ANALYSIS EFFECT OF MORTALITY DEATH RATE ON WOMEN AGE GROUP

CHAPTER TWO

LITERATURE REVIEW

2.1 Maternal Health in Nigeria: The Present Position

Nigeria has one of the worst records of maternal deaths in the world and this situation is worsening with time.

Table 1: Reproductive Health Indicators in Nigeria for the year 2007

Source: UNICEF.

The problem of poor organization and access to maternal health services has always been a major challenge in Nigeria. Omo-Aghoja et al (2008) asserted that maternity care in Nigeria is organized around three tiers: primary, secondary and tertiary care levels. Primary health centres are located in all the 774 local government councils in the country. Pregnant women are to receive antenatal care, delivery and postnatal care in the primary health centres nearest to them. In case of complications they are referred to secondary care centres, managed by states, or tertiary centres, managed by the federal government.

The Nigerian health system as a whole has been plagued by problems of service quality, including unfriendly staff attitudes to patients, inadequate skills, decaying infrastructures, and chronic shortages of essential drugs. Electricity and water supply are irregular and the health sector as a whole is in a dismal state. In 2000, the World Health Organization ranked the performance of Nigeria’s healthcare system 187th among 191 United Nations member states. A 2003 study revealed that only 4.2 percent of public facilities met internationally accepted standards for essential obstetric care (Harrison, 2009). Approximately two-thirds of all Nigerian women deliver outside of health facilities and without medically skilled attendants present. The weak performance of the health system must be understood in the context of the country’s long-standing problems with governance. Corruption in the political system is endemic while social development, including the promotion of the health of Nigerian citizens, has been more a rhetorical than a real aim of the state.

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.

2.2 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.

2.3 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.

2.4 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 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.

2.5.1 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 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.

2.5.3 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).

2.5.5 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)

2.5.6 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.

2.5.7 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.