Introduction

Every woman desires to have a safe and uneventful Pregnancy and delivery period which is free of complications; however, reverse is the case as maternal death in Nigeria is on a daily increase. Despite the launching of the safe motherhood initiative about twenty years ago, maternal mortality ratio has been on a steady increase in Nigeria and developing Africa as a whole. The high maternal mortality rate has been consistently identified as one of the key indicators of our poor health services In September 2000, eight millennium developmental goals were endorsed by 189 heads of state to reduce the rapidly increasing maternal deaths globally. Reducing maternal mortality is one of the millennium development goals (MDG5) which was adopted. According to the World health Organisation Progress on health-related Millennium Development Goals (MGDs) (2005), an alarming average of 1500 women die every day from Pregnancy or child birth related complications; the global maternal mortality ratio was 400 maternal deaths in every 100,000 births and 1,100 maternal deaths per every 100,000 births in Nigeria. Overall, an estimated 536,000 women die yearly from child birth or pregnancy. This essay would focus on maternal mortality and how it has risen to become a very important and contemporary public health issue, the Inequalities affecting maternal mortality and why its still on the increase. It would furthermore, suggest the policies that would help in reducing the maternal mortality ratio and achieving the Millennium development goal 5 of reducing maternal mortality by three quarters by 2015.

The United Nations Millennium development Goal (MDG5) is targeted at reducing maternal mortality ratio by three quarters between 1990 - 2015, surprisingly, between 1990 -2005, it has only declined by merely 5%.This is largely due to a wide variety of factors including: Low socio economic status, Ignorance, access to good quality health services, lack of health promotion and awareness campaign, religious beliefs, cultures. Over the years, recent data shows that while some countries have made

impressive and significant improvement in accordance with the MDG5, a whole lot are still falling way behind. Coincidentally, the majority of the cases recorded in Nigeria are avoidable. Haemorrhage is the leading cause of maternal mortality globally, it accounts for 25% according to the world health organisation. Contrarily, In Nigeria, the most common cause is eclampsia according to Mairiga and Saleh (2009) cited in the East Africa Medical Journal, they added that Eclampsia is responsible for about 34% of cases of maternal mortality and it results from unattended Pregnancies and unbooked deliveries. Other recognised causes are infections, unsafe abortion and obstructed labour.

Definition
The international journal of Obstetrics and Gynaecology cited by Bates et al (2008) defined maternal mortality ratio as the number of maternal death during a given time period per 100,000 live births during the same time. For example, the maternal mortality ratio (MMR) is estimated at 1,100 per 100,000 live births in Nigeria, 920 per 100,000 live births in Africa while MMR in Asia is 330 per every 100,000 live births compared to 10 in every 100,000 live births in Europe. The above statistics goes a long way to support the fact that Maternal mortality is a very important Public health issue most especially in Nigeria and other developing African countries, where there seem to have been no significant

improvement since 1990. According to this source, they also defined maternal mortality/Maternal death as the death of a woman while pregnant or within 42days of termination of pregnancy (delivery) irrespective of the duration and the site of pregnancy, from any cause related to or aggravated by the Pregnancy or its management but not from accidental or incidental causes. Maternal mortality is measured or estimated by maternal mortality ratio.

Causes of Maternal Mortality

Haemorrhage which can be defined as severe bleeding or severe blood loss is the leading cause of maternal deaths worldwide. The World health Organisation health report (2005) shows that haemorrhage accounts for 25% of the total maternal mortality ratio. This condition is highly preventable and can be managed effectively in tertiary centres where modern equipments and highly skilled personnel are available. This is one of the major contributory factors why maternal mortality ratio is significantly low in developed countries as compared to the higher figures in developing countries. According to Onakewhor et al cited in the Nigerian Journal of Clinical Practice (2008), it was observed that the leading cause of maternal mortality in Nigeria is eclampsia. Eclampsia can therefore be defined as a clinical condition occurring after 20 weeks of gestation that is characterised by convulsions, high blood Pressure (B.P > 140/90) in a woman who has been

normotensive before pregnancy and proteinuria (abnormal amount of protein in the urine). This condition is associated with high level of maternal morbidity and mortality. Eclampsia is also highly preventable and should not always result in maternal deaths when pregnant women book into antenatal clinics in the early stages of their pregnancy (First Trimester) and there is provision of efficient and adequate emergency obstetric services.

Another significant cause of maternal mortality is sepsis. Sepsis is a clinical condition used to describe a severe or overwhelming infection, it is often characterised with high body temperature and this according to the World health report (2005), accounts for about 15% of maternal mortality rate worldwide. Other causes of maternal mortality are unsafe abortion which contributes about 13% to the 2

maternal mortality ratio globally. Obstructed labour, direct and indirect causes also contribute to the steady increase in maternal mortality ratio.

Inequalities
In developing Africa and Nigeria to be precise, the inequalities that affects the maternal mortality rate, varies from social class to level of education , religious beliefs and cultural beliefs. The socio-economic status of Nigeria has been a contemporary debate. According to Abe et al (2008) cited in the African Journal of Reproductive Health, it has been observed that the majority of the Nigerian population fall below the poverty line. However, the socio- economic status of the populace does play a major role in their accessibility to good health services, even when the services are available. In Nigeria where there is no structured national health service scheme like the NHS in the United Kingdom, the larger part of the population have to patronise Private health service providers which tend to be very expensive, these private health service providers are however mostly located in major cities and towns making it more difficult for the lower socio economic class who tend to reside more in the rural areas to access these services. Most Pregnant women with low literacy level tend not to register for ante natal clinic because they are not aware of the importance of delivering in hospitals and regular antenatal visits. In a survey carried out at the State Specialist Hospital Bauchi, Northern Nigeria, the maternal mortality ratio for the period under review was 5,146 per 100,000 births in unbooked mothers (pregnant women who do not register for ante natal clinic) which was eleven times more than booked live deliveries hence, it has been deduced that unbooked emergencies accounted for about 68.7% of Maternal deaths which was double the booked women. Commentators such as Ikeako et al (2006) reviewed some previous studies in which they argued that formal maternal education is the most potent tool for reducing the mortality ratio in Nigeria. Some cultures/ethnic groups in Nigeria e.g, the Hausa- Fulani ethnic group where teenage pregnancy is common because female children are betrothed to older men at early ages, hence, they lack adequate education and care to a safe motherhood, thus increasing maternal mortality during child birth and afterwards. On the contrary, if this group of women register for antenatal, it would reduce the risk of unwanted complications and eventually reduce the increasing maternal mortality ratio. Amongst their various cultural belief is that their young women can have as many kids hence, family planning education is not encouraged neither is contraceptive services, thus, making parity specific maternal mortality ratio in this cultural region high. Furthermore, unavailability or low level of contraceptive services may lead to unsafe abortion which is considered one of the lead causes of maternal deaths.

The African Journal of Reproductive Health trend explains the records of all deliveries and case files of all women who died during pregnancy and childbirth between January 1, 1985 and December 31, 2001 in the maternity unit of Jos University teaching hospital, Northern Nigeria. The data collected were analyzed for culture and ethnic group mode of delivery, it was observed that there were 38,768 deliveries and 267 maternal deaths during the period under review giving the maternal mortality ratio of 740/100,000 total deliveries. The trend fluctuated between 450 in 1990 and 1,010/100,000 deliveries in 1994. These findings tend to be more amongst teenagers of the northern part of Nigeria which can be largely blamed on their lack of education and culture. Religious belief has been identified as one of the inequalities affecting maternal mortality. According to the department of Obstetrics and Gynaecology, University of Calabar (1999), obstructed labour continues to be a major obstetric complication in Nigeria. This issue as effectively remain a huge contribution to maternal mortality in Nigeria caused by spiritual churches and religious sects. These spiritual churches and religious sects are actively involved in obstetric care and services; hence, they remain popular primary resort for pregnant women and women in labour. They however often reluctantly release cases of obstetric complications to conventional health centres and services. It has however been explained that the main cause of seeking churches and religious sects during pregnancy can be blamed on the poor economic situation in Nigeria. Harrison et al (1985) explained the importance of faith amongst Nigerian pregnant women. He added that beliefs and fears are instilled into the church attendants through prophecies and visions and are used as tools to brain wash the church attendants. The truth however remains that formal education may reduce the likelihood towards patronage of traditional birth attendants but may not change the religious faith of even the highly educated women. The Jehovah witness society which is a common religious sect and known for its refusal of blood transfusion even when such a refusal may lead to death. This remains huge inequality affecting maternal mortality as pregnant women refuse blood if needed during pregnancy or delivery in adherence to their religious belief.

The Way Forward

With just 5 years left before the 2015 deadline of the MDG5 without significant reduction in maternal mortality rate, there is still a lot to be done. Pregnant women need a lot of care during the period of Pregnancy because it is a critical period for their health and that of the baby. Medical emergencies or complications do not give notice; hence, presence of skilled and trained professionals at ante natal clinics and delivery rooms to attend to emergencies is very important. Maternal mortality ratio remains the most important indicator for maternal health in Nigeria and to reduce this alarming and increasing maternal mortality ratio, policies should be put in place both at the central and local government levels 4

to tackle the underlying causes and Inequalities that has been identified based on data and statistics available. Kullima et al (2009) in the Annual African Medical journal concluded that there is need to educate and encourage the general public for antenatal care and hospital delivery. The Central government should put in a place an education for all policy, which will focus on female education, public enlightenment, advocacy activities which would reduce the burden of maternal mortality. Ikeako et al (2006), explained in the journal for obstetrics and gynaecology that maternal educational level was the main predictor variable of maternal mortality. It was also suggested that sustained community education and

mobilisation is essential so that women and their families would understand and appreciate the need for special care during pregnancy and child birth under trained personnel. National Policy should be made on poverty alleviation and improvement of socio economic conditions of the populace because maternal mortality has been found to be more among the low socio economic class. This includes good housing scheme, good road transportation networks, security of life and property because the absence of all this basic amenities are all contributory factors, either directly or indirectly. All this would help reduce avoidable tragedy and reduce the escalating maternal mortality ratio in Nigeria.

The central government should make a policy for free health services for all and this should be backed up with provision of more health facilities where both basic and comprehensive antenatal services ,skilled attendants at birth, community mobilisation to improve regular antenatal attendance are

provided to all pregnant women in all nooks and cranes of the country at free or highly subsidized level .This would go a long way in tackling the underlying problems encountered by the lower economic class with regards to the difficulty accessing health facilities, the Local Government areas and community leaders are to champion the cause for the provision of these facilities in their localities. Women would be able to register freely for ante natal clinics, and would be entitled to free drugs and routine checks which would diagnose symptoms of complications in pregnancy thereby effectively preventing maternal deaths.

Kigbu et al (2009) cited by the Nigeria journal of medicine emphasized that at the local government level, there should be a policy in place to promote the use of contraception and review existing abortion laws. As its been observed after Sedgh et al(2003) conducted a research using the united nation statistics, they found that 97% of unsafe abortion were in developing countries, hence, they suggested the local government should ensure that the need for contraception are met and all abortions are safe.

This policy should focus on availability and enlightenment campaign on the use of contraceptive to prevent unwanted pregnancies as unsafe abortion is among the leading causes of maternal deaths. The community should also be aware of the relationship between high parity and maternal mortality. According to Umeora et al (2005), they described the socio-cultural barriers affecting voluntary blood donation for obstetric use in a rural part of Nigeria. They also emphasized that the availability of blood transfusion is of utmost importance in achieving the millennium developmental goal 5 of reducing maternal mortality before 2015.The study was conducted to identify reasons for declining voluntary blood donors, it was found that illiteracy was prevalent among the population and their major reason for decline was that there were not strong enough, not having enough blood, blood donation might result in loss of manhood and reduced libido, and also exposure of their blood to witchcraft . Consequently, a lot of maternal deaths have been linked with blood loss; hence, a National policy should be made to encourage voluntary donation and effective blood banking services. This policy would focus on encouraging members of the community to donate blood voluntarily and educate them on the benefits and tackle the problem of misconception and misinformation about blood donation. The policy would also ensure all donated blood are screened and channel all resources towards reducing maternal mortality.

Conclusion In conclusion, this article has carefully and critically examined the various inequalities affecting maternal mortality rate in Nigeria and have suggested Policies based on the available evidences. With the background knowledge that majority of the causes of Maternal mortality are preventable and largely as a result of illiteracy. Low level of formal maternal education, poverty, difference in cultural and religious beliefs has all been identified as inequalities affecting the increasing rate of maternal death. However, despite the alarming increase in the maternal mortality rate has highlighted above, there is still obvious lack of commitment from all tiers of government. They are not making resources available, funding is poor or nonexistent and existing facilities are highly short staffed as cited by Inegbenebor, U (2007). The policies suggested would therefore solve the problems of educating, training and re-orientation of care givers and traditional birth attendants to enhance awareness and early recognition of the danger signs and pointers to complications in pregnancy. Overall, the level of formal education determines where a woman delivers, within or outside health institutions. If the above policies suggested are implemented, there would be better chances of achieving the Millennium development goal 5 of 6

reducing the maternal mortality rate by three quarters by 2015 and the community as a whole would gradually be relieved of losing their loved ones through death from pregnancy or childbirth.

References

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