Praying for Divine Intervention: The Reality of “The Three Delays” in Northern Nigeria

BM Tukur, U Bawa, K Odogwu, S Adaji, P Passano, I Suleiman

Abstract

This paper describes how pregnant women in three northern Nigerian communities responded to maternal complications that occurred outside of a hospital setting. The sample consisted of 322 women who had recently delivered, of which 15% had at least one complication. Thirty-seven percent of women described antepartum or postpartum haemorrhage. Over 60% of women went to a health care facility, but 35% first tried herbal remedies and another 20% simply waited for their husband to return. The median interval between recognizing the problem and deciding to seek help was two hours. It took approximately one to two hours to reach the hospital and upon arrival, most respondents got care in one to two hours. Rural communities clearly have their own hierarchy of appropriate actions in the face of a household emergency which need to be understood in order to develop creative intervention strategies to reduce unnecessary risks to the life of a mother (Afr. J. Reprod. Health 2010; 14[3]: 113-119).

Key words: Maternal mortality, obstetric emergency, three delays, obstetric complications, actions taken.

This study assessed antenatal care (ANC) coverage, place of delivery and use of skilled birth assistants in three communities in Kaduna State, Nigeria. The sample included 332 women who had delivered within two years of the survey. ANC attendance rates were high, with 76.2% of women reporting at least one visit, and 63.3% receiving four or more. However, median gestational age at the first visit was four months and only 9.3% received all the recommended components. Health facility deliveries (11.7%) were far lower than ANC attendance. Educational status was found to be statistically significantly associated with all ANC and safe delivery outcomes. To make significant progress towards the fifth MDG in northern Nigeria, effective strategies to encourage women’s education paired with improvements in ANC quality (especially within communities) is essential. Most importantly, safer delivery options that would be acceptable in communities where women traditionally birth at home need to be explored (Afr. J. Reprod. Health 2010; 14[3]: 89-96).

Although maternal mortality is a significant global health issue, achievements in mortality decline to date have been inadequate. A review of the interventions targeted at maternal mortality reduction demonstrates that most developing countries face tremendous challenges in the implementation of these interventions, including the availability of unreliable data and the shortage in human and financial resources, as well as limited political commitment. Examples from developing countries, such as Sri Lanka, Malaysia and Honduras, demonstrate that maternal mortality will decline when appropriate strategies are in place. Such achievable strategies need to include redoubled commitments on the part of local, national and global political bodies, concrete investments in high-yield and cost-effective interventions and the delegation of some clinical tasks from higher-level healthcare providers to mid- or lower-level healthcare providers, as well as improved health-management information systems.

Objective: Guide policy-makers in prioritizing safe motherhood interventions.

Methods: Three models (LOW, MED, HIGH) were constructed based on 34 sub-Saharan African countries to assess the relative cost-effectiveness of available safe motherhood interventions. Cost and effectiveness data were compiled and inserted into the WHO Mother Baby Package Costing Spreadsheet. For each model we assessed the percentage in maternal mortality reduction after implementing all interventions, and optimal combinations of interventions given restricted budgets of US$ 0.50, US$ 1.00, US$ 1.50 per capital maternal health expenditures respectively for LOW, MED, and HIGH models.

Results: The most cost-effective interventions were family planning and safe abortion (fpsa), antenatal care including misoprostol distribution for postpartum hemorrhage prevention at home deliveries (anc-miso), followed by sepsis treatment (sepsis) and facility-based postpartum hemorrhage management (pph).

In the 1970s, policy-makers in both India and China, convinced that reducing population growth was critical for ending poverty, instituted coercive population policies. Yet fertility had already been declining in both countries before the population policies were instituted. In China, the total fertility rate (TFR) had already fallen to 2.9 before the institution of the One-Child Policy. In India, fertility continued to decline at roughly the same rate before, during and after ‘The Emergency’. Regardless of government mandates, couples in both countries before the policies and since have shown a desire to reduce their family size and when given access to family planning, have voluntarily limited the number of children they chose to have.

A look at abortion from the perspective of a doctor who has performed abortions, a physician who also has a PhD in embryology, and someone who had the privilege of working all over the world in various aspects of human reproduction and sexuality.

The current paper examines the realities of women delivering in resource-poor settings, and recommends cost-effective, scalable strategies for making these deliveries safer. Ninety-five percent of maternal deaths occur in poor settings, and the largest proportion of these deaths are women who deliver at home, far away from health care facilities, and without financial access to skilled providers. This situation will improve only when policymakers and programme planners refocus their attention on service delivery and financing interventions, with the potential to reach the largest portion of women living in places where mortality is the highest. We suggest three feasible interventions that can potentially minimise both demand and supply side problems of safe delivery: (1) misoprostol to treat postpartum haemorrhage, an easy to use and heat stable technology to reduce the leading cause of maternal deaths; (2) alternative providers, such as clinical officers, trained to offer emergency obstetric care services; (3) financing safe delivery through vouchers or other mechanisms that can be implemented in poor settings and made attractive to the donor community through output-based assistance (OBA).

Keywords: postpartum haemorrhage; maternal mortality; safe delivery; vouchers; misoprostol

Published In Global Public Health, Volume 4, Issue 6 November 2009 , pages 575 – 587

This comment in the explores the role of policy and research in using the prevention of postpartum hemorrhage and suggest a joint meeting by WHO and FIGO to revisit the 2009 statement by WHO which does not recommend the use of misoprostol at the community level.