The death of a woman or women within 42 hours after child birth or as a result of pregnancy related complication, otherwise known as maternal mortality, is a health threat and thus, poses grave concern to public health (WHO 2010). Although, it is a global phenomenon, it is however unacceptably high particularly in low resourced environments or developing countries, for example, statistics indicate that about 99% of global maternal deaths occur in developing countries (Anderson 2009; UN 2000). This paper presents a critical comparative analysis of maternal mortality in Nigeria (a developing country) and United Kingdom (a developed country), paying greater attention on the causative agents, responses from government and health practitioners and strategies and methods employed to protect public health. The paper equally draws from diagrammatical data to argue that socioeconomic factors significantly affect the rate of maternal mortality.
Background and Overview
WHO further confirms that about 800 women die daily either as a result of child birth or pregnancy related conditions and more disturbing is that most of these deaths are preventable. Caldwell (1993) note that maternal mortality is a global indicator of inequality in reproductive health of women however about 99% of all maternal mortality takes place in low income or developing countries. So, one of the key measures in determining the health condition, socio-economic development and the quality of life in a society is the prevalence of maternal mortality. Considering the public health treat that maternal mortality portends, the international community in 2000 proposed the improvement of maternal health as the fifth out of eight identified Millennium Development Goals (MDGs). The terms of this international proposal mandates all participating countries to reduce maternal mortality by three quarters between 1990 and 2015 (WHO 2000).
According to WHO, there have been a 47% decrease of maternal mortality as a result of the global concerted effort, however the number of maternal death per every 100 000 live births (equally known as maternal mortality ratio: MMR) declined by 3.1% as opposed to the required 5.5% so as to achieve MDG5. In relation to the African context, Hogan et al. (2008) observed that in Sub-Saharan Africa, maternal mortality rate remains significantly high compared to the developed or Western world from the period 1990 to 2005. A study by Okara et al (2001), shows that the rate of maternal deaths has increased astronomically in some part of Nigeria with about 600%. Such data clearly indicates the lack of social mobility, paucity of resources and inadequate healthcare facilities because maternal mortality serves as a yard stick to determine the level of development within a country.
Brockerhoff and Hewett (2000) argue that there is a strong connection between socio-economic status and maternal mortality rate. On the one hand, developed countries with high socio-economic status exhibits low maternal mortality rate however on the other hand, the story is different: there are acknowledged prevalence of maternal mortality in low income countries. Although the global estimate of maternal deaths is estimated at 358 000, it is alarming that developing countries account for 99% or 355 000. A greater number of these maternal deaths occurred in Sub- Saharan Africa with a figure of about 204 000, while South Asia constitutes 109 000. These two regions: Sub-Saharan Africa and South Asia, therefore accounts for 87% of global maternal deaths. Sub-Saharan Africa had the highest MMR with about 640 maternal deaths per 100 000 live births in 2008 and Nigeria has the second largest number of maternal deaths with an approximation of 50,000 ranking close to India's 63, 000 (see figure 1 below).
Caldwell (1993) note that maternal mortality is an important indicator of health inequality, socio-economic development and quality of life. Similarly, the World Health Organisation (WHO 2005) and the United Nations highlight that maternal mortality is a key factor for social development and has thus, proposed the reduction of maternal mortality as goal for women and children health. Additionally, maternal mortality is usually employed as an indicator of the overall effectiveness of healthcare delivery within any given country. From the foregoing, the view that the goals of contemporary public health policies should be widened beyond its traditional preoccupation with protecting and improving health to address issues of health distributions and inequalities (Graham 2006) is relevant.
Figure 1: Global Maternal Mortality 2008
Source: Hogan et al (2010).
Causes of Maternal Mortality
Smith & Haddad (2002) identifies five major direct causes of maternal mortality as: obstetric complications, post-partum haemorrhages, sepsis, unsafe abortion, pregnancy-induced hypertension, and prolong or obstructed labour. Apart from the above factors, it is necessary to state that health inequality and poverty also contributes significantly to maternal mortality, as Graham (2006) notes people in more advantage circumstances have better assess to health than those who find themselves down on the socio-economic ladder (See Lanre-Abass 2008). Consequently, there is a considerable difference between the rate and causes of maternal mortality in Nigerian and United Kingdom. The Centre for Maternal and Child Enquiries (CMACE) observes that the leading cause of maternal mortality in the UK is infection although it does not rule out issues such as hypertensive disorder and embolism. The diagram below further makes such distinction.
Figure 2: The Causes of Maternal Mortality
in Africa
Figure 3: The Causes of Maternal Mortality
in Latin America and the Caribbean
Figure 4: The Causes of Maternal Mortality in Europe
Although the above diagrams represents 'Africa and Europe' however given the huge similarities that is common to all African or European countries; very minimal national variations may exist, it is therefore logical and proper to extrapolate data from Africa to Nigeria and Europe to UK. Fig 2 to 4 suggests that there are a number of factors that informs the prevalence of maternal mortality albeit depending on the particular part of the world. For example, figure two and four representing Africa and Europe respectively indicates that causes to a considerable degree is informed by the social divides in various parts of the world. Thus, the rate of maternal mortality as a result of sepsis in Africa is conspicuously higher than that of the developed world; this is due to the fact that the likelihood of pregnancy related infections are lower in the developed than in the developing world. Similar arguments can equally be advanced concerning deaths due to haemorrhage, AIDS/HIV and hypertensive disorder.
Another key issue that exacerbates the propensity of maternal mortality in Nigeria and which of course is very much improbable in the UK is the use of Traditional Birth Attendants (TBA) also referred to as Traditional Midwife (TM). The use of TBAs in Nigeria is still very fashionable especially in the rural areas, a study by Udoma et al (2005) confirms that a significant proportion of Nigerians women still patronize TBA in their homes. Despite the fact that most Traditional Birth Attendants lack any form of formal or medical training, they nonetheless remain very popular in developing countries (Buowari 2011), in fact many people still maintain that their relevance remains the same as it was before the advent of Western orthodox medicine. However, a number of recent studies have raised serious questions about their methods and sometimes unexplainable practices, for example, due to several complicated instances of obstructed labour from TBAs: some of their patients come up with obstetric complications that often results to severe maternal and prenatal morbidity and mortality (Buowari 2011; Udoma et al 2005; Ofili et al 2006; Agwubike 2002).
Given that the aims and scope of this paper goes beyond establishing the appropriateness of TBAs, it suffice however to state that the writer have not been able to locate their equivalents within the NHS in UK (Killoran et al 2007). Hence the potential hazards that emanate from their practices, with regards to maternal complications and fatality, is not applicable in England. Buowri (2011) however highlights some risk assessment measures that could reduce possible hazards: promotion of appropriate technology, increased community awareness, effective health care, strategic planning beginning from the grassroots levels to tertiary levels and establishment of a streamlined and effective referral system. Additionally, other outcome measures taken by the government to negotiate and improve the quality and knowledge-base of Traditional Health Attendants will be examined next.
Government/Health Professionals Responses to Maternal Mortality
Consistent with requirement of the International Community regarding MDG5, the Nigerian government has demonstrated leadership by initiating strategies used to protect public health as well as health promotion issues ranging from training of Traditional Birth Attendants, Safe Motherhood Initiative, the National Health Policy (1999), Reproductive Health Policy and Strategy in Nigeria (2001) and the Maternal, Newborn and Child Strategy. Two of these policies will be discussed in further details. First, the National Reproductive Health Policy and Strategy (2001) was adopted to replace the existing Maternal and Child Health Policy 1994.This change was informed by the need to privilege issues of maternal health, which will then be followed by child health and well being. Other vital issues were equally addressed and to be reconfigured; the increase of maternal and neonatal mortality, to increase research activities on reproductive health, and lack of awareness over the use of family planning services. Again, the limited access to reproductive health information and services at the three tiers of healthcare delivery: primary, secondary, and tertiary, in Nigeria was to be bridged by this policy (Lanre-Abasss 2008). The above policy was orchestrated by a number of opposing voices that the extant 1998 National Health policy has not shaped or produced meaningful reduction in maternal mortality (FMOH, 2001).
Thus, the Nigeria's National Reproductive Health Policy and Strategy of (2001) established some bench mark or frame work that captures its essence, they include: removing barriers to reproductive health care, improving access to emergency obstetric care and post-abortion services, effective corroboration of reproductive health at all levels, increasing training of health-care personnel and enhancing access to family planning information and services. The policy equally notes the need for comprehensive referral system, a quality and equitable, accessible and appropriate reproductive health services. Additionally, the policy aims to develop a consistent and integrated framework of policies, legislations, strategies, and programmes that focuses on reproductive health at the local, state and federal government. Furthermore, to facilitate relevant resources for reproductive health programmes by way of more financial commitment and institute measures to promote financial.
The second policy to be discussed is: the Integrated Maternal, Newborn and Child Health Strategy (IMNCH Strategy, 2007) initiated by the Federal Ministry of Health, Nigeria. This policy include intervention packages that deal with causative factors of maternal, newborn, and child mortality, it is designed to engage with integrated method of implementation of maternal and child health services. The policy involves a three stages implementation covering 2007-2009, 2010-2012, and 2013-2015 operating under the sponsorship of primary health care. A number of aims were outlined: to ensure that about 70% of deliveries take place in an environment equipped with health facilities by 2015, to put in place necessary measures for basic emergency obstetric care are offered at primary health-care clinics and general hospitals with 70% (FMOH & IMNCHS, 2007). Further more, this Strategy acknowledges the significant and crippling effects of poverty as inimical in accessing health care services, consequently, the introduction of basic health insurance scheme that will ensure that pregnant women, newborn babies, and children under the age of five are given free treatment and care can only be seen as a step in the right direction. In addition, the policy relies on the good will and explicit roles of the executive, legislative, and judiciary within the three tiers of government. On such account, the country's First Lady will usually play the role of the Goodwill Ambassador for women and children, both to keep the policy focus within the public domain and promote the implementation of the strategy (IMNCHS, 2007).
Analysis of the Nigerian and UK Outcome Measures
The Nigerian demographic and Health Survey (2003) anchored by the Federal Ministry of Health revealed that 30% of women in Nigeria cannot afford the cost of undertaking pregnancy related treatment, 24% of them complained of difficulties in accessing health facilities due to transportation problem, while another 17% indicate their disapproval of being attended to by male staffs and a total of 14% do not like going to the hospital (FMH 2008). According to UNICEF (2006), the prevalence of maternal mortality is still as high as 1100 per 100,000, Sierra Leone has the highest at 2000 per every 100 000 live birth followed by Afghanistan with 1900, while Iceland has the lowest rate of 0% and 4% per 100 000 respectively (UN 2007). This alarming statistics speaks volume about the state of maternal and child health delivery in these countries. Unlike the Nigeria situation, maternal mortality in the UK and US, presents a different story: 6.7 per 100 000 and 11 per 100 000 respectively in 2005 (UN 2007; Anderson 2009; CMACE 2011). One obvious implication of these data is that gaps become established resulting to ineffective dissemination of information from surveillance and monitoring systems.
Maternal health risk management responses in place in the UK seem more robust and integrative of other related/allied agencies. For example, (Anderson 2009) note that maternal mortality rate is usually calculated through one: official death certification to the Registrars General, secondly through deaths reported to the Confidential Enquiry into Maternal and child Health (CEMACH). In the Nigerian setting, similar and accurate record might be difficult because of lack of information co-ordination as well as poor monitoring system. This type of weak multi disciplinary co-ordination do create gaps among health workers, which eventually results to serious health complications or even fatality. It is therefore not surprising that maternal mortality remains high within such environment. Again, on one hand, there is the need in UK for the goals of public health policy to take due account of the health needs of ethnic minorities, migrants, children, elderly and women as health promotion measures and thus effect health equity. On the other hand, the Nigerian government, in collaboration with international bodies, should put socioeconomic measures in place, capable of offering financial empowerment to its citizen and elevating them from poverty; because as Lanre-Abass (2008) argues, poverty is a significant driver and contributor to maternal mortality in Nigeria.
Fig 5: Graph showing maternal mortality in the USA
Fig 6: Graph showing Maternal Mortality in United Kingdom
Consistent with established studies (UN 2000; Anderson 2009; ), fig 5 and 6 shows a significant fall in the rate of maternal mortality in the US and UK; further substantiating the argument that MMR is used as a measure to determine the quality of a health care system. The Centre for maternal and child enquiries (CMACE) asserts that the overall number of maternal deaths in the UK has declined over the years (CMACE 2011). Anderson (2009) attributes such decline to: asepsis, better understanding and use of caesarean section, fluid management and blood transfusion and better parental care. Ironically, while the rate of maternal mortality showed considerable decrease consistently over the past fifty years, the trend in Nigeria is on the increase. Such occurrence echoes WHO (2000) assertion that an estimated global death of 529 000 as a result of maternal mortality, less than 1% occurred in the developed world.
Conclusion
Maternal mortality still remain a serious threat to public health in contemporary societies especially, the developing ones. It inadvertently mirrors the ever increasing gap between the rich and poor and further epitomizes the level of inequality in accessing healthcare services within a country. The role of TBAs in Nigeria have been subjected to critical debate due to several cases of obstructed labour and other pregnancy-related complications, to abolish their activities seems increasing difficult, if not impracticable, because of cost effective purposes as well as being closer to the people. So, an adequate risk assessment calls for a regular and on-going training and re-training in order to improve their skills and courage to make referrals. In contrast to Nigeria's healthcare services, the United Kingdom's approach is underpinned by surveillance and sound monitoring systems hence relevant health policies that goes beyond the traditional role of health protection to incorporate issues of equity are in place.
