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International Journal of Women’s Health 2013:5 431–436
International Journal of Women’s Health
Maternal mortality at Nnamdi Azikiwe University
Teaching Hospital, Southeast Nigeria: a 10-year
review (2003–2012)
NJ Obiechina
VE Okolie
ZC Okechukwu
CF Oguejiofor
OI Udegbunam
LSA Nwajiaku
C Ogbuokiri
R Egeonu
Department of Obstetrics and
Gynaecology, Nnamdi Azikiwe
University Teaching Hospital,
Nnewi, Nigeria
Correspondence: Vitus Okolie Ezike
Department of Obstetrics and
Gynaecology, Nnamdi Azikiwe University
Teaching Hospital, PMB 5025 Nnewi,
Anambra State, Nigeria
Email vitusokolie@yahoo.com
Background: Maternal mortality is high the world over, especially in sub-Saharan Africa,
including Nigeria. Nigeria has consistently demonstrated one of the most abysmally poor
reproductive health indices in the world, maternal mortality inclusive. This is a sad reminder
that, unless things are better organized, Southeast Nigeria, which Nnamdi Azikiwe University
Teaching Hospital (NAUTH) represents, may not join other parts of the world in attaining
Millennium Development Goal 5 to improve maternal health in 2015.
Objectives: This study was conducted to assess NAUTH’S progress in achieving a 75%
reduction in the maternal mortality ratio (MMR) and to identify the major causes of maternal
mortality.
Materials and methods: This was a 10-year retrospective study, conducted between
January 1, 2003 and December 31, 2012 at Nnamdi Azikiwe University Teaching Hospital,
Nnewi, Southeast Nigeria.
Results: During the study period, there were 8,022 live births and 103 maternal deaths, giv-
ing an MMR of 1,284/100,000 live births. The MMR was 1,709 in 2003, reducing to 1,115 in
2012. This is to say that there was a 24.86% reduction over 10 years, hence, in 15 years, the
reduction should be 37%. This extrapolated reduction over 15 years is about 38% less than
the target of 75% reduction. The major direct causes of maternal mortality in this study were:
pre-eclampsia/eclampsia (27%), hemorrhage (22%), and sepsis (12%). The indirect causes
were: anemia, anesthesia, and HIV encephalopathy. Most of the maternal deaths occurred in
unbooked patients (98%) and within the first 48 hours of admission (76%).
Conclusion: MMRs in NAUTH are still very high and the rate of reduction is very slow. At
this rate, it will take this health facility 30 years, instead of 15 years, to achieve a 75% reduction
in maternal mortality.
Keywords: maternal mortality, MDG-5, 2015, achievability, causes, NAUTH, Southeast
Nigeria
Introduction
Pregnancy and childbirth are physiological events that should bring joy to the family
and society at large, but sometimes it turns out to be a source of sorrow. Globally, there
is an unacceptably high maternal mortality; the maternal mortality ratio (MMR) in
sub-Saharan Africa is among the highest in the world, at 1,000/100,000 live births.
1
Maternal mortality is a major reproductive health index and could indeed be
considered to be a measure of the socioeconomic development of any nation. Nigeria
has progressively demonstrated one of the most abysmally poor reproductive health
indices in the world. Nigeria constitutes less than 2% of the world population but
contributed 10% of the world’s maternal deaths.
2
Maternal mortality only tells part
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of the story: for every woman that dies as a result of com-
plications of pregnancy and childbirth, between 20 and
30 women will develop short- and long-term disabilities such
as obstetric fistula, ruptured uterus, or pelvic inflammatory
diseases. This is a sad reminder that, unless things are bet-
ter organized, Millennium Development Goal (MDG)-5, to
improve maternal health, will not be achieved by 2015 in
Southeast Nigeria.
Maternal mortality is considerably influenced by the
socioeconomic and political context of a health care system
and the cultural and biological realities of women seeking
care. This complex interplay may result in the women
delaying seeking care, and delays for women to receive care
during pregnancy and delivery.
As a result of high MMRs, the world’s attention was drawn
some decades ago to the thousands of deaths and millions
of serious complications that occur every year in association
with pregnancy and delivery, resulting in a conference held
in Nairobi, Kenya, in February 1987. Termed Safe Mother-
hood Initiative, the target was to reduce maternal mortality by
half by the year 2000. This target was to be achieved through
provision of widely available and affordable family planning
services, easily accessible antenatal care services, facilities
for safe and clean deliveries, and emergency obstetric care
services. This target was not achieved by the year 2000. In
September 2000, 147 world leaders met to articulate the prob-
lems of the world, especially those of developing countries,
and this conference resulted in eight MDGs. MDG-5 is to
improve maternal health, with a target of reducing maternal
death by three-quarters (75%) by 2015. To achieve this, there
must be a 5% reduction in maternal deaths per year over this
15-year period.
This study was conducted to assess the progress in achiev-
ing this 75% reduction in maternal mortality in a tertiary
health institution in Southeast Nigeria and to identify the
major causes of maternal death.
Materials and methods
File numbers of all the pregnant women that died between
January 1, 2003 and December 31, 2012, during pregnancy,
delivery, or within 42 days of termination of pregnancy,
irrespective of gestational age or site of the pregnancy but not
due to accidental or incidental causes, were collected from
the labor, antenatal, and postnatal wards, intensive care unit,
and operative unit of Nnamdi Azikiwe University Teaching
Hospital (NAUTH), Nnewi, Southeast Nigeria. The case files
of the patients were retrieved from the records department of
the hospital. The following data were collected from each of
the files: age; booking status (whether they received antenatal
care services or not); the primary cause of death; and the
number of hours the patient stayed in admission before the
death occurred. The total number of maternal deaths, along
with the total number of live births in each year, was col-
lected, from which the total number of maternal deaths per
100,000 live births was calculated. Finally, the total num-
ber of maternal deaths, along with the total number of live
births, during the 10 years of the study was calculated, from
which the final maternal deaths per 100,000 live births (the
MMR) was calculated. The categorical data were collected
and represented in percentages. The data was analyzed using
SPSS statistical software (v 16; IBM Corporation, Armonk,
NY, USA).
Results
During the study period (2003–2012), there were a total of
8,022 live births and 103 maternal deaths, giving an MMR
of 1,284/100,000 live births. Table 1 shows the distribution
of maternal mortality over the 10-year period of the study:
maternity mortality was over 1,000 per 100,000 live births
except in 2006 (808), 2009 (749), and 2010 (691).
The causes of maternal mortality are shown in Figures 1–3.
Direct and indirect causes of maternal death contributed
74.75% and 23.3%, respectively, while unidentified causes
constituted 1.94% of maternal deaths. The common direct
causes of maternal death were pre-eclampsia, hemorrhage,
sepsis, and ruptured uterus. Other direct causes of maternal
death, although less common, were unsafe abortion and
obstructed labor. Anemia, anesthesia, and HIV encephalopa-
thy were the major indirect causes of maternal death.
Out of 103 maternal deaths recorded in this study,
101 (98.06%) were unbooked patients, while only two
(1.94%) were booked. Seventy-eight (75.73%) mortali-
ties occurred within the first 48 hours of admission, while
25 (24.27%) occurred after 48 hours of admission.
Discussion
The MMR of 1,284/100,000 live births in this study is high; it
is higher than that reported in Ibadan (309)
3
or Lagos (852),
4
and almost the same as that reported in Jos (1,260).
5
It is also
higher than those reported in other developing countries like
South Africa (340), Uganda (344), Tanzania (308), Namibia
(300), and Botswana (480), and incomparably higher than
what is obtainable in developed countries.
6–8
This MMR is,
however, lower than those reported in Port-Harcourt (2,735)
9
and Sokoto (2,138).
10
It is almost the same as that reported
in NAUTH in 2007 (1,282).
11
This shows that the steps that
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Obiechina et al
International Journal of Women’s Health 2013:5
are currently in place in this center to combat maternal
death is not effective enough to reach the goal of improving
MMR by 2015. The higher maternal mortality in Sokoto can
be explained by the relatively lower socioeconomic status
of women, cultural/religious beliefs, and poorer antenatal
attendance. This results in type 1 delay, which is a delay in
recognizing and reacting to problems relating to pregnancy
and childbirth. In some instances, the pregnant woman needs
to wait for her husband to provide money and permission
before action can be carried out.
It is also of note that the MMR is lower in Ibadan and
Lagos; this may be due to higher levels of education and
availability of many qualified health professionals in western
Nigeria, which is in sharp contrast with what happens in
northern Nigeria. In western Nigeria, women have high levels
of education and independence, and there are good communi-
cation systems and road networks, and many government and
privately owned health facilities. These invariably reduce the
three types of delay, which are the delay in recognizing and
reacting (type 1), delay in reaching a health facility (type 2),
and delay in receiving medical assistance (type 3).
Analyzing MMR trends over the 10 years under
review, there was a steady decline over 2008, 2009, and
2010; this may have been due to the provision of 24-hour
blood bank services; employment of more doctors; the
creation of an independent obstetric anesthetic unit; the
introduction of daily audit reviews of all obstetric and
gynecological cases managed the previous day by all
residents, consultants in the department, and representatives
of hospital management; sleep-in provision for the senior
registrar and the consultant on call; stopping registrars from
performing cesarean sections (all being performed by either
the senior registrars or the on-call labor ward consultants);
and provision of emergency care services to the patients in
the first 48 hours without the requirement for immediate
payment. During audit reviews, all challenges encountered
that might have caused a type 3 delay in rendering of clinical
services the previous day are taken care of. But in 2011, the
MMR increased again, possibly due to increased confidence
in the maternity homes within the catchment area of this cen-
ter developed for the hospital, and referral of more patients,
which possibly overwhelmed the system. Another reason
could be that there were some levels of complacency in the
system. This calls for upgrading of the system, especially
regarding increased workforce numbers as demand rises to
avoid the system being overstretched.
In this 10-year review (2003–2012), it is notable that the
MMR in 2003 was 1,709/100,000 live births, while at the end
of the tenth year (2012), it was reduced to 1,115/100,000 live
births – a reduction of 24.86% over 10 years. This equates to
a 2.486% reduction per year, instead of the required 5% per
year to achieve MDG-5 in 15 years. At this rate, only a 37.29%
reduction will be achieved in 15 years, meaning it will take
30 years instead of 15 to achieve MDG-5; ie, MDG-5 will be
achieved in 2030 rather than 2015. This means that NAUTH
may be 15 years behind the rest of the world in achieving
MDG-5 if nothing is done to improve the current situation.
This goal can, however, be achieved by vigorously sustaining
audit reviews and identifying type 3 delays on a daily basis
and correcting them early. The provision of 24-hour blood
bank services and an independent obstetric anesthetic unit
are of great value. Increasing the workforce when necessary
is also a very important measures toward achieving this goal.
Research should be encouraged, possibly prospective studies,
in intervals to study maternal mortality, its causes, and the
effective or inefficient measures put in place to reduce it.
The direct causes of maternal mortality contributed
74.75% of maternal deaths, while indirect causes contrib-
uted 23.3% in this study. This represents what is obtainable
in developing countries, where direct causes are the major
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Trend of maternal mortality ratio in NAUTH, Southeast Nigeria
Table 1 The maternal mortality ratio (MMR)
Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Total
Live births, n 351 382 433 619 731 802 935 1,013 1,198 1,558 8,022
Deaths, n 6 6 8 5 12 9 7 7 25 18 103
MMR (/100,000) 1,709 1,570 1,848 808 1,642 1,122 749 691 2,087 1,155 1,284
Unknown
Indirect
Direct
Figure 1 Medical causes of maternal death.
International Journal of Women’s Health 2013:5
factors in maternal deaths, while indirect causes are the lead-
ing factors in developed countries.
12
This finding is in contrast
to the previous study in this center, in which indirect causes
contributed 64% of maternal mortality.
11
The major causes of maternal mortality were pre-eclampsia
(27%), hemorrhage (22%), and sepsis (12%). All of these
are preventable causes of maternal death. The contribution
of pre-eclampsia to maternal death is on the increase, and
it contributes to more maternal deaths than hemorrhages,
as observed in other recent studies in Nigeria,
10,11
although
some studies in Nigeria have found that hemorrhage is still
the leading cause of maternal mortality.
12–14
The finding that
pre-eclampsia contributes more than hemorrhage to maternal
death may be explained by the availability of functional blood
bank services and use of oxytocic drugs in our hospital, which
help to reduce the contribution of hemorrhage to maternal
death. Therefore, the functional blood bank service and use
of oxytocic drugs should be sustained. Despite the use of
magnesium sulfate in the management of pre-eclampsia in
this center, the MMR was still very high; this may be due to
the fact that most of the patients were not booked, and tend to
present to the hospital when it is too late to save them. If
they were booked, raised blood pressure and protein in urine
could have been detected earlier and appropriate action taken
to arrest the situation. This suggests the need for increased
awareness about the importance of antenatal care services,
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Obiechina et al
30
25
20
15
%
10
5
0
Pre-eclampsia/eclampsia
Hemorrhage
Infection
Ruptured uterus
Abortion
Obstructed labor
Figure 2 Direct medical causes of maternal death.
14
12
10
8
6
4
2
0
Anemia Anesthesia HIV/AIDS Thromboembolism
%
Figure 3 Indirect medical causes of maternal death.
International Journal of Women’s Health 2013:5
where pre-eclampsia could be detected and treated before
the stage of eclampsia, which has a high mortality rate, is
reached. Furthermore, the peripheral health facilities that
refer patients should be educated on the need for early refer-
ral, rather than referral when the patient is moribund and
saving their life is near impossible.
The major indirect medical causes of maternal death were
anemia, anesthesia, and HIV encephalopathy. There is a need
to improve on both the hemoglobin status (which can be done
when they are booked for antenatal care) and socioeconomic
(which is a remote cause of maternal death) status of our
women. Anesthetic-related deaths can be reduced in number
by training/retraining our anesthetic doctors in order to keep
up to date with the newest and safest techniques available,
especially epidural in pre-eclampsia/eclampsia cases. There
is a need for preventive counseling and testing for HIV in
pregnancy; those detected to be HIV-positive should be
placed on highly active antiretroviral therapy, as this will help
reduce HIV encephalopathy among our women.
It is notable that, in this study, unbooked patients consti-
tuted about 98% while booked patients accounted for only
2% of maternal mortalities. This is in keeping with previ-
ous studies, in this center
15
and in a neighboring center.
16
Some patients in Nigeria utilize traditional birth attendants,
maternity homes, and spiritual houses for deliveries.
17
This
is because the community believes that maternal death is
due to punishment from the gods as a result of antisocial
activities (adultery) of the woman, hence does not require
orthodox medications. Even in instances when they decide to
seek medical assistance, women are often hampered by poor
communication and transport systems and badly maintained
roads; as such, they may only present to hospital in a mori-
bund state, when any intervention would produce little or no
result.
18
The inability to recognize or react to risks or reach
the medical facilities and delays in referral may be other
causes of the high maternal mortality in Southeast Nigeria.
There is a need for both governmental and nongovernmental
organizations to aid in creation of awareness and abolition of
laws that militate against safe motherhood, as well as in the
provision of effective communication and road networks and
accessible, affordable, and functional health care.
It was found that most of the deaths (75.73%) in our
study occurred within 48 hours of admission; hence, there
is a need for urgent, aggressive, and close monitoring of
our patients during the first 48 hours, which may require the
involvement of the labor consultant in the management of
high-risk patients in the first 48 hours of presentation to the
hospital, when crucial decisions on the management of the
patient must be made. This period also requires intensive
monitoring and care of the patient.
To increase the chances of achieving MDG-5 earlier
than 2030, as predicted by this study, all hands must be on
deck – women, men, the community, and governmental and
nongovernmental organizations must all get involved. The
socioeconomic status of the populace should be improved
upon, along with women’s independence, creation of aware-
ness, and political determination, with the aim of encouraging
pregnant women to book for antenatal care, where the preg-
nancy will be monitored and abnormalities can be detected
and corrected. Availability, accessibility, and affordability of
emergency care services to pregnant women are of utmost
importance, irrespective of class, tribe, creed, and socioeco-
nomic conditions.
Conclusion
Unless something is done to improve on the present situ-
ation, it will take NAUTH until 2030 to achieve MDG-5.
The major causes of maternal mortality are preventable.
Suggested measures to reduce maternal mortality include:
universal education and women’s independence; availability,
accessibility, and affordability of antenatal services; and
24-hour emergency obstetric services. Partnership among
the community, health workers, and governmental and
nongovernmental organizations should be encouraged. The
roles of political determination and further research cannot
be overemphasized in the aim of reducing the MMR in this
tertiary health institution in Southeast Nigeria.
Disclosure
The authors report no conflicts of interest in this work. The
authors alone are responsible for the contents and writing of
the paper. The study was conducted in the course of service in
the hospital and no funding was received from any source.
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