The main causes of maternal death in Nigeria can be avoided

Northern Nigeria is one of the most dangerous places in the world to be an expectant mother. Women who have had pre-natal care have a much better chance of delivering their babies safely


The delivery ward of Murtala Mohammed specialist hospital in Kano, Nigeria. The hospital encourages women to come in for pre-natal treatment. Photograph: Maggie Flick

In the delivery ward of Murtala Mohammed specialist hospital in Kano, northern Nigeria, the life and death of a mother and child depend on more than just the expertise of the medical staff. Whether women have received pre-natal advice or not is proving significant.


Zulfa'a Aminu gave birth to a healthy baby boy in the hospital's ward on a recent sweltering Wednesday. For her, giving birth in a hospital bed has become second nature. This is her third delivery at Murtala Mohammed.


But for another woman, who asked for anonymity, visiting Murtala Mohammed, the largest government-run hospital in Kano, the ancient Muslim trading city and urban hub of the vast, poor northern region of Nigeria, was an unfamiliar experience and a last resort. The care the maternity nurses were able to provide was not enough to save the life of her child, who was delivered minutes after Aminu's boy began crying. The staff here call this a "macerated birth" and say the baby died in the womb at least one day before being born – which was before her mother arrived at the hospital in serious pain.


The dedicated staff at Murtala Mohammed are on the forefront of the fight to reduce maternal mortality in northern Nigeria, one of the most dangerous places in the world to be an expectant mother. According to Unicef figures, the number of women who died from pregnancy related causes in Nigeria between 2005-09 was 550 per 100,000 live births, although this figure is estimated to be higher when adjusted for underreporting. In northern Nigeria the problem is particularly acute. A recent report by Columbia University on maternal and newborn health (pdf) in northern Nigeria said cultural beliefs and birth practices were more of a contributing factor to maternal morbidity than in the south.


Since Nigeria abandoned military rule 12 years ago, this hospital, and other government hospitals in densely populated Kano state, have pioneered efforts to provide quality, free pre-natal services.


Hauwa Mansour Waziri, the nurse who heads the hospital's pre-natal clinic, says that between 350 and 450 pregnant women, some as young as 15, now take advantage of these services each week. Some travel from neighbouring states to receive ultrasounds, counselling on "danger signs" in pregnancies, and information on nutrition. They are strongly urged to arrive at the hospital to deliver "while you can still walk". Those who wait until the last minute can endanger the life of their child.


With the help of public health organisations like USAid-funded Pathfinder and the MacArthur Foundation, midwives and nurses have been trained in simple but effective strategies for preventing post-partum haemorrhaging, formerly the cause of death for many mothers who delivered at Murtala Mohammed.


In 2009, the hospital opened a blood bank. Dr Bello Umar Dikko, an obstetrician-gynecologist by training and the chief medical officer at Murtala Mohammed, says this is dramatically improving the hospital's ability to give transfusions to mothers whose relatives may not be able to immediately donate or purchase the blood required in an emergency.


These medical efforts have been accompanied by community outreach to local religious leaders, many of whom now deliver messages on family planning and safe childbirth during the widely attended Friday prayers.


"[The imams] understand our angle to this story," says Dikko, noting that religious authorities, including the ulama council – comprised of imams who officially oversee Muslim affairs in the city – have welcomed dialogue with hospital staff and public health groups about how women in their communities can give birth more safely.


"The point we are making to our communities is that the major causes of maternal death can be avoided," said Halima Ben Umar, a Muslim women's activist in Kano who travels throughout the north to meet religious leaders and inform them about religiously sensitive family planning practices.


Umar says that in Kano and other northern cities, imams have begun extolling the virtues of leaving more time between giving birth, which can reduce the chances of complications for northern Nigerian women, nearly half of whom have become mothers by the age of 20 (pdf).


Aisha Hassan, head of the Kano state chapter of a Nigerian-wide Muslim women's group called Fomwan, says that religious leaders have been essential in delivering public health messages to community members who have been the most resistant to changing their childbirth practices. Some of the most resistant are older women, who do not believe young women should space out their pregnancies or give birth outside of the home.


While the progress made at Murtala Mohammed, and at many of the 17 other government-run hospitals in Kano, is a cause for hope, medical and public health officials in this dusty metropolis are quick to emphasise that their improved services are still not reaching the poor rural populations in small villages scattered across the edge of the Sahel desert.


"The reality is that for educated, wealthy people, maternal death is very low compared to the poor majority here," said Umar.


Dije Abdul, of Pathfinder, a group that has worked on maternal health in northern Nigeria for more than 30 years, says that it is working to build links between the facilities and resources available in urban areas and rural communities across Kano state.


For example, Pathfinder has recruited volunteers in villages who own cars to donate their time to drive women in labour to hospitals. In return, they receive fuel donations from their communities and from Pathfinder. Still, Abdul says, reaching the point where adequate and affordable services are available to mothers in the more than 1,000 health centres in Kano state will take time.


"We try to help everyone who arrives on our doorstep," said Hauwa Isa Borado, the chief matron of the maternity department at Murtala Mohammed, noting that the women who have already sought pre-natal care typically stand a much better chance of delivering safely.
http://www.guardian.co.uk/global-development/poverty-matters/2011/may/05/maternal-health-northern-nigeria-kano