oil rich Delta State of Nigeria, the State Government launched a free maternal health scheme probably inspired by the one carried out by Niger Delta Development Commission (NDDC) in 2006, to be implemented at the public health facilities. Reports of these various institutions, though inconsistent, indicated marginal progress at the urban centers, but whether this was truly the case in rural communities was yet to be determined since studies from such areas were scanty. Reviewing the progress so far and its associated factors in the rural communities would provide information that could assist in strengthening or modifying the program. It was against this backdrop that this study intended to determine the maternal mortality ratio and how it correlated with antenatal care and skilled delivery, as well as determine obstetric cause of death over the 5 year period.
| Methodology|| |
The study area, Ika South local government area (LGA) of Delta State of Nigeria had a population of 162,594 (79,628 males and 82,966 females) according to 2006 national census. The community had several health institutions including one secondary health facility (Agbor Central Hospital located in Agbor Metropolis, which served as a referral center) and 17 primary health centers.
The study was a descriptive evaluation study involving 11,136 women who delivered at Government Health facilities during the 5-year period. It was carried out for a period of 6 months. MMR was computed based on total number of annual deaths and total number of annual live births recorded over the 5-year period. Data were retrieved from the yearly summary health report of Ika South LGA. This was a report that summarized on yearly basis selected health events in the local government which included the total number of antenatal registrations, total number of live births, total number of maternal deaths, total number of health staff employed etc. However, it did not give details about diagnosis and cause of deaths. Hence, data used in computing cause of death were retrieved from specific case notes of mothers at Central Hospital Agbor, which served as referral center for other primary health care facilities in Ika LGA. The specific case records from Central Hospital, Agbor were assumed to approximate for case records of maternal deaths available in government health facilities in Ika South LGA. This was based on the fact that other primary health care facilities were required as a rule to refer all complicated cases and those suspected to be at high risk to Central Hospital, Agbor. They were not expected to admit or treat such cases. Hence, case records of maternal deaths were not expected to be found in such facilities. The maternal death included were only those resulting from pregnancy and childbirth within the period. A written permission was obtained from the Director of primary health care in Ika South local government as well as the Chief Medical Director of Agbor Central Hospital.
Data analysis was carried out using Microsoft Excel (2007 version) and Social Science Statistical Package, version 16 (United States, 2007). Computation of cause of death was based on actual number of death records retrieved instead of the hospital's annual report. MMR was computed based on 100,000 live births. Pearson correlation coefficient was used to determine linear relationship between maternal mortality and factors such as antenatal care registration (ANC), number of skilled delivery, number of skill staff employed, etc. These were also factors targeted by the state government's free maternal health program. The level of significance was taken at 0.05 (95% confidence interval [CI]). Cross-tabulation tables were used to explain the relationship between obstetric cause of death and its associated variables since the number of case notes available were not large enough to enable the significant test of relationships by Chi-square to be done.
| Results|| |
The result was presented in three tables and three figures. The results of the statistical analysis have been summarized below.
[Table 1] shows that the number of deaths i.e. the numerator remained the same (14 in number) from 2007 to 2009. However, the number of live births that formed the denominator increased over the period resulting in differences in MMR. According to the table, the highest record of MMR was in 2005 (932/100,000) while the lowest was in 2006 (391/100,000).
[Table 2] shows that ANC increased by 573 in 2006 with a corresponding MMR reduction of 541/100,000. In 2007, there was ANC registration decrease of 750 from the 2006 record with a corresponding MMR increase of 445/100,000. The year 2008 recorded a marked ANC registration increase of 1066 with a corresponding MMR reduction of 212. However, the decrease by 20/100,000 recorded in 2009 did not lead to a decrease in maternal mortality. Nonsignificant moderately negative correlation (r =−;0.74, P = 0.15) was recorded between annual ANC records and annual MMRs. However, it was only about 50% of the changes in maternal mortality recorded that was accounted for by changes in ANC (r2 = 0.55).
|Table 2: Potential correlates of maternal mortality over the 5-year period|
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[Table 2] also showed that the proportion of skilled deliveries decreased steadily from 74.6% (2288/3065) in 2005 to 59% (1703/2888) in 2007, and then gradually increased from 59% in 2007 to 64.6% (2441/3778) in 2009. Though the 10% decrease in the proportion of skilled deliveries (hospital-based delivery) in 2006 did not witness any increase in MMR, a further decrease of 5.6% in 2007 corresponded with MMR increase by 445/100,000. The proportion of skilled delivery increased marginally by 0.5% in 2008 with a correspondent MMR reduction of 212/100,000. Another MMR increase of 5.1% in 2009 corresponded with MMR reduction of 20/100,000. With exception to the 2006 experience, MMR seemed to be reducing with increasing proportion of delivery by skilled attendants, even though not proportionately. There was a gap between the number that registered for ANC and the number that delivered in the hospital. Nonsignificant weak negative correlation (r =−;0.5, P = 0.4) was observed between the number of skilled deliveries and annual maternal death rates though it was only about 25% of annual maternal deaths that was seemingly accounted for by number of skilled deliveries recorded.
According to [Table 3], eclampsia was more common among the primigravidae, 33.3% (2/6) and women of parity 1–3, 66.7% (4/6) compared to those of parity >3 where it was none existing. Hemorrhage tended to increase with parity, being higher for women of parity 1–3, 36.4% (8/22), and those of parity >3, 54.5% (12/22) compared to primigravidae, 9.1% (2/22). The same was also applicable to infection, 16.7% (2/12) among primigravidae, 33.3% (4/12) among women of parity 1–3 and 50% (6/12) among those with parity >3.
[Table 3] also showed that 50% (3/6) of deaths among mothers aged 15–24 years, was as a result of infection, followed by eclamspsia, 33.3% (2/6), and then hemorrhage, 16.7% (1/6). There was no case of anemia, obstructed labor or ruptured uterus among them. For mothers aged 25–34 years, the leading cause of death was hemorrhage, 51.5% (17/33) followed by infection, 18.2% (6/33), and then eclampsia, 12.1% (4/33). Mothers above 35 years of age died mainly of hemorrhage, 36.3% (4/11), followed by infection, 27.3% (3/11) then obstructed labor, 18.2% (2/11). There was no record of eclampsia among them.
[Figure 1] shows that mortality rate that was 932/100,000 in 2005 markedly decreased to 391/100,000 in 2006 (a decrease of 541/100,000), then increased to 836/100,000 in 2007 (an increase of 445/100,000). It then substantially reduced to 624/100,000 in 2008 (a reduction of 212/100,000) and slightly to 604/1000 in 2009 (a reduction of 20/100,000). With the exception of 2007, mortality rate seemed to be on the decrease from 2009 to 2005 with marked reductions in 2006 and 2008 (a decrease of 541/100,000 and 212/100,000 respectively).
|Figure 1: Maternal mortality rate over the 5-year period. That mortality rate which was 932/100,000 in 2005 markedly decreased to 391/100,000 in 2006 (a decrease of 541/100,000), then increased to 836/100,000 in 2007 (an increase of 445/100,000). It then substantially reduced to 624/100,000 in 2008 (a reduction of 212/100,000), and slightly to 604/1000 in 2009 (a reduction of 20/100,000). With the exception of 2007, mortality rate seems to be generally on the decrease from 2005 to 2009 with marked reductions in 2006 and 2008 (a decrease of 541/100,000 and 212/100,000 respectively)|
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[Figure 2] shows that the number of skilled staff employed has increased remarkably from 89 in 2005 to 140 in 2009 (about 36.4% increases). This correlated negatively (r =−;0.34, P = 0.56) with decrease in MMR from 932/100,000 in 2005 to 604/100,000 in 2009. This negative correlation was not significant and seemed to be weaker for doctors (r =−;0.27, P = 0.67) than nurses (r =−;0.48, P = 0.41).
|Figure 2: Correlation between maternal mortality rate and number of skilled staff employed. That the number of skilled staff employed has increased remarkably from 89 in 2005 to 140 in 2009 (about 36.4% [51/140] increase). This generally correlates negatively (r =−;0.34, P = 0.56) with decrease in maternal mortality rate from 932/100,000 in 2005 to 604/100,000 in 2009. This negative correlation seems to be weaker for doctors (r =−;0.27, P = 0.67) than nurses (r =−;0.48, P = 0.41) even the results cannot be said to be significant|
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As shown in [Figure 3], most deaths over the 5 year period were as a result of hemorrhage (44%), followed by infection (24%) then eclampsia (12%), and obstructed labor (8%).
|Figure 3: Cause of death. Most deaths over the 5 year period were as a result of hemorrhage (44%), followed by infection (24%) then eclampsia (12%), and obstructed labor (8%)|
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| Discussion|| |
Despite the fact that the numerator remained the same from 2007 to 2009, differences in MMR were recorded due to differences in the size of the denominator (live births). With exception to 2007, MMR seemed to be on the decrease from 2005 to 2009. There were marked reductions in 2006 and 2008 as shown in [Figure 1]. This fell in line with the reported global decline between 1990 and 2008 by World Health Organization (WHO). Official report of Delta State Government was 301/100,000 live births in 2009 compared to 456/100,000 live births in 2005. These were low compared to 2005 and 2009 records reported in this study. While it was possible that the larger sample size probably used in the state government's report might have contributed to the lower figure reported, other competing interests such as political image could not be ruled out. However, both the governmental report and the findings of this study suggested a decreasing incidence. It should be noted that in 2008, the national maternal death rate reported in National Demographic Health Survey was 545/100,000 live birth, WHO's own report was 840/100,000 live births while an independent local study reported 963/100,000. The marked decrease in 2006 might be associated with a free maternal health program launched in the state by NDDC that year, just as the reduction reported for 2008 in this study could be traceable to the introduction of free maternal health program by Delta state in 2007. However, the sharp rise noted in 2007 seemed to reflect a gap between the end of NDDC free maternal health program toward the end of 2006 and the beginning of that of State Government in 2007. There might have been a reduction in hospital patronage following the end of NDDC program before the Government revitalized the program on the platform of Delta State Government. The subsequent gradual reduction from 2008 suggested the effectiveness of the state government's free maternal health program even though not at the same rate with that of NDDC, probably due to a better package by NDDC. Personal interviews seem to suggest better commitment by the NDDC team.
More so the sharp increase in MMR in 2007 seemed to correspond with a reduction in the number of doctors employed that year as shown in [Figure 2]. It seems the government could not immediately retain or engage the doctors recruited by NDDC following the expiration of their free maternal care program. It was a known fact that greater and more critical component of the comprehensive emergency obstetric care (EmOC) were mostly handled by doctors. Reports have shown that 15% of deliveries may result in complications requiring EmOC,, with a minimum of 5% of deliveries likely to require a caesarean section. The increase in number of health professionals with midwifery skills as a means of reducing maternal mortality has been stressed in literature.,
The positive role of antenatal care in reduction of MMR seemed as shown in [Table 2] where every increase in ANC corresponded with the reduction of maternal death rate. The negative correlation between the number of women that registered for antenatal care and maternal death rate was not significance. It is, therefore, possible that other factors in addition to antenatal care might have contributed to the death rates recorded. Higher maternal rate among nonrecipients of antenatal care has been reported. Antenatal care provides an opportunity for multiple interventions, early detection and management of complications.,
Furthermore, [Table 2] shows that with exception to 2005 experience, MMR seemed to be decreasing with increasing proportion of deliveries that occurred in hospital. The deviation in 2005 could probably be attributed to poor manpower as shown in [Figure 2]. It has been previously reported that substantial proportion of maternal and perinatal deaths was attributable to the poor technical quality of care., The disparity between the number that registered for antenatal care in public health facilities and the number that actually delivered in those health facilities seemed to reflect the strong role of traditional birth attendants in the locality.
The pattern or distribution of the causes of death fitted properly into the global and Nigerian picture reported in previous studies., However, the figures reported for hemorrhage and sepsis in this study were higher than that of those of the globe, as well as figures reported in a lecture delivered by Aderonke in 2007. However, Olapede and Lawoyin  reported a close figure for sepsis, a higher figure for eclampsia and again a lower figure for hemorrhage. This study, therefore, seemed to caution that the prevalence of some of these variables especially hemorrhage may be higher in the rural areas than the national and global figures may present. This result, however, differed from a previous study in Northern Nigeria where the leading cause of death were eclampsia and sepsis, followed by obstetric hemorrhage.
Eclampsia was found to be the leading cause of death among primigravidae and women of who has 1–3 children compared to those with more than 3 children. This might suggest a higher risk among those who were beginning to bear children. A previous study had identified primigravidae and nulliparity as risk factors to eclampsia., Close to three-quarter of deaths among nulliparous women had been attributed to it. However, maternal age >40 had also been mentioned as a risk factor in multiparous women. This, according to literature, reflects superimposition over existing hypertension. This study also suggested that the risk of hemorrhage increased with multiple births, being higher among those with 1–3 children, and those with >3 children compared to primigravidae. This also corroborated the findings of several studies conducted previously.,, Multiple pregnancy has been shown to be associated with an increased risk of postpartum hemorrhage., Infection according to this study was also shown to increase with parity. One could have thought, however, that preventive experience should have grown with multiple births.
As shown in [Table 3], half of deaths among mothers aged 15–24 years were a result of infection, followed by eclamspsia and then hemorrhage. This might probably suggest poor knowledge and practices in relation to hygiene due to inexperience. It could also be related to septic induced abortions that make a significant proportion of maternal deaths. An estimated 610,000 women engage in illegal induced abortion, each year in Nigeria. It calls for targeted health education amidst other multidisciplinary approaches such as poverty reduction and moral instruction. The findings in this study tended to give support to other previous studies where eclampsia had been recorded as a leading cause of death among women <25 years., High incidence of preeclampsia often fulminating had been said to be a common problem in teenage pregnancy., The high risk of hemorrhage among women 20 years of age had also been stated in a previous study. Hemorrhage according to this study was the dominant cause of death among mothers 25 years and above, as well as in those above 35 years of age. Hemorrhage had been found to be the dominant cause of death among mothers >29 years old  and those >35 years. In Nigeria, Tsu reported that advanced maternal age (≤;35 years) was associated with an adjusted relative risk of 3.0 (95% CI 1.3–7.3) for postpartum hemorrhage. Ijaiya et al. found that the risk of postpartum hemorrhage in women >35 years was two-fold higher compared to women <25 years in Nigeria. Postpartum hemorrhage tended to increase with advanced maternal age. More so this study did not record obstructed labor or ruptured uterus among primigravidae or among those <25 years of age. This also was in consistent with Olapede's finding  where obstructed labor occurred mainly in women aged between 25 and 34 years (80%) and in women that had delivered at least a child before. This according to him might be due to delay on the part of the patients and their relatives as they may not readily consent to operative delivery especially where she has had a successful vaginal delivery in the past.
In relation to the discrepancy between medical record and hospital report, these may possibly involve referral cases that arrived to the hospital dead or those who died shortly on arrival following complication. Most times, the practitioners do not bother about determining their actual cause of death, and there might not be any case note opened for them, even though they were usually noted in daily record notebook.
| Conclusion|| |
The study showed that MMR has been on a gradual downward trend since introduction of free maternal health services in Delta State Nigeria. Increased ANC, increased number of skilled staff employed as well as improved preference for hospital delivery among other variables might have contributed to this. Implementation of free maternal health services would, therefore, be very helpful in reducing the scourge of maternal death among women in rural and poor communities of Nigeria.
Limitation of the study
It must be borne in mind that the findings in this study did not include deaths outside the health facility. How that could affect the study results was not accounted for. Moreover, test of association between cause of death, parity, and age could not be properly established statistically except with a cross-tabulation. This may be due to the small number of deaths recorded. It might not be known exactly how this could affect the study findings. It is therefore our recommendation that a more comprehensive community-based study with larger sample size be carried out. Meanwhile the findings here still form a good basis for consideration or further discussion on the role of free maternal health care in the reduction of maternal mortality among women in rural communities.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]