Dr. Oluwafemi Kuti is a Professor of Obstetrics and Gynecology at the Obafemi Awolowo University, Ile-Ife. In this interview with TIMOTHY AGBOR, the don, who lectures at the Department of Obstetrics, Gynecology and Perinatology of the institution and who recently carried out various researches both in Nigeria and across the world on maternity mortality and its causes, says Nigeria is one of the worst places to give birth in the world and urges governments and other stakeholders to equip hospitals, train personnel and make delivery free for pregnant women. Excerpts:
Maternal mortality appears to be worsening in Nigeria. As a health expert, how do you react to this?
At creation, the Almighty God pronounced a blessing on mankind asking them to be fruitful and multiply. At the fall of man in the Garden of Eden, the woman was cursed by God when He said “In sorrow you shall bring forth children.” In His mercies, the Almighty God provided a way out of the sorrow in child bearing through obstetricians. Hence, the developed world has successfully overcome the pains and sorrow associated with giving birth. Unfortunately, in Nigeria and Africa at large, pregnancy and childbirth still remain hazardous for the woman, where giving birth is like passing through the valley of the shadow of death. Hence newly delivered mothers are usually congratulated for escaping the danger of childbirth. The Yorubas say “E ku ewu omo o.”
Nigeria is one of the worst places to give birth in the world. Many of our women either die or become maimed during pregnancy and childbirth, and many of the children would not be able to achieve their God given potential. I have spent my entire academic career to make the journey of pregnancy and childbirth safe and also to ensure that women are adequately rewarded for their labour by having outstanding children that would fulfill their destinies. That was why I titled the inaugural lecture I recently delivered: “That They Will Not Labour in Vain Nor Bear Children Doomed for Misfortune; the Efforts of an Obstetrician and Gynecologist.” The lecture was part of my efforts in ensuring that pregnancy and childbirth do not end in sorrow and the woman does not labour in vain. But, a woman can labour in vain if she dies or suffers significant morbidity childbirth, if the babies are unable to achieve their full potentials or coming too soon (premature) or suffering insults in uterus resulting in growth restriction or intrauterine death.
“More than 70% of patients from orthodox hospitals and maternity were mismanaged and almost 60% were admitted in poor conditions. The implication of these findings is that mismanagement of patients in our primary and secondary health care facilities is a major contributor to the high rate of morbidity and mortality among unbooked patients”
How can maternal morbidity and mortality plaguing the nation be reduced?
The World Health Organization defines a maternal death as the death of a woman while pregnant or within 42 days of termination of pregnancy from any cause or its management but not from accidental or incidental causes. In real terms, a maternal death has dire consequences. It can be likened to a bright and shining star suddenly turning dark. It is a tragedy of immeasurable proportion. Beside its serious impact on the survival of the children, the death of these mothers has considerable adverse social, economic and psychological impact on the immediate and extended families and even the medical staff.
The causes of maternal death are well known, as many families who unfortunately have lost loved ones during pregnancy and childbirth can remember exactly the gory stories surrounding the unfortunate event. Many will recall how these women bled or convulsed to death. They will remember how, at these critical periods, help was not found as a result of failure in health services or financial constraints.
My first observation when I joined the Obafemi Awolowo University Teaching hospital was that most women that died from obstetric complications were not booked or registered for care in our hospital. My colleagues and I, therefore, investigated the sources of referral of these patients, the quality of care they received, and their conditions on arrival. Contrary to the common belief that these unbooked patients came from home and were unsupervised in pregnancy and labour, the study showed that almost 60% of these patients were supervised in pregnancy and or labour. More than 70% of patients from orthodox hospitals and maternities were mismanaged and almost 60% were admitted in poor conditions. The implication of these findings is that mismanagement of patients in our primary and secondary health care facilities is a major contributor to the high rate of morbidity and mortality among unbooked patients.
We therefore recommended two solutions to the problem of unbooked patients. The first is to ensure good standard of care in orthodox health institutions through adequate monitoring of and training and retraining of personnel. The second recommendation is to make care during pregnancy and childbirth free to encourage more women take advantage of available good care. The current situation in which as many as 40% of unbooked patients did not receive any form of care is unacceptable.
Having established the poor standard of care at the primary and secondary health facilities, I and a consortium of national and international researchers conducted a nationwide prospective cross-sectional study involving 42 tertiary hospitals across Nigeria to assess, among other things, the quality of emergency obstetric care in referral centers, which are the patients’ last hope. In the 12-month period of surveillance, a total of 100,107 women were admitted for obstetric complication in the 42 participating referral centers, out of which 2449 (2.5%) had Severe Maternal Outcome (SMO). The maternal mortality index in this group was 41%. This means 4 of every 10 cases of severe maternal complications will not survive. This figure is double the reported index from the WHO Multi-country Survey on Maternal and Newborn Health.
We also carried out a prospective study to determine the level of and reason for the unmet need for contraception among Nigerian women. We recruited 256 nursing mothers from the infant welfare clinic. All the mothers have previously received antenatal care in our Teaching Hospital during the antecedent pregnancy. Our study revealed that although 80.5% of the nursing mothers believed that family planning was beneficial, 152 of the 256 mothers did not use any, giving unmet need of 59.4%. Only 7.9% of non-users claimed not to have knowledge of family planning, confirming that exposure to family planning education does not translate into improved practice of contraception as reported by previous authors. Reducing maternal morbidity and mortality in Nigeria and Africa therefore requires innovative strategies to increase uptake and promotion of more culturally acceptable and safe method of family planning.
How has patronage of traditional birth attendants by pregnant women contributed in making Nigeria global capital of maternal mortality?
The Nigeria Demographic and Health Survey of 2018, showed that only 39% of deliveries occur in health facilities. That is more than 60% of our mothers still deliver in unorthodox facilities, with considerable risk of morbidity and mortality. My team and I recently embarked on a series of studies with the sole aim of making labour in health facilities safe and attractive to women thereby increasing the number of women delivering in our health facilities. Any visitor to the labour ward in Nigeria will be greeted by the uncontrollable shouts of women in labour, apparently in agonizing pains, in sharp contrast to the serene ambience of labour rooms in the developed world.
This is in contrast to the traditional belief that our women are stoic. We conducted a prospective study to access the perception of labour pains among our women and to determine their need for pain relief. We interviewed 281 women within 2 hours of delivery to assess pain perception using a 3-point verbal pain rating and also asked for their desire for analgesics. The study showed that almost 70% of the women described the pain as very severe and only 5.3% perceived it as mild. More than 80% wanted the pain relieved. We recommended that adequate attention be paid to effective obstetric analgesia in order to make labouring in our health facilities a delight, thereby attracting more women to orthodox facilities for delivery.
Because of this, birth attendants who are not proficient in the use of the pantograph can be advised to refer patients to secondary or tertiary centers if not delivered within 8 hours. The study showed that all the parturient were able to recall the time of onset of regular labour pains. The patients can therefore request for referral to higher level of care if they do not deliver within 8 hours of the onset of labour pains. This will certainly prevent delay in presentation and enhance early diagnosis of poor progress, thereby averting morbidity and mortality from obstructed labour.
“For the accelerated reduction of maternal and perinatal mortality rates in Nigeria, we need to learn from the experience of the developed countries who have been able to rapidly reduce their maternal and morbidity rates to less than 10 per 100,000”
Do we take this to mean a suggestion that government should ban traditional birth attendants?
I am not saying Nigeria should ban traditional birth attendants. They can be used as more profitable variants. They can be used and not banned. You see, when you ban anything, they will start to be practicing underground, let’s become their friends. We use them because there are areas they can help. They are not really trained to take delivery. They can be used in other areas. A state in this country did this and they didn’t ban traditional birth attendants, they used them and they achieved the goals. We can make them partners in progress.
Why has there not been a progress in reducing maternal death rates in Nigeria in the last 30 years?
It may interest you to know that more than 90% of the cases of maternal deaths are from direct obstetric complications which occur in 20% of all pregnancies everywhere in the world, including developed countries. In other climes, however, these complications very rarely lead to death because the treatment which has been available for decades is accessible to the people and applied promptly and efficiently.
The simple answer as to lack of progress in reducing the maternal death rates in Nigeria for the past 30 years is that we had employed wrong strategies to address the problem. Previous strategies have been generic, patchy and unsustainable. Programmes such as the Integrated Maternal New Born Child Health, Life Saving Skills, Task Shifting and Task Sharing are generic, as they were not solely directed at preventing and managing direct obstetric complications. Other programmes, such as the Conditional Cash Transfer, implemented in 12 of 36 states of Nigeria, Midwives Service Schemes, implemented in 10% of the local governments in Nigeria and the Maternal and Perinatal Death Surveillance and Response, were patchy, poorly planned and badly implemented. Besides, many of the laudable programmes executed by state government were not sustainable.
What’s the way forward in reducing rising mortality rates in the country?
For the accelerated reduction of maternal and perinatal mortality rates in Nigeria, we need to learn from the experience of the developed countries that have been able to rapidly reduce their maternal and morbidity rates to less than 10 per 100,000. They (developed countries) professionalized midwifery, removed economic and geographical barriers to accessing care and backed these up with an enabling law to make it a National programme. Professionalising care in pregnancy and childbirth is key to their success and involves the training of enough midwives to make sure that only qualified personnel attend all births. Sweden, United States of America and England used this strategy and the result was a drastic and rapid reduction of maternal mortality rates within 20 years. The few African countries that made significant progress at the end of MDG, employed strategies that professionalized midwifery care and removed barriers to accessing care.
I, therefore, propose a National Safe Delivery Programme that will involve interventions to address direct obstetric complications. The programme should use the existing health centres for the distribution of interventions and should be backed up with an enabling law to make it a national project. A strong political will is, however, required for financial support and implementation.
The obvious challenge to the programme is securing the political will to make prevention of maternal and prenatal death a priority. This is only possible if we make maternal health one of the ways of assessing government performance. This will require strong advocacy from all stakeholders as was the case in England in 1902. If the truth has to be said, there is no amount of money that is too much to save the life of mothers in carrying out their God given national assignment.
Our efforts have generated sufficient body of knowledge, competent personnel and solid institutions to deliver women and their families from the agony and tragedy of maternal and perinatal death. Unfortunately, we do not have what is required to make all these accessible to women – the political will. With a strong political will, three things need to be done to save our women and take Nigeria away from the unenviable position of being the global capital of maternal death. These are for the government at all levels to professionalize midwifery care, improve standard of health care at all levels of health service and make the care of women during delivery and child birth completely and totally free.
How realistic is it for the government to start picking bills of pregnant women after delivery?
It is very realistic. Governments need to consult experts. You can make it workable and it’s not a political issue. It concerns the life of people and I want them to know that this has to be done. Nigeria is one of the worst places to give birth in the world. I stand by that and I stand to be challenged. Effects of prolonged labour are that children may not do well in school. We have some people we call cerebral clumsy and they have white injuries.
Do we have enough medical personnel to actualise this?
This thing cannot be achieved in a day. We need to set things in the programme. America targeted it and they got there. What is happening now is that we are not starting it. We should start it by having a national programme to midwife it in this country. No person touches a pregnant woman except that you are trained. It is either you are a midwife or an obstetrician. We can do that in Nigeria.
What can the government do to stop medical practitioners from leaving the country?
The government will have to prioritize their welfare. It is because of the passion for this country that some of us are still remaining in Nigeria. I am in this country because I felt I should pay back. Why I am doing this is not for me, it’s for the women in the village. It’s for the common human beings there. I no longer give birth and my children may not give birth in Nigeria. But, we must stop this death. For me, coming back to Nigeria in 1996 should not be in vain.