Growing pains of pregnant women in Nigeria’s most populated state

KANO – 5:00 AM, Monday. 20 year-old Naima Saleh, a 9 months pregnant mother mounts a motorcycle in Kushuma heading to Dukawa community, several kilometers away, in a bid to obtain antenatal care services. She is not alone. About 50 other pregnant women have to arrive on time not to risk missing checks at the primary health center in Dukawa. The facility is manned by one female health worker with the services provided twice a week, Mondays and Thursdays. “We don’t have any other means of transport here,” says an exhausted Naima.

Despite the several interventions between 1990 and 2015, including the Millennium Development Goals (MDGs), which have seen indices improve in several parts of the country, the statistics remain unflattering. Women in remote and hard-to-reach rural communities being the most impacted. In 2015 alone, at least 58,000 women died as a result of pregnancy and childbirth complications in Nigeria with states in Northern Nigeria recording above the average maternal mortality ratio of 576 deaths per 100,000 live births in Nigeria, according to the National Demographic Health Survey (NDHS).

State of Health Facilities

According to the 2016 National Health Facility Survey, Kano ranks worst state in the country scoring 1.4% in terms of proportion of primary health facilities with basic health equipment. The North West scores lowest with respect to availability of skilled birth attendants.

It is common sight to find fully equipped health facilities without skilled personnel in rural communities that are privileged to have one.

“We need more health workers so that we can receive antenatal care with ease and be able to deliver in the hospital. At the moment, only one lady attends to us when we come for ante-natal care,” says Maimuna, a 25-year old woman in the second trimester of her pregnancy, who has been receiving care in Dukawa for about 3 months. She is expecting her sixth child.

Built in 2005, the Dukawa PHC was only revitalised in 2014 and fully equipped with facilities including a labour room, a laboratory, theatre and immunization room and equipment, all left to gather dust. The facility does not operate 24 hours a day.

“If any of us (pregnant women) go into labour in the night, we have to begin to scout for a vehicle to take them to either Kura or Dawakin Kudu or even Kano city,” says Rabi Ismaila, speaking of distance, tens of kilometers away from their community.

Terrible Planning

As a result, rural health facilities record far more maternal deaths compared to those in urban centers. A Maternal Death Review (MDR) scorecard, between April to September 2016, found a high maternal mortality ratio up to 2965 maternal deaths (per 100,000 live births) at the general hospital at Dambatta, a rural LGA in Kano, which represents the highest in the state. The general hospitals in Doguwa and Tudun Wada LGAs recorded 2785 and 2647 maternal deaths, respectively, within the same period.

With poor access roads, ill-equipped and understaffed facilities, not many pregnant women in hard-to-reach area will brave the risk others like Naima undertake in a bid to access services. This leaves them at the mercy of unskilled Traditional Birth Attendants (TBAs), a common practice within their communities.

The geographical concentration of healthcare facilities in the urban areas, reflect poor planning against the evidence that the rural areas in Kano are more populated. Most rural LGAs where there are PHCs have no secondary healthcare facilities within proximity to handle referrals; many do not have access to either.

“Major healthcare facilities across Nigeria are concentrated in urban areas and Kano is not an exception and so access to healthcare in Nigeria is mostly through out-of-pocket expenditure, which is beyond the reach of people in rural areas where unfortunately there are more population than urban areas,” Dayyabu Mahmud, Kano state team lead for DFID’s Maternal, Newborn and Child Health programme (MNCH2) explains.

Health Workers Avoid Rural Kano

Fatima Adamu, national programme manager for the Women for Health programme (W4H) observed that most of the female health workers are based in the urban areas, while culture prohibits male health workers from examining female patients. “The challenge is that about 80% of female health workers are based in the urban areas whereas most of the people including pregnant women reside in rural areas. So, we are helping these rural communities produce their own female health workers,” Fatima noted.

Government efforts to incentivise staff redeployment to rural areas have suffered set back. Some of the health workers are posted to rural areas and get paid special allowances but would stay back in the city.

“The roads are bad; there are no social amenities so health workers won’t go to these rural communities since at least they would want their children to have quality education,” Mahmud observes.

Widespread Poverty and Ignorance

The communities of rural northern Nigeria are predominantly agrarian but most of the people are poor and suffer malnutrition, which is responsible for a large number of maternal deaths. The need to furnish them on nutritional information based on locally available staples has not been met, yet.

“I believe pregnant mothers in rural areas should be able to feed well, balanced diet must not be expensive.” Hafsat Kolo of the Partnership for the Promotion of Maternal and Child Health (PPMCH), a coalition of Kano NGOs working to promote child and maternal health.

“There are fruits and vegetables in these rural areas and if pregnant women feed on them, their BP will be normal.”

Many pregnant women in rural communities die because they are unable to afford life-saving commodities, with some costing as low as N100 (30 cents). Drug availability remains a challenge, most facilities within rural communities lack common drugs such as Magnesium Sulphate, an agent used for the treatment of eclampsia – a leading cause of maternal deaths – including malnutrition, malaria, bleeding.

The patriarchal society contributes a great deal; in many cases women are not allowed to earn any income and recourse to their husband for everything.

“A pregnant woman cannot go for antenatal care without the permission of her husband who has been away in Abuja or Lagos for 6 months.”

Budgeting and Government Priorities

Kano state budgetary allocation falls below the 15% minimum commitment to health recommended by the Abuja declaration. The current budget does not appreciate the burden of maternal deaths but the situation is improving.

“State Budgetary allocation to Health sector has been on the gradual increase from 6% in 2014 to 8% in 2015 and 9.8% in 2016. The 2017 budget allocation to health sector in the state is 9.85% of the total budget,” says Getso, the commissioner for health. He informed that the state public service has absorbed 190 Midwives Service Scheme and establishing a school of community midwifery in Dambatta and Gwarzo in a bid to groom more personnel for rural communities.

The challenge of fully functional health facilities lingers still, and the government knows it. Mahmud Nasir, Secretary of the state’s primary healthcare development agency agrees more needs to be done.

“We have realized that our 40 general hospitals cannot cater for the needs of over 20,000 communities across the state; so we are revitalizing about 484 PHCs as part of efforts to increase access to maternal healthcare for pregnant mothers in rural areas.”

The state has high hopes that its proposed healthcare trust fund, a sustainable healthcare financing mechanism will “greatly address the challenge of maternal deaths in the state.” But its implementation will be key.