MATERNAL HEALTH CARE DELIVERY IN NORTHERN NIGERIA AN ASSESSMENT OF ROTARY INTERNATIONAL

CHAPTER ONE

INTRODUCTION

1.1        Background to the Study

Maternal Mortality or maternal death is defined as “the death of a woman while pregnant, or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to, aggravated by the pregnancy or its management, but not from accidental cause” (WHO, 1993).

The death of a mother is more than a personal tragedy; it represents an enormous cost to her nation, her community and her family. When a mother dies, her children lose their primary care giver, communities are denied her paid and unpaid labour and countries forego her contributions to economic and social development (Fathala, 1992).

An estimated 585,000 (over half million) mothers die each year from causes related to childbirth, ninety-nine percent (99%) of these in developing countries (Maine, 1987). In Nigeria, 1 in every 13 women face a lifetime risk of maternal death. Yet, most maternal deaths are preventable mainly through medical intervention and political will by the government (Shiffman and Okonofua, 2007).

Maternal mortality has received global attention. The reduction of maternal mortality is one of the Millennium Development Goals (MDGs), specifically, it is number five (5^th MDGs) of the MDGs. The target is to reduce it by 75% by the year 2015. The state of maternal and child health is one of the indicators of a society’s level of development, as well as an indicator of performance of the health care delivery system.

According to Goulet (1992:470), development is “a two-edged sword which brings benefits but also produces losses, and generates value conflicts. One of the benefits is the improvement in maternal well-being. But the gains or benefits of development will be felt differently according to factors such as: ‘who are you’ and ‘where you live’, among others” (Turner and Hume, 1997: 10). Development administration was created in the post-war period to play a major role in facilitating development through a system of bureaucracy. Bureaucracy has however been found to be affected by a number of issues such as: size of bureaucracy, poor administrative capacity, a nation’s culture, bureaucratic bias against the rural poor, corruption, and issues of gender, to mention a few.

Maternal mortality is certainly a gender issue. Awareness to gender issues were brought to the fore in 1981, when the then UN Assistant Secretary General stated that women would not make full contribution to development ‘until there were more women involved in the planning process, in the administration at all levels, and in all sectors’. And that this would increase women’s participation in decision-making in public bureaucracies leading to “increase in overall productivity, to increase in public sector responsiveness to women’s needs…” (Turner and Hume, 1997:97). One of the needs of women is certainly to live in good health, and for maternal mortality to be eliminated. But as Goetz (1992: 6) has argued, “public administration is in itself a gendered and gendering process, such that the outcomes, internal organization and culture reflect and promote the interests of men. And so long as researchers treat men as the norm, the medical care of women continues to be compromised”(Women’s Global Network for Reproductive Rights, 1994, 4: 27-28). Since constraints on public sector spending obviously affect both sexes, but in conditions of poverty, it is usually women who face the greatest problem in acquiring adequate health care (Ibid). And it is in the poorest parts of the world that women’s lack of access to health care is at its most acute (Jacobson, 1993; Timyan, Measham and Ogunleye, 1993).

Health, a basic human right, that is vital to sustainable development, eludes the majority of women (World Bank Report, 2003). Harmful cultural practices perpetuated on women and girls… particularly during pregnancy; certain birthing practices … result in the mitigation of their health or their quality of life (Dawitt, 1994).

In a community-based study of women who delivered and are resident in northern Nigeria, it was reported that home delivery was still the norm throughout the zone, with 1791 (85.3%) deliveries at home; and that up to 80.5% of the deliveries were supervised by personnel with no verifiable training in sanitary birthing techniques (Galadanchi, Ejembi, Iliyasu, Alagh and Umar, 2007). They therefore concluded that “maternal health care as evidenced above is far from the ideal, and likewise, the achievement of the 5^th Millennium Development goal is totally far-reaching; to reduce the maternal mortality ratio by 75% by the year 2015 with this level of maternal care (ibid:448).

The challenge of development according to the world Bank in its 1991 World Development Report is to improve the quality of life, especially in the world’s poor countries. It is in an attempt to foster development that the 189 member countries of the United Nations adopted a total of eight (8) Millennium Development goals (MDGs) in September 2000. They committed themselves to making substantial progress towards the eradication of poverty and achieving other human development goals by the year 2015.

One of those eight MDGs, goal number 5 is “Improvement of Maternal Health”. The target for this goal was to “reduce by three-quarters, that is to achieve a seventy-five percent (75%) reduction in maternal mortality between1999 and 2015.

Awareness to the appalling condition of women’s health was drawn by the United Nations Fund for Population Activities (UNFPA) when it reported that “every minute, another woman dies in childbirth (UNFPA, 2008). The World Bank Report (2003) also reported that about half a million women die every year from the complications of pregnancy and childbirth, and that most of these deaths are preventable with simple technologies that have been available for decades.

The International Conference on Population and Development (ICPD, Cairo, 2004) also called the attention of the world to the magnitude of maternal mortality, and the necessity for its reduction. Maternal mortality ratios (Maternal deaths per 100,000 live births) are, on average, 30 times higher in developing countries than in high-income countries (The World Bank Report, 2003).

In Nigeria, one in every 13 women face a life time risk of maternal death. In the United Kingdom (UK), it is 1 in 5,100, while in Canada, it is 1 in 7,700 (FMOH, n.d).

Apart from the high number of women dying daily from pregnancy related causes, another estimated 2 million women are living with fistula, another debilitating disease with its attendant social and economic consequences (WHO, 1993). Nigeria alone accounts for between 800,000 and 1,000,000 women with fistula and 5,000 new cases are added every year (UNFPA, 2009); it is a disease which usually results from prolonged obstructed labour in pregnant women.

Rathgeber (1990) on why we must look at the health of women separate from men, opined that “women have special health problems that men do not experience; women are more vulnerable to certain conditions than are men…” According to Babalola and Adebayo (2003), women are seen primarily as child bearers, and child carers. Beyond these, they are also seen as community care-givers as well as contributing 60-70% of the labour needed in the agricultural sector in Africa (Ogunlela and Ogunlela, 2008) as well as their contributions in diverse ways to the economy (Boserup, 1995).

The causes of maternal death or maternal mortality, as well as the pregnancy-induced diseases such as fistula can be addressed if the government of Nigeria is willing to commit itself politically. According to Zinser (2007:7), www.globalhealthtv.com); “it is estimated that 15% of pregnancies experience complications world-wide, but in Nigeria, it stands at over 40%. Many pregnant women still deliver at home due to exorbitant antenatal and post-natal costs.  In most Nigerian villages, women still give birth with traditional birth attendants in huts, with no running water, no sterilization, no equipment and no skilled birth attendants capable of providing emergency obstetric care.         Socio-cultural and economic factors that relate to the low status of women, poverty, ignorance and traditional harmful practices also account for the alarming Maternal Mortality Rate (MMR) in Nigeria”.

The MMR landscape in Nigeria will only begin to change for the better when its government

acquires the political will to institute the necessary programs (www.allafrica.com/westafrica).

According to Shiffman and Okonofua (2006:217):

Maternal mortality in Nigeria first received international notice through a 1985 paper presented by obstetrician and gynaecologist, Kesley Harrison … at an international Safe Motherhood Conference in Nairobi, Kenya in 1987, which launched a global Safe Motherhood Movement. Harrison and other Nigerians attended, with a commitment to achieving in their country the objective agreed to at the conference; a reduction in the number of maternal deaths by half by the year 2000. The Federal Ministry of Health subsequently established a national Safe Motherhood Committee, and the Society for Obstetrics and Gynaecology of Nigeria (SOGON) heightened efforts to promote maternal mortality reduction. Also, Columbia University established the Prevention of Maternal Mortality Network, conducting formative research. However, these initiatives were not scaled up, and under the military government Safe Motherhood activities in Nigeria stagnated.

According to Zinser (2008:6), “maternal mortality is the least successful of

all the MDGs because the current rate of progress is less than one-fifth of what is needed to hit the target, as over 99% of maternal deaths occur in developing countries, with women still dying from pregnancy-related causes at the rate of one per minute. Only one-third of births in the poorest countries are attended by skilled health professionals”.

The MDGs were developed in consultation with the developing countries, to ensure that they addressed their most pressing problems. Key international agencies, including the United Nations, the World Bank, the International Monetary Fund (IMF), the Organization for Economic Cooperation and Development (OECD), and the World Trade Organization (WTO) were involved, and they all helped to develop the Millennium Declaration and so they have a collective policy commitment. The MDGs assign specific responsibilities to rich countries, including increased aid … (Todaro and Smith, 2006).

The rich countries such as United States of America (USA), United Kingdom (UK), Germany, among others, often provide assistance or aid to the less developed countries (LDCs) or poor countries through some international non-governmental organizations or development partners. One such international non-governmental organizations or development partners is Rotary International, with its headquarters in Evanston, USA and with branches in many countries of the world.

Rotary International (RI) has through its 3-H programme (Health, Hunger and Humanity) embarked on various projects world-wide to provide assistance in the form of grants to tackle the MDGs. In Nigeria, a major project was undertaken by RI to address maternal health. The project was tagged “Rotary International 3-H project (child spacing, Family Health and HIV/AIDS Education)”. The project was implemented in Northern Nigeria.

1.2      Statement of the Problem

Nigeria is only 2% of the world’s population, but accounts for over 10% of the world’s maternal deaths in childbirth (Adamu, 2003; Shiffman and Okonofua, 2007). Nigeria has the second highest number of maternal deaths following after India (Ujah, et al, 2005a). The picture of maternal mortality and morbidity in Nigeria typifies that of most countries in Sub-Saharan Africa, some regions in Nigeria have some of the highest maternal mortality rates in the world (Amadi, 2007). Estimates from the National Health and Demographic Survey (2003) put Nigeria’s National rates at approximately 800 per 100,000 live births. But there are marked regional variations in rates:

North East     –  1,549 maternal deaths per 100,000 live births

North West    –  1025 maternal deaths per 100,000 live births

South East     –    286 maternal deaths per 100,000 live births

South West    –    165 maternal deaths per 100,000 live births

Rural                   –       828 maternal deaths per 100,000 live births

Urban                 –       351 maternal deaths per 100,000 live births

National           –    740 maternal deaths per 100,000 live births

Nigeria’s 2006 National Population Census figures revealed that Nigeria’s population is 140,033,542 (National Population Commission; 2006). The female population is 68,293,683, which is approximately half of the overall population of the country. Therefore, any health condition which affects either the generality of a nation’s population or that which affects half of the overall population, should in effect constitute a national concern. This fact was captured and highlighted by Awe, in Kisekka (1992) while commenting on the importance of women’s health issues in Nigeria, that “the importance of a healthy female population cannot be over-emphasized in any discussion of women’s contribution to the development of this nation; for it is when women are healthy that they can fulfill their reproductive and productive roles most effectively”.

Nigeria was one of the countries that participated in the 1987 Safe Motherhood Initiative International conference with a commitment to take necessary measures to improve maternal health. The original goal of the Safe Motherhood Initiative was to halve maternal mortality ratios by the year 2000 (Ransom and Yinger, 2002). It was to be done through the following areas of care: Antenatal care, Delivery care, Postnatal care and Family Planning Services. However, years after the launch of this initiative, it was still reported that 1 woman in every 13 women face a lifetime risk of maternal death. In the United Kingdom, it is 1 in 5,100, and in Canada, it is 1 in 7,700 (FMOH, n.d). Also, out of an estimated 2 million women living with fistulae (VVF and RVF), Nigeria alone accounts for between 800,000 and 1,000,000 women with this obstetric fistulae, with additional 5,000 new cases added every year (WHO, 2009 and UNFPA, 2009). This various governments in Nigeria had tried over the years to address the issue of maternal health at the national level. A number of policies in the health sector that are relevant to maternal health were put in place. Among them were the National Health Policy and Strategy (1988, 1998), which emphasized primary health care as the key to the development of the health care delivery system in Nigeria. The provisions of this policy were not strictly implemented especially the maternal health component, hence the poor state of maternal health. Other relevant policies include the National Policy on Population for Development, Progress and Self-Reliance (1988); Maternal and Child Health Policy (1994); National Adolescent Health Policy (1995); National Policy on HIV/AIDS/STIs, Control (1997); National Policy on the Elimination of Female Genital Mutilation (1998); and Breastfeeding Policy (1994). While the provisions of many of these policies are relevant to the promotion of maternal health, their targets were sometimes contradictory.

Another policy, National Reproductive Health Policy and Strategy to Achieve quality Reproductive and Sexual Health for All Nigerians, was formulated for implementation in 2001. This policy was developed to address among others, the unacceptably high levels of maternal and neonatal morbidity and mortality; the low level of male involvement in reproductive health; the low level of awareness and utilization of contraceptive and natural family planning services.

In that policy, specific roles were assigned to Non-Governmental Organizations in collaboration with the federal, state and local governments. Those roles include that:

1. Non-Governmental Organisations shall identify the reproductive health needs of the communities, through studies to provide relevant data

1. Initiate pilot schemes that will serve as models for replication.

iii.               Use innovative approaches in addressing reproductive health needs of the communities.

1. Assist in developing Information, Education and Communication (IEC) materials and programmes.

1. Assist in Monitoring and Evaluation Programmes.

1. Mobilise the community to embark on awareness campaigns to eradicate harmful practices.

vii.             Assist in the development and maintenance of a functional referral system.

viii.          Initiate studies on the knowledge, attitude, beliefs, practice and ethical considerations on reproductive health issues within the communities.

1. Assist in the collation and updating of relevant data about reproductive health resources, the utilization or available maternal health services.

1. Assist in the retraining of various levels of health workers involved in reproductive duties.

This shows that the government of Nigeria has not been able to successfully tackle the problem of maternal mortality alone, hence, the need for the intervention by various NGOs to complement the efforts of the government.

Rotary International’s 3-H project was established by Rotary International to intervene in the area of clinical service delivery in order to complement government efforts towards improving maternal health in Nigeria, especially in the North.

It is against this backdrop that the study was undertaken to precisely assess what Rotary International (RI) has done in the area of service delivery to improve maternal health in some northern states of Nigeria. This is premised on the fact that a large number of NGOs, especially the international ones, claim to be partners of the less developed countries (LDCs) in the development process or what is usually regarded as “development partners”. This is why an assessment of such claims was carried out by studying Rotary International and focused on the following questions.

1.3        Research Questions

1. Why did Rotary International intervene in maternal health care delivery and what was the nature of its intervention?

1. What were the objectives of Rotary International’s intervention and what were the strategies adopted?

iii.               What type of administrative system did the R.I. 3-H Project adopt in implementing the project?

1. Were there any challenges encountered in the implementation of the R.I. 3-H project and what were the lessons learnt?

1.4      Objective of the Study

The primary objective of the study was to examine the nature of the intervention orchestrated by Rotary International to address the poor maternal health, an identified problem of great concern in the area of human development in a less developed country.

Specifically however, the sub-objectives of the study were:

1. To find out reasons for and the nature of the intervention of Rotary International in maternal health care service in Nigeria.

1. To examine the objectives of RI 3-H Project in its project states in Nigeria.

iii.               To find out the types of strategies adopted for the intervention in maternal health care service delivery?

1. To examine how the R.I. 3-H Project was implemented.

1. To find out what type of outcomes or effects the R.I. 3-H Project had on the delivery of maternal health care services in Northern Nigeria.

1. To ascertain if there were any challenges encountered in the course of implementing the project and the type of the lessons learnt.

1.5      Significance of the Study

The significance of this study stemmed from the fact that Nigeria is a developing country that has witnessed a proliferation of NGOs, both local and international types. Each of those NGOs have been laying claims to being contributors to the development process. Whereas there have been arguments that NGOs are partners indeed, making positive contributions to promote development, there have also been arguments to the contrary that NGOs are conduit pipes for siphoning donors’ funds without any tangible achievements towards the development process. Hence, this study was carried out to study a specific NGO, indepth, in order to ascertain what contributions or otherwise, it has made to the social development of a segment of the Nigerian population, that is, the health of mothers (maternal health). Other areas of significance can be itemized as follows:

1. This study has been able to establish a link between issues of Public Health and Public Administration. Maternal mortality which is an indicator of poor maternal health, is a Public Health issue; but has been established as an issue in Public Administration by examining the socio-economic causes of maternal mortality, using the three-delay model as expounded by Thaddeus and Maine (1994): Delay in decision to seek care – due to cultural practices which require a woman to obtain her husband’s permission before she can access maternal health care services; Delay in arrival at a health facility – due to costs of transportation, drugs and supplies; Delay in provision of adequate care at the health facility – due to shortage of trained and competent personnel; the cultural and economic factors which can impact

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