REVIEW OF RELATED LITERATURE
2.1 Introduction
This chapter aims at reviewing the main contributions made by researchers, scholars and authors on the concept of poverty and the environment as well as the main linkages between the two concepts. It unveils some of the global views that people have shared particularly on the concept of poverty and the ideas expressed on the issue of poverty and maternity. The chapter is categorised into seven main sections with the first four sections looking at the definitions and concepts of poverty, measurement of poverty, causes of poverty and poverty trends and situations in Nigeria respectively. The final section of the chapter describes the theoretical foundation of the study.
2.2 Definitions and measurement of poverty
2.2.1 Concept of poverty
Poverty has a rich vocabulary, in all cultures and throughout history. The first poverty standard for individual families based on estimates of nutritional and other requirements was published by Rowntree‟s study in 1901. In the 1960s, the main focus was the level of income, reflected in macro-economic indicators like Gross National Product per head. In the 1970s, poverty became prominent, notably as a result of MacNamara‟s celebrated speech to the World Bank Board of Governors in Nairobi in 1973. Other factors that played a big role include the emphasis on relative deprivation, inspired by works in the United Kingdom by Runciman and Townsend (Philip and Rayan, 2004). Townsend had the opinion that poverty was not just a failure to meet minimum nutrition or subsistence levels, but rather a failure to keep up with the standards prevalent in a given society. Thus, following International Labor Organization‟s (ILOs) pioneering work in the mid-1970s, poverty became to be defined not
just as a lack of income, but also as lack of access to health, education and other services (Philip and Rayan, 2004). However, while there is worldwide agreement on poverty reduction as an overriding goal, there is little agreement on the definition of poverty (Laderchi, R. C., Saith, R. and Stewart, F. (2003).
The definition of poverty assures a distinction between the traditional unidimensional approach and more recent multi-dimensional ones. Whereas the traditional approach refers only to one variable such as income or consumption, multi-dimensional ones, such as Sen‟s capability theory or studies derived from the concept of fuzzy sets extend the number of dimensions along which poverty is measured. The complex reality of poverty, however, makes it difficult to capture the nature of this phenomenon via a single uni- or multidimensional definition or measure (Fusco, 2003). The traditional approach to poverty is characterized by the fact that poor people are identified according to a shortfall in a monetary indicator. The theory implicitly underlying this assumption is the utilitarianism, theoretically based on the criteria of utility and practically on the use of income or expenditure as a proxy of well-being. From this time onwards, the criterion for defining poverty is based on income and thus poverty can be defined as a lack of economic welfare, i.e. income. In terms of this definition, absolute poverty refers to a lack of income in order to satisfy the essential requirements for physiological survival. Whilst relative poverty is a lack of income in order to reach the average standard of living in the society in which one lives (Fusco, 2003). In 2005, Fusco‟s view on the concept of poverty was being stressed on by the Food and Agricultural Organization (FAO) of the United Nations (UN) indicated that; The standard of living, hence poverty, may be represented by a uni-dimensional indicator (e.g. income) or a multi-dimensional approach (e.g. income, health conditions, family status, etc.). In the first case, poverty is defined by income poverty and the standard of living is defined in the space of economic welfare, a narrower concept than well-being. In the second case, the concept of
poverty is closer to well-being, where other welfare indicators support income in defining poverty (FAO of UN, 2005). Any of the above choices entail additional problems, which include; In the case of the uni-dimensional approach, you have to define what the appropriate single monetary indicator for standard of living is.
There are two natural candidates here, income and expenditures. Total expenditures are often used as an indicator of poverty, as they better reflect the concept of permanent income of an individual. In the case of the multi-dimensional approach, you have to define what the appropriate list of poverty indicators is and how to weigh them in order to get a comprehensive vision of poverty. For example, if you have low incomes and good health, are you richer than an ill individual with more income? If you are illiterate, yet in good health and with enough food, are you poor? An alternative view of the multi-dimensional approach could be that of explaining poverty with a set of indicators, leaving the task of defining how poverty is explained by which factor to statistical techniques. This raises the objection that simple correlation is not a causal relation: are you poor because you are in bad health? Or are you in bad health because you are poor? The answers to these questions may entail quite different anti-poverty policies (FAO of UN).
In his view, Aigbokham defined poverty as a state of long-term deprivation of well-being, a situation considered inadequate for decent living. There are, however, many debates on how well-being should be measured and what indicators should be used. There are two broad approaches to defining wellbeing. These are the „welfarist‟ approach and the „non-welfarist‟ approach. The „welfarist‟ approach defines well-being in terms of the level of utility attained by an individual. The approach attaches great importance to the individual‟s perception of what is useful to him or her. The „non-welfarist‟ approach defines well-being independently of the individual‟s perception of it. The approach relies on what planners consider desirable from a social point of view (Aigbokham, 2008).
In a related view, Boccanfuso (2004) expounds that the welfare approach refers to the numerous microeconomic precepts that postulates that economic actors are rational and that they behave in ways to maximize their benefit. Since economic welfare is not observable, the welfarist school has fallen back on real income and consumption expenditures as indicators of economic welfare. This is the approach advocated by the World Bank (WB), the International Monetary Fund (IMF) and the main development partners (Boccanfuso, 2004 cited in Philip and Rayan, 2004). The non-welfare approach is more sociological in nature. In contrast to the previous approach, this has to date been a multidimensional approach. There are two schools of thought under this approach; the first is the basic needs school and the second is the capabilities. The basic needs approach appeared in its operational guise in the 1970s in response to the policies for the fight against poverty proposed by the welfarists, and particularly to the policies of growth trumpeted as a tool for reducing poverty. It reviews poverty as a problem of unacceptable social inequality (Kanbur, 2002 cited in Philp and Rayan, 2004). Sen‟s (1981) school of capabilities approach was also developed in opposition to the welfare approach. The aim of this approach is for an individual or household to have the capacity to function well in society and not solely on the basis of its own function.
Today, the main focus on poverty continues to be on material deprivations, i.e., the failure to command private resources rather than the earliest definitions of poverty that centred on the inability to obtain adequate food and other basic necessities. Development experts, including Sen (1987), though, have argued that this notion of economic welfare remains too narrow to reflect individual well-being, spurring active efforts over the past several decades to expand the concept of poverty. One direction of expansion begins with recognition that even material deprivations may involve more than lack of private resources. If a village has no wiring for electricity, residents can have substantial income but no steady power source. If quality
health facilities do not exist, no amount of money may be enough to purchase effective, convenient care (Kamanou, et‟al 2005).
The absence of a consensus of definition for poverty has stimulated several concepts, definitions and ideas from researchers and institutions all with the aim of influencing the poverty discourse. It is on this background that, the International Poverty Centre (IPC) of the United Nations Development Programme (2006) indicated that, what poverty is taken to mean depends on who asks the question, how it is understood, and who responds. From this perspective, it has at least five clusters of meanings. The first is income-poverty or its common proxy (because less unreliable to measure) consumption-poverty. The second cluster of meanings is material lack or want. Besides income, this includes lack of or little wealth and lack or low quality of other assets such as shelter, clothing, and furniture, personal means of transport, radios or television, and so on. This also tends to include no or poor access to services. A third cluster of meanings derived from Amartya Sen, and is expressed as capability deprivation, referring to what we can or cannot do, can or cannot be. This includes but goes beyond material lack or want to include human capabilities, for example skills and physical abilities, and also self-respect in society. A fourth cluster takes a yet more broadly multi-dimensional view of deprivation, with material lack or want as only one of several mutually reinforcing dimensions.
The United Nations (UN) view on poverty provides a broader definition of the concept. According to the UN, poverty is defined as; „a human condition characterized by the sustained or chronic deprivation of the resources, capabilities, choices, security and power necessary for the enjoyment of an adequate standard of living and other civil, cultural, economic, political and social rights‟ (UN, 2001). This definition brings together two important and related themes in contemporary understandings of poverty: the „capability
approach‟ of Nobel-prize winning economist Amartya Sen and the „human rights‟ approach. The „capability approach‟ addresses poverty as „the deprivation of basic capabilities rather than merely as lowness of incomes‟ (Sen, 1999). Suggested basic capabilities for a life with human dignity include the capability to live a human life of normal length, to ensure one‟s bodily health and integrity, to be treated as someone whose worth is equal to that of others, to have control over one‟s political and material environment (Nussbaum, 1999). The understanding of poverty as a deprivation of these capabilities thus includes situations of low income, under-nourishment, illiteracy, premature mortality, and also social stigmatization and low self-esteem. Similarly, in his paper, Practices of Poverty Measurement and Poverty Profile of Bangladesh, Ahmed (2004) defines poverty as forms of economic, social, and psychological deprivation among people arising from a lack of ownership and control of or access to resources for the attainment of a required minimum level of living. It is a multidimensional problem involving a deficiency of income, consumption, nutrition, health, education, housing, etc. (Ahmed, 2004). Just like the United Nation‟s definition on poverty, Ahmed also provides a broader definition on the concept of poverty where he does not only link poverty with a lack of income but tries to encompass social and psychological deprivation with the concept.
According to the European Union (EU), poverty is referred to as “Persons, families, and groups of persons whose resources (material, cultural, and social) are so limited as to exclude them from the minimum acceptable way of life in the Member State to which they belong” (European Commission, 2007: 5 cited in Nyasulu, 2010). This definition concentrates on the individual entity, like person or groups of persons, whose level of resources would exclude them from the minimum acceptable way of life deemed acceptable by a member state. This definition is problematic because it assumes that it is okay to be under some conditions, however deplorable as long as the member state has not declared them as such. This
definition abrogates responsibility by focusing on a less contentious issue of “person” or “group of persons” in a member state. Poverty, however, is not what the member state says or thinks, or what a particular culture accepts. Poverty is poverty, regardless of one‟s geographic location. Poverty has everything to do with the dignity of the human spirit in particular conditions and not what is considered politically correct or culturally acceptable.
In reviewing literature on the definition and concept of poverty, two schools of thought have emerged; the traditional approach to poverty which is characterized by the fact that poor people are identified according to a shortfall in a monetary indication, and multidimensional approaches such as Sen‟s capabilities approach which allow us to have a more shaded comprehension of poverty because it takes into account its complex and pervasive nature. In terms of the traditional approach, absolute poverty is a lack of income in order to satisfy the essential requirements for physiological survival. However, in terms of the relative approach, poverty is a lack of income in order to reach the average standard of living in the society in which one live.
It is imperative to note that the two approaches have their pros and cons. The capabilities approach does not only change the measurement focus in poverty assessments, it alters quite significantly policy approaches to poverty alleviation by directing attention to the need to strengthen the capabilities of individuals and households to take action for the improvement of their own welfare. Moreover, it directs attention to political, social and economic constraints external to the individual or household, and thus emphasizes the importance of participatory democracy. The capabilities approach to the concept and definition of poverty is therefore broad and takes into account the complex and pervasive nature of poverty as compared to the traditional approach that identifies poverty with a shortfall in monetary indication. The main challenge of the traditional approach according to Fusco (2003) is that, it fails to capture the complex reality of poverty at the level of each individual and that
income can‟t take account of the diversity and the vague aspect of poverty. Despite the weaknesses of this theory, the simplicity of the computation of monetary indicators as well as the policy implications derived from them can happen to be useful in the framework of an overall strategy to fight poverty. For the purposes of this study, poverty is defined as the lack of adequate income to procure one‟s basic needs and wants of life.
2.2.2 Measurement of Poverty
Poverty as has been defined in the earlier section is multidimensional, thus measuring it presents a number of challenges. Beyond low-income as a key indicator, there are also low human, social and financial capitals. The most common approach to measuring poverty is quantitative, money-metric measures, which use income or consumption to assess whether a household can afford to purchase a basic basket of goods at a given point in time. The basket ideally reflects local tastes, and adjusts for spatial price differentials across regions and urban or rural areas in a given country. Money-metric methods are widely used because they are objective, can be used as the basis for a range of socio-economic variables, and it is possible to adjust for differences between households, and intra household inequalities (Baker and Schuler, 2004).
Prior to 1992, the conventional way of measuring poverty in Canada was in terms of “relative” deprivation. You are poor, in this sense, if you are less well-off than most others in your community regardless of your actual standard of living. However, in 1992, The Fraser Institute published a book entitled, ``Poverty in Canada‟‟, which argued that measuring poverty in a relative sense was really an attempt to redefine poverty as inequality. Accordingly, poverty is generally understood to mean real deprivation and a “lack” of the basic necessities of life. The book set out a methodology to measure poverty in an approach sometimes referred to as “absolute” poverty. A follow-up study, also called Poverty in Canada, published in 1994 by The Fraser Institute, argued that both absolute and relative
measures should be used in all studies of poverty (Sarlo, 2001). Similarly, according to Gordon (2000), participating countries in an international social development summit held in Copenhagen in 1995 issued a declaration that all participating nations should develop measures of absolute and relative poverty (Gordon, 2000: 35).
According to the final report for Eurostat (2000), before the Second World War, most poverty standards were based on notions of absolute needs or minimum subsistence or basic necessities and were generally derived using budget standards, in which the food budget was commonly based on ideas of nutritional adequacy. In the post-war period poverty emerged in social scientific debates with a new conceptualization - as relative deprivation. A variety of methods have been developed to measure relative poverty but the one most commonly employed by national governments and in comparative studies, has been the use of an income (and sometimes expenditure) threshold (Eurostat, 2000). In their survey on: „the impact of poverty on health‟‟, the Canadian Institute for Health Information (CIHI, 2003) outlined three main approaches to explain the meaning of poverty and how it is measured: the absolute, relative and subjective approaches.
2.2.2.1 The Absolute Approach
After the World Summit on Social Development in Copenhagen in 1995, 117 countries adopted a declaration and programme of action, which included commitments to eradicate ``absolute‟‟ poverty. Absolute poverty was defined as "a condition characterized by severe deprivation of basic human needs, including food, safe drinking water, sanitation facilities, health, shelter, education and information. It depends not only on income but also on access to services"(Gordon, 2005).
By the absolute approach, poverty is defined based on the idea that individuals are poor if they have insufficient income to purchase some `0bjective‟ minimum bundle of goods (CIDI, 2003). In his paper `Estimates of Relative and Absolute Poverty Rates for the Working
Population in Developing Countries‟, Sharpe (2001) indicates that, absolute poverty is defined in absolute terms. The World Bank (1999) has developed an absolute poverty line for underdeveloped countries of one U.S. dollar per day per family (Sharpe, 2001). However, there has been a re-evaluation of the World Bank‟s ``$1 a day‟‟ poverty line since 1999. The international poverty line has been recalibrated at $1.25 a day, using new data on purchasing power parities (PPPs), compiled by the International Comparison Program, and an expanded set of household income and expenditure surveys. This has been widely accepted as the international measure for absolute poverty (World Bank, 2008). In their working paper entitled ``Chronic poverty: meanings and analytical frameworks‟‟, (David et al) indicated that absolute poverty is perceived as subsistence below the minimum requirements for physical wellbeing, generally based on a quantitative proxy indicator such as income or calories, but sometimes taking into account a broader package of goods and services (David et al, 2001). By the absolute approach, therefore, poverty is based on the capacity to survive, and thus based on a person‟s nutritional status. This therefore implies that an individual can be classified as poor if he/she is unable to purchase enough food to meet his/ her essential nutritional requirements. However, Gordon (2005) indicates that absolute poverty threshold is equal to two or more severe deprivations of basic human needs.
Several scholars and schools of thought have identified a myriad of problems with the concept and use of absolute poverty. According to the Food and Agricultural Organization (FAO) of the United Nations, the absolute approach to the measurement of poverty has two fundamental shortcomings- that the minimum diet costs may vary among households as they do not all share the same preferences of nutrition pattern, and secondly, non-food items are not considered (FAO, 2005). Similarly, Lister (1993) indicated, “within the absolute poverty approach human needs are interpreted as being predominantly physical need - that is, for food, shelter and clothing, rather than social needs. People are not, it is argued, simply individual organism requiring replacement of sources of physical energy. They are social beings expected to perform socially demanding roles as workers, parents, partners, neighbours and friends” (Lister cited in Donkor, 1997). Furthermore, the Canadian Institute for Health Information expounds that a major disadvantage of the absolute approach is that it is extremely difficult to choose an objectively defined ``minimum set of necessities‟‟, and that this minimum standard will necessarily change over time (CIHI, 2005). Also, according to Woolard and Leibbrandt, the household's consumption behaviour is not taken into account. The minimum cost for attaining the necessary energy intake may be less than the expenditure level at which a household normally attains that kilojoules intake. People do not simply consume food in order to stay alive. They have preferences for particular types of food: a diet of maize meal and beans may provide all the necessary nutrients at very low cost, but it may be loathsome to the individual (Woolard and Leibbrandt, 1999). The measurement of poverty based on the nutritional intake of a household or individuals is therefore not sufficient.
2.2.2.2 The Relative Approach
By the relative approach, poverty refers to a standard of living defined in relation to the position of other people in the income or expenditure distribution. In this sense, poverty is basically a phenomenon of inequality. For example, one could define as poor those individuals that have incomes below 50 per cent of the average income of the society. Therefore, if average income grows because richer people gain more, people in relative poverty might increase. This concept automatically reflects changing social and economic conditions in a given country (FAO, 2005). Similarly, according to the Canadian Institute for Health Information, the relative concept of poverty defines individuals as poor if they have significantly less income than others around them. Relative measures of poverty define poor individuals as having less than some percentage (40% or 50%) of median equivalent income (CIHI, 2003). Townsend also argued that, by the relative approach, individuals, families and groups in the population can be said to be in poverty when they lack the resources to obtain the type of diet, participate in the activities and have the living conditions and amenities which are customary, or at least widely encouraged or approved, in the societies to which they belong. Their resources are so seriously below those commanded by the average individual or family that they are, in effect, excluded from ordinary living patterns, customs or activities (Townsend, 1979 cited in Townsend and Kennedy, 2004). Although this definition gained widespread currency, Fahey (2010) indicated that it proved difficult to implement since no agreed basis could be found for deciding how far below the standard of the `average individual or family‟ one had to be counted as poor. Thus, the selection of appropriate poverty thresholds became arbitrary and was a persistent focus of debate in the field (Fahey, 2010). Another criticism to Townsend‟s definition was formulated by Sen (1983) who argues that the consequences of taking a rigid relativist view is that poverty cannot be eliminated, and an anti-poverty programme can never really be quite successful. A counter-critique to this argument is by Atkinson (1983), who replies that it is quite possible to imagine a society in which no one has less than a half the average income, and therefore where there is no poverty according to this definition (Bellu and Liberati, 2005).
In their report entitled ``the measurement of absolute poverty‟‟, Eurostat (2000) indicated that after the Second World War, a variety of methods have been developed to measure relative poverty but the one most commonly employed by national governments and comparative studies has been the use of an income threshold (Eurostat, 2000). By this measure therefore, for example the proportion of individuals or households living below a threshold of half national average could be considered as poor. According to Kamanou et al, many wealthier countries set poverty lines based on relative standards. In the United Kingdom, for example, the poverty line is 60 percent of the median income level (after taxes and benefits and adjusted for household size), an approach adopted broadly in the European Union. The relative benchmark used in Europe reflect the belief that important deprivations are to be judged relative to the well-being of the bulk of society, approximated by the income level of the household at the mid-point of the income distribution (Kamanou, G. Morduch, J., Isidoro, P.D., Gibson, J., Havinga, I., Ward, M., Kakwani, N., Hyun, H.S., Glewwe, P., Bamberger, M., Grootaert, C. and Reddy, S. (2005).
There have been a number of criticisms of this standard of poverty. Eurostat argued that it is a measure of inequality not poverty and essentially arbitrary. It is also argued that this approach produces unreasonably large poverty rates in communities or countries with dispersed income distribution (Eurostat, 2000).
2.2.2.3 The Participatory Poverty Assessment (PPA)
Participatory Poverty Assessments (PPA) evolved from Participatory Rural Appraisal (PRA) defined as a growing family of approaches and methods to enable local people to share, enhance and analyse their knowledge of life and conditions, to plan and to act (Chambers 1994, cited in Laderchi et al, 2003). Conventional poverty estimates, including both monetary and capability ones have been criticized for being externally imposed, and not taking into account the views of poor people themselves. The participatory approach, pioneered by Chambers, aims to change this, and get people themselves to participate indecisions about what it means to be poor, and the magnitude of poverty (Chambers1994; Chambers 1997cited in Laderchi et al, 2003). According to Ravallion (1998), the subjective poverty line developed in the 1970s, casts doubts over the objectivity of using “basic needs” in poverty measurement including nutritional requirements. If value judgments affect measurements, then the methods are not objective and therefore who is making such value judgments matter, and most likely they are the statisticians and researchers. Certain adjustments have been made to respond to these issues. Rather than dichotomizing their income between needs and luxury, this approach asks the Minimum Income Question (MIQ) where individuals or households are
asked ``at what income level is considered absolutely minimal to survive‟‟ or ``at what point will their families not be able to make both ends meet‟‟ (Ravallion 1998: 21 cited in Nunes, 2008). The Canadian Institute for Health Information (CIHI) points out that subjective approach argues that individuals are poor when they feel they do not have enough to get along. Proponents argue that the best way to assess how much income people need to make ends meet is to ask them. Thus, subjective poverty lines are constructed from surveys that ask questions such as: Living where you do now and meeting the expenses you consider necessary, what would be the very smallest income you and your family would need to make ends meet? It went further to state that, answers to this question increase with the respondent‟s income, and estimates of subjective poverty lines take this phenomenon into account (CIHI, 2003). In a similar fashion, Hulme et al (2001) indicated that, the „subjective‟ approach to understanding and measuring poverty argues that poverty and ill-being must be defined by „the poor‟ or by communities with significant numbers of poor people. Meanings and definitions imposed from above are seen as disempowering poor people and removing their right to create and own knowledge (Hulme, D., Moore, K. and Shepherd A, 2001).
The use of the Participatory Poverty Assessment has the advantage of understanding poverty from the perspective of the poor, as it gives them the voice in the definition of their own poverty and analysis of what they know, experience, as well as their needs and wants. It therefore brings to bare dimensions of poverty, which might not be captured by professionals. Robb (1999), indicated that the participatory poverty assessment enables the views of the poor to be incorporated in national policy and opens up the process of policy dialogue to include a cross section of civil organization in the formulation of poverty reduction policies (Robb, 1999).
2.3 Causes of Poverty
In their working paper, ``Chronic poverty: meanings and analytical framework‟‟, Hulme et al (2001) indicated that the causes of poverty can range from the simple (such as environmental determinism, which argues that poverty is the result of too many people living on poor lands that are unhealthy for humans) to the highly complex (such as theories of globalization e.g. Castells 2000 that attempt to weave all of these factors, and more, into an analysis that goes from the micro to the macro level). Thus, they classified the causes of poverty into four broad thematic areas as economic, social, political and environmental causes (Hulme et al, 2001). In their research, Okidi and Mugambe (2002) expressed that in view of the multidimensionality of poverty the World Development Report 2000/2001 identifies institutional, social, economic and human factors as the major causes of poverty. Furthermore, they stated that when countries are experiencing growth a sub section of a society may lag behind and slide into relative poverty when there is no political will to undertake appropriate social spending programs. They also identified lack of human and technical skills to exploit available income generating and life improving opportunities as both a cause and symptom of poverty (Okidi and Muambe, 2002).
According to Bourne (2005), many factors underlie the high incidence of poverty in the Caribbean, the major ones included low income and levels of unemployment; inequality of income and wealth within countries; the global inequality of income, access to resources and consumption; the volatile nature of the Caribbean economy as well as the absence of government-financed safety nets in most Caribbean counties (Bourne, 2002). In his report, Rynell (2008) indicated that macroeconomic performance is a key determinant of poverty. According to him, a strong economy typically results in reduction in poverty because more jobs are created, unemployment drops, and wages increase; on the other hand, recessions have a disproportionate impact on lower-income families because they cause rising unemployment, a reduction in work hours, and the stagnation of family incomes (Rynell, 2008). It is on this background that the World Bank indicated that, the decline of poverty in Ghana from around 42 percent in 1997 to 35 percent in 2003 was mostly due to acceleration in economic growth (World Bank, 2006).
2.4 Maternal Health in Nigeria: Historical Perspective
In the 1940s, the Church Missionary Society, the Native Administration and the colonial government undertook to raise the standard of midwifery work in eastern Nigeria. The effort combined community health education on a massive scale with the setting up of maternity homes manned by trained midwives under rigorous supervision. Affordable fees were charged. By 1949, in the 31 maternity homes that handled 6500 deliveries yearly, the maternal mortality ratio became 46 per 100,000 births, comparable to the standard at that time in England and other countries (Harrison, 2009). Also, beginning in 1945, Katsina province in Northern Nigeria ran a reliable system of compulsorily obtaining and keeping records of all births and deaths.
The excellence of the quality of this source of data is attested to by the publication of good papers based on them. Harrison goes on to note that In the Ilesha area of Western Nigeria the Methodist Church of Nigeria introduced the concept of a base hospital with linkages between the base hospital and all the maternity centres in the area at urban and village levels. Close to perfection, it offered a good opportunity for replication in the rest of the country but this did not happen.
2.5 Causes of Maternal Mortality
The WHO Factsheet (2008) indicates that globally, about 80 percent of maternal deaths are due to four major causes- severe bleeding, infections, hypertensive disorders in pregnancy (eclampsia) and obstructed labour. Complications after unsafe abortion cause 13% of maternal deaths. Among the indirect causes of maternal death are diseases that complicate pregnancy or are aggravated by pregnancy, such as malaria, anaemia, hepatitis, anaesthetic death, meningitis, HIV/AIDS, sickle cell anaemia, anaemia and acute renal failure, which could be a complication of eclampsia. Women also die because of poor health at conception and a lack of adequate care needed for the healthy outcome of the pregnancy for themselves and their babies.
Omoruyi (2008) estimated that in Nigeria, more than 70 percent of maternal deaths could be attributed to five major complications: haemorrhage, infection, unsafe abortion, hypertensive disease of pregnancy and obstructed labour. Also, poor access to and utilization of quality reproductive health services contribute significantly to the high maternal mortality level in the country.
As explained in Mojekwu (2005) the causes of maternal deaths can be classified into medical factors, health factors, reproductive factors, unwanted pregnancy and socioeconomic factors. According to the author, medical factors include direct obstetric deaths, indirect obstetric deaths and unrelated deaths. Direct obstetric deaths result from complications of pregnancy, delivery or their management. Indirect obstetric deaths result from worsening of some existing conditions (such as hepatitis) by pregnancy. Health service factors include deficient medical treatment, mistaken or inadequate action by medical personnel, lack of essential supplies and trained personnel in medical facilities, lack of access to maternity services and lack of prenatal care. Other risk factors for maternal mortality in Nigeria include maternal age, illiteracy, non-utilisation of antenatal services and grand multiparity ( Ujah et al. 2005
As explained in the WHO Factsheet (2008), drugs already exist (oxytocin) which, if administered immediately after childbirth, can reduce the risk of bleeding very effectively. Sepsis – a very severe infection – is the second most frequent cause of maternal death. It can be eliminated if aseptic techniques are respected and if early signs of infection are recognized and treated in a timely manner. The third cause, eclampsia, emerges as pre-eclampsia, a common hypertensive disorder, which can be detected during pregnancy. Although pre-eclampsia cannot be completely cured before the delivery, administering drugs such as magnesium sulfate can lower a woman’s risk of developing convulsions (eclampsia), which can be fatal. Another frequent cause of maternal death is obstructed labour, which occurs when the fetus’ head is too big compared with the mother’s pelvis or if the baby is abnormally positioned. Skilled practitioners can now use the partograph (a simple tool for identifying problems early in labour) to recognize and deal with slow progress before labour becomes obstructed, and, if necessary, ensure that Caesarean section is performed on time to save the mother and the baby.
For women to benefit from these cost-effective interventions they must have antenatal care in pregnancy, in childbirth they must be attended by skilled health providers and they need support in the weeks after the delivery (WHO, 2008). Whereas in many developed countries almost all pregnant women receive antenatal and postnatal care and are attended by a midwife and/doctor at childbirth, available data show that less than two thirds receive similar services in developing countries. Many pregnant women in Nigeria do not receive the care they need either because there are no services where they live, or they cannot afford the services because they are too expensive or reaching them is too costly. Some women do not use services because they do not like how care is provided or because the health services are not delivering high-quality care. Further, cultural beliefs or a woman’s low status in society can prevent a pregnant woman from getting the care she needs. To improve maternal health, gaps in the capacity and quality of health systems and barriers to accessing health services must be identified and tackled at all levels, down to the community.
2.5 Current Efforts to Reduce Maternal Mortality in Nigeria
Although attempts have been made in the past aimed at reducing maternal mortality in Nigeria, such attempts, especially by the Federal and state governments, have generally not proved very successful in achieving the desired results. Some promising results however have recently begun to be recorded through some policy initiatives by a few state governments. In Anambra state, the state house of assembly approved a bill in 2005, guaranteeing free maternal health services to pregnant women (Shiffman and Okonofua, 2007). The state commissioner of health, who is an obstetrician and gynaecologist, played a central role in its development and adoption. In Kano state, the state government included in its budget a line item for free maternal health services. The former state commissioner of health together with a senior obstetrician and gynaecologist, played central roles in creating this positive environment for maternal health. In Jigawa state, state and local budgets have provided funds for the upgrading of obstetric care facilities in hospitals, the recruitment of obstetricians and gynaecologists and the provision of ambulances at the local level to transport pregnant women experiencing delivery complications to health facilities. The former executive secretary for primary health care, who subsequently became state commissioner for health, stood behind these initiatives.
A common trend to these initiatives is that they were championed in each case by a state commissioner of health who obtained political commitment from the governor, state assembly and other relevant government officials, thus lending credence to the view that the battle to combat high maternal mortality is not just a medical or technical matter but rather requires high level political commitment.
Another thing common to these initiatives is the attempt to introduce free maternal care, usually through user-fee waivers. However, these policies mostly do not seem to be adequately planned for and are consequently unsustainable. The main challenge to the introduction and implementation of user-fee waivers is the provision of adequate number of skilled health care personnel to handle the huge influx of pregnant women who come to avail themselves of the free maternal care services. A second challenge is that large amounts of drugs are used up in very short periods of time. Also, an overwhelming amount of clerical work is required to account for the distribution and use of medicines. Hence there is need for adequate planning before the introduction of user-fee waivers.
The Lagos State Government, in an effort stem the tide of maternal and child deaths recently set up five Maternal and Child Care centres (MCCs) fully equipped and well staffed to provide a wide spectrum of care including family planning, ante- and post- natal care to facilitate safety of women during child delivery. The MCCs are located in surulere, Ikorodu, Isolo, Ifako-Ijaiye, and Ajeromi. Other locations include Alimosho, Ibeju-Lekki, Epe and Badagry among others (Sunday Punch, 2012).
One recent initiative that seems to be successful is the Ondo State Government initiative known as Abiye. This initiative in the rural communities in Ondo State, uses mobile phones to save lives of indigent pregnant women. According to the World Bank (2008) 51.6 Percent of Nigerians live in rural areas, most of whom are cut off from modern medical facilities, making pregnant women vulnerable to readily preventable adverse outcomes. Most of these adverse outcomes result from delay in seeking care, getting to health centres when care is sought, receiving care on getting to the health centre, and referring patients to more advanced centres when necessary.
In the Ondo State initiative, pregnant women go for antenatal care at primary health care centres where each one is given a mobile phone. The pregnant women are put in government prepaid, caller-user groups and tracked by trained personnel so the pregnancy is monitored. Calls to the healthcare personnel are toll free. The Pilot scheme is in Ifedore Local Government Area of Ondo state (Sunday Punch, 2011). Primarily because the lines are toll- free the delay in seeking care is minimised to almost zero. The programme also takes care of the delay in reaching health centres since ambulances are stationed to bring in the pregnant women when they call. In emergencies, the health personnel go on motorcycle with a First Aid box. If it is something they can’t handle, the women are taken to the general hospital.
A major shortcoming of all these efforts is that they are disjointed and uncoordinated, with each state working according to its own dictate and vision. What is required is an integrated approach to replicate successful programmes in other states of the country. The disjointed nature of these efforts is indicative of overall failure in leadership and governance in the healthcare sector and, indeed in other spheres of Nigerian life.
The resulting chaos manifests in inconsistent, contradictory, ill-thought-out, and ever changing policies. For instance, one stop-gap initiative introduced to address the issue of low proportion of births attended by skilled health personnel is the Midwives Service Scheme. Under this scheme the three tiers of govt are to share the costs of engaging midwives on a massive scale. It is not clear, however, where the midwives are to come from since the relevant regulatory bodies, the Nursing and Midwifery Council of Nigeria and the Federal Ministry of Health appear determined to drastically restrict the number of midwives and nurses that may graduate each year. As a result of regulations aimed at achieving such ends, many states do not have enough nurses and midwives to effectively meet the basic demand for maternal care, let alone handling things on a massive scale.
Not helping matters also is the unwillingness of governments in Nigeria to reveal how they spend money. It is difficult to comprehend the rationale behind the phenomenon of unspent funds whereby funds are usually returned as unspent at the end of each budget period even as 52,000 Nigerian women are consigned to early graves owing to failure of the government to provide facilities to assist in pregnancy and childbirth. A recent report by the Centre for Reproductive Rights (CRR), notes that in 2008 Nigeria gave about 5% of its annual budget to the health sector. This amounts to just one third of what it promised in a regional treaty. And without public access to fiscal information, it is difficult to find out who received the money and how it was spent.
2.5.1 Policies and Declarations on Maternal Mortality Reduction in the Past
The issue of maternal deaths emerged as a world health concern through the United Nation's launching of the Safe Motherhood Initiative (SMI) in Kenya in 1987. The Safe Motherhood Initiative, whose target was the reduction of the estimated yearly world maternal mortality figure of 500,000 by 50 percent by the year 2000 was formally launched in Nigeria in 1990. Other international conferences that established similar targets of reducing the 1990 levels of maternal mortality by fifty percent include the Beijing Conference held at the instance of women activists from across the globe back in 1995 (Daily Independent, 2010), the World Summit for Children (WSC) in 1990, the International Conference on Women in 1994, the Fourth Conference on Women in 1995 (Mojekwu, 2005), and the United Nations Millennium Summit in 2000, which developed the Millennium Development Goals (MDGs) to enable the poorest countries improve the quality of life of their citizens, and resolved to achieve these goals by 2015. The fifth MDG requires all member states to improve maternal health and, in order to achieve this goal, a number of targets were set, including reducing maternal mortality by three quarters (75%) between 1990 and 2015 (U.N. 2008).
Regional Treaties, Policies and Declarations include the African Charter (O.A.U, 1982), the Maputo Protocol (CRR and WARDC, 2008), and the 2001 Abuja Declaration in which African Union governments pledged to allocate at least 15% of their annual budgets towards improving the health sector (O.A.U, 2001).
National Policies and Strategies include the 1988 National Health Policy and Strategy to Achieve Health for all Nigerians, which was Nigeria’s first comprehensive health policy (Federal Ministry of Health, Nigeria 1988). The 2004 Revised National Health Policy replaced the 1988 National Health Policy. Reproductive Health Policies include Nigeria’s National Reproductive Health Policy and Strategy of 2001 (Federal Ministry of Health Abuja, 2008), the Integrated Maternal, Newborn and Child Health Strategy in 2007 (2007 IMNCH Strategy) and the National Millennium Development Goals Report (2004).
2.5.2 The Medical Explanatory Model
A number of studies have proven the following as the most frequent clinical factors of maternal deaths and lasting morbidity during pregnancy and delivery.
2.5.2.1 Postpartum Hemorrhage (PPH)
PPH is currently reported as the principal cause of maternal death. For instance, in the United States, PPH account for approximately 11.4% of maternal deaths. In developing countries such as Ghana, lack of experienced caregivers who might be able to effectively handle PPH if it occurs, and lack of blood transfusion services have been cited as major contributions of unfavorable outcomes of PPH. Postpartum Hemorrhage is simply explained as blood loss of more than 500ml following vaginal delivery or more than 1000ml following Cesarean delivery. If these blood loss occurs within 24hours of delivery, it is called primary PPH, otherwise, secondary PPH.
Out of 634 pregnancy-related deaths that happened between 2004 and 2008 at Korle-Bu Teaching Hospital, 21.8% was as a result of Postpartum Hemorrhage (Der et al., 2013).
2.5.2..2 Hypertensive disorders
This is one of the obstetric emergencies that are difficult to prevent or manage. It is a major factor of maternal death in Africa. In a retroactive descriptive study conducted at the Korle-Bu Teaching Hospital (KBTH) in Accra, the Authors reported that 63 out of 199 maternal deaths that happened between 2010-2011 were attributable to hypertensive disorders (Adu-Bonsaffoh, Oppong, Binlinia & Obed, 2013). Hypertensive disorders normally progresses to eclampsia characterized by severe renal failure, intracerebral hemorrhage, pulmonary edema and death.
2.5.2.3 Anemia
According to the Ghana Demographic Health survey, the number of pregnant women with anemia climbed from 65 percent in 2003 to 70 percent in 2008. The report further stated that at least 9000 expectant mothers in Ghana would lose their lives by 2020 if the high levels of anemia among pregnant women were not put to check (Ghana Demographic Health Survey). Malaria is the principal cause of anemia in Ghana.
2.5.2.4 Sepsis
Unnoticed or poorly handled maternal infections can result in Sepsis, death or disability on the part of the mother and a corresponding greater possibility of premature neonatal infection and other adverse consequences (WHO, 2017). Sepsis normally occurs when the amniotic sac raptures way before delivery occurs, when the vaginal examinations are too common or when obstructed labour happens. Long term consequences of puerperal sepsis include pelvic inflammatory diseases, secondary infertility and in rare cases, maternal tetanus (Senah, 2003).
2.5.2.5 Obstructed Labour
This is mostly caused by cephalo-pelvic disproportion- a mismatch between the fetal head and the mother’s pelvic brim. This therefore impairs the smooth passage of the baby. In severe cases, it could lead to fistulation, whereby urine and faecal matter have access to the reproductive system. The number of maternal deaths due to obstructed labour or labour dystocia varies between 4% and 70% of all maternal deaths, accounting to maternal mortality ratio of 410 per 100,000 livebirths (Neilson, Lavender, Quenby & Wray, 2003)
2.5.2.6 Abortion
In a study conducted in Benin, Ivory Coast and Senegal, “4116 women were admitted for obstetrical complications during the first trimester of pregnancy. 1525 (37%) were admitted for complications of induced abortion, 1834 (45%) for complications of spontaneous abortion, 651 (16%) for ectopic pregnancy and 106 (3%) for molar pregnancies. A total of 42 of these 4116 women died, 37 (88%) of these deaths resulted from complications of induced abortion” (New Englang Journal of Medicine[NEJM], 2002). This supports past studies findings that complications of induced abortion is the major contributory factor of death in the first trimester of pregnancy. According to the Ghana Demographic and Health Survey (Ghana Statistical Service and Macro International, 1998) 12 percent of all pregnancies that happened before the study failed to result in a live birth. Moreover, the study stated that approximately one out of four pregnancies to women aged between 15 and 19 years was lost early due to spontaneous or induced abortion. It was observed further that early miscarriages were particularly high among women aged between 15 and 19 with about two out of five pregnancies to women in this age group resulting in early miscarriage. Abortion is usually characterized by severe bleeding, lower abdominal pains, and passage of foetal and placental tissue.
2.5.2.7 Others
Other medical factors that contribute to maternal death include HIV and Cardiac disorders.
2.6 Empirical literature
Different analytical frameworks have been used in studies on maternal mortality. Mojekwu (2005) categorized the causes of maternal deaths into medical factors, health factors, reproductive factors, unwanted pregnancy and socioeconomic factors. Ibe (2008) employed a multistage sampling technique while Okaro et al. (2001) carried out retrospective comparative analysis of maternal deaths for two ten-year periods.
Okonofua, Abejide, and Makanjuola (1992) examined the background factors that predisposed women to maternal mortality at the Obafemi Awolowo University hospital in Nigeria. The study investigated their socio- demographic characteristics, their use of prenatal care, and the incidence of delay in clinical management. The results showed that the maternal deaths involved women who were younger and of poorer socioeconomic status than the women in the control group. Both groups showed an equal lack of prenatal care. However, a higher incidence of delayed treatment was found in the management of the cases of maternal deaths. The study also found that maternal mortality in the study population can be reduced through improved transportation and institutional management, and, on a long-term basis, through the adoption of measures to improve the socioeconomic status of women.
Ni and Rossignol (1994) in a community-based maternal mortality surveillance study in Sichuan, China assessed the impact of family planning status on maternal mortality. They found that the leading causes of death for both planned and unplanned pregnancies were the same: hemorrhage, postpartum infection, pregnancy-induced hypertension, cardiac diseases, and pulmonary diseases. As among women with "planned" pregnancies, about 40% of maternal deaths among women with "unplanned" pregnancies occurred at home, and 20% occurred en route to a hospital. After controlling for the confounding effects of gravidity and education, with additional control for the effect of prenatal care visits the study indicates that women with "unplanned" pregnancies have a higher risk of maternal death, which is only partially attributed to less prenatal care.
Garenne et al. in a 1997 case control study to analyze risk factors for maternal mortality in three leading hospitals in Dakar, Senegal identified the leading causes of death as puerperal sepsis and other infections, haemorrhage, eclampsia, ruptured uterus, and anaemia. Results of the case-control study revealed the major risk factors associated with health system failure as medical equipment failure, late referral, lack of antenatal visit, and lack of available personnel at time of admission. Various indicators of maternal status at time of admission (complications, blood pressure, temperature, oedema, haemoglobin level) and of health history prior to admission (previous complications, previous C-section, lack of treatment) were also strong predictors of survival. Lastly, socio-demographic factors also appeared as correlates of maternal mortality, in particular: first pregnancy, pregnancy of high birth order, rainy season, being unmarried, and low level of education. Okaro et al. (2001) carried out retrospective comparative analysis of maternal deaths at the University of Nigeria Teaching Hospital, Enugu for two ten-year periods (1976-1985 and 1991-2000) in order to evaluate the effect of Safe Motherhood Initiative on maternal mortality in the hospital.
The main finding of the study was that since the launching of the Safe Motherhood Initiative, maternal mortality ratio increased five-fold as a result of institutional delays and deterioration in the living standards of Nigerians. During the period under review, the health sector, like all other sectors, suffered from underfunding, industrial unrest, inconsistent policies, and mass exodus of health care personnel from the public sector to either the private sector or foreign countries. Liljestrand and Pathmanathan (2004) presented a model to guide analyses of national health systems based on evidence from case studies from Sri Lanka and Malaysia and seven other developing countries. The study largely confirms recent recommendations of the major multilateral agencies that improvement of maternal health standards requires focused prioritization, planning and implementation over many years. The study found no visible progress in maternal mortality reduction at the global level.
Ujah et al. (2005), in a seventeen-year review of factors contributing to maternal mortality in North-Central Nigeria found a bimodal pattern of maternal deaths occurring at both extremes of the reproductive age range. They found that the greatest risk of maternal death was among early teenagers and older women. They also found that ethnic group of the women was also an important risk factor for maternal mortality.
Mojekwu (2005) explained that due to complexity in measuring maternal mortality, even countries with complete vital registration systems find it a daunting task to measure it accurately. Assessing levels of maternal mortality is complex because it requires knowledge about deaths of women of reproductive (15-49) years, the cause of death and also whether or not the women were pregnant at the time of death or had recently been so. Yet, few countries record births and deaths, even fewer register the cause of death and fewer still systematically note pregnancy status on the death form. Misclassification of maternal deaths could arise for a variety of reasons such as under- reporting, illiteracy and cultural norms. Where vital registration systems are absent or inadequate, it is possible to estimate maternal mortality using survey techniques. Usually, high mortality counties have neither adequate systems of registration nor the resources to rely on surveys. Shah and Say (2008) recommend careful evaluation of data and periodic measurement by multiple methods in order to obtain accurate estimates. Because of huge variation across countries in sources of data, type and completeness of information available and extent of missing information, the estimates are sometimes based on reconciliation of data from different sources. Some data could be derived from vital registration-with good or poor and uncertain attribution of cause of death; some data from the direct sisterhood methods used in Demographic and Health Surveys of households; some other data could be obtained from Reproductive Age Mortality Studies (RAMOS); and some from disease surveillance, sample registration, censuses or special studies.
Lawoyin et al. (2007), carried out a cross-sectional, community-based study to assess men’s perception of maternal mortality in Nigeria and found that efforts were required to improve men’s attitudes and knowledge in order to make them active participants in the fight to reduce maternal mortality. Maternal deaths in this study were blamed on healthcare workers not being skilled enough, financial barriers, failure to use family planning, emergency, antenatal, and delivery care services. Factors associated with knowledge and attitude to preventing maternal mortality are discussed. Healthcare reforms must be coupled with socio-economic improvements and efforts made to improve men's attitudes and knowledge in such a way as to make them active stakeholders, more supportive of preventing maternal mortality. Curiously, this study found that several African countries where facility delivery is quite high show that maternal mortality remains high also, informing that facility delivery alone is not enough to significantly reduce maternal deaths implying that workers had to be trained in emergency care or the benefits of facility delivery will not be appreciated
Alves (2007) in a study titled Maternal Mortality in Pernambuco, Brazil: What has changed in ten years? examined changes in levels and patterns of maternal mortality in Pernambuco, Brazil, in 1994 and 2003. The research was carried out in five sub-regions of Pernambuco using the Reproductive Age Mortality Survey (RAMOS) method. The study found that the illegal status of abortion in Brazil remains an important contributory factor for abortion-related deaths. Approximately 94% of the maternal deaths were judged to be avoidable with improvements in health care. Maternal mortality declined by 30% over the ten-year period.
Shah and Say (2007), reproductive health researchers with the WHO, produced a paper on Maternal Mortality and maternity care. The authors showed that gains in reducing maternal mortality between 1990 and 2005 have been modest and uneven, and that countries with high maternal mortality ratios shared problems of high fertility and unplanned pregnancies, poor health infrastructure and low availability of health personnel.
Shiffman and Okonofua (2007) assessed the state of political priority for maternal mortality reduction in Nigeria and identified the challenges that advocates face in promoting political priority. They found that priority is as yet in its infancy and that advocates need to coalesce into a potent political force in order to be able to push government to take appropriate action to reduce maternal mortality.
Abe and Omo-Aghoja (2008) in a ten year retrospective study of maternal mortality at the central hospital in Benin City, Nigeria documented the number and pattern of obstetric deaths at the Central Hospital, Benin City, over a ten year period and identified common causes of maternal deaths. The leading direct causes of maternal deaths were sepsis, hemorrhage, obstructed labor and pre eclampsia/eclampsia, while the major indirect causes are institutional difficulties and anaemia.The study also found that low literacy, high poverty levels, extremes of parity and non-utilization of maternity services were associated with maternal mortality. The overall maternal mortality ratio (MMR) was 518/100,000. MMR was 30 times higher in unbooked as compared to the booked patients, while 60% of maternal deaths occurred within 24 hours of admission.
Ibe (2008) conducted a study in Anambra state of Nigeria on care utilization and poor mortality index. A multistage sampling technique was employed in a cross sectional study to assess the use of maternal services in Anambra state and found that the problem of maternal mortality in the country may not necessarily lie with utilization but with the quality of services. This finding tends to support Taiwo et al. in the view that the problem of maternal mortality in Nigeria may not necessarily lie with failure to utilize maternal care but that the health care system probably needs to be repositioned to meet the challenges of modern obstetric care.
Mairiga et al. (2008) conducted a population- based qualitative study in two urban and two rural communities in Borno state, Nigeria to find out community's knowledge and perceived implications of maternal mortality and morbidity as well as the community members' perception on ways to prevent the scourge. Through focus group discussions the study demonstrated that maternal mortality and morbidity is common and well known in the communities studied and that the implications are well appreciated. The study found that the communities perceived the causes of maternal death to be medical, cultural and socio-economic but that there were serious misconceptions with dire consequences for maternal mortality.
Harrison (2009), argued that attempts to reduce the high maternal mortality ratio in Nigeria have failed. Such attempts had been focussed on transforming the health system by directly applying expertise and resources on high maternal mortality and its surrounding elements. He argues that the complexities and uniqueness of Nigeria’s situation call for a fundamental remedy based on stamping out the chaos in the country by the country getting its politics and governance structures right.