Maternal mortality is defined as the death of a woman while she is pregnant or within 42 days of termination of pregnancy irrespective of the duration and site of the pregnancy and from any cause related to or aggravated by the pregnancy or its management but not from any accidental or incidental causes. Maternal mortality ratio is the number of maternal deaths divided by the total number of births per 100,000 deliveries. The stories below are just a tip of the iceberg of the maternal mortality story in Nigeria - they highlight the causes, the sociodemographic milieu, the sequelae and some medical approach to the issue:

Mrs O.M, a 34yo para1+0 (1 alive) unbooked woman whose last confinement was 2 years, presented in the emergency room with a 3-hour history of bleeding par vaginum 20 minutes after a delivery conducted by an auxiliary nurse. ANC was poor and no investigation was done. Pregnancy was term and her labour was augmented with an unknown unit of oxytocin. A live baby was delivered and thereafter IV ergometrine 0.5cc was given. Ten minutes later, the patient started to bleed and her introitus was then packed with sanitary pads; thereafter she had IM vitamin K administered. The bleeding continued and she became weak. The pads were changed 3 at a time. Patient was given glucose drink and blood tonic to ʽmake her strongʼ. No good intravenous access was secured (a scalp vein needle was used instead) and no blood was taken for grouping and cross-matching. Husband is a clergyman.

 Significant findings on presentation were that of an acutely ill young woman with blood-soaked clothing, afebrile with severe pallor, anicteric, mildly dehydrated, nil significant peripheral lymphadenopathy, nil pedal edema. Pulse was thready and BP was not recordable. Heart sounds 1 & 2 were heard and a gallop rhythm was elicited. Random blood sugar was 17.2mmol/L. Vaginal exam showed severely soaked perineal pads, blood clots+++, cervical laceration extending into the uterus at the 7 oʼclock position, moderately bulky uterus. Abdomen moves with respiration, was moderately distended and had some tenderness, uterus was at 16 weeks GA. Nil organomegaly. CNS exam showed a semi-conscious patient with an altered sensorium. Patient was tachypnoeic. Impression of post-partum hemorrhage secondary to ?ruptured uterus, hypovolemic shock and severe anemia was made. IV access was secured with a wide bore canulla; blood was taken for grouping and cross matching and 0.9% normal saline rapidly infused to expand the intravascular volume. Meanwhile the foot of the bed was raised and subcutaneous adrenaline 0.5cc was given. However patient started gasping exactly 8 minutes after admission, immediate resuscitation was not successful and she was confirmed dead at 0310 hours.

Mrs I.D was a 25yo primipara who delivered in the make-shift of a church. Source of information was church members and not reliable. A petty trader Christian convertee, she did not book in any hospital for antenatal care. Pregnancy was term and 1^st and 2^nd stages of labour were uneventful. However she had a retained placenta and forcible attempts at removal led to the cord been avulsed. Patient started to bleed heavily. Few minutes later, the prayer warriors were called in to pray for her. Seeing no improvement, she was taken to the hospital where her case was recorded as brought in dead.

Mrs O B, a 28yo para 1+0 (none alive) was brought from the church with a history of 3 days of labour, 2 days of draining of liquor and a day of swollen private part. In the church, she has had some ʽhot injectionsʼ and drips given to hasten labour, however there was poor progress. Patientʼs last confinement was 20 months when she had a prolonged labour and fresh still birth at a nursing home. For the index pregnancy, she booked at a hospital but defaulted after the first four visits. In addition she visits an Ijaw masseur who assured her of safe a delivery and placed her on a course of massaging twice weekly. She was encouraged to deliver at the church by her pastor. Patient is an undergraduate while the husband is a travel agent. Past medical history and systemic review were not contributory. Examination revealed an ill-looking young woman, febrile (39.6C), not pale, not icteric, mildly dehydrated, no significant peripheral lymphadenopathy, pitting pedal edema up to the ankle level. Enlarged abdomen that moved with respiration, Bandlʼs ring, symphysiofundal height at 35cm, moderately strong contractions at 3 in 10 minutes, single fetus in longitudinal lie with cephalic presentation and 3/5 palpable, moderate tenderness over the suprapubis, fetal heart tones heard but irregular at 150 beats per minute. The vulva was severely edematous extending to the upper third of the thighs, foul smelling discharge, and cervical os was anterior but poorly effaced and fully dilated. Presenting part was vertex, station at 0cm, position at left occipitolateral, severe molding and caput. Gloved finger was stained with foul smelling liquor. Other systems were within limits of normal. An assessment of prolonged labour with cephalopelvic disproportion, chorioamnionitis and fetal distress was made. Patient was worked up for an emergency caesarian section for which she was delivered of a distressed female baby weighing 3.8kg. At surgery, the lower segment was found to be paper thin. Baby went on to develop neonatal jaundice for which she had phototherapy. Patient and baby eventually made good improvement and were discharged in a good clinical condition three weeks later.

Mrs A.K, a 34yo para3+0 (3 alive) woman presented in the ER with a 6-hour history of abdominal pains, weakness and vomiting. Her last confinement was 4 years; she had the baby (who went on to develop cerebral palsy) at an auxiliary nurseʼs home. Patient was apparently well until she fell sick in the morning for which a neighbor gave a cup of concoction. A generalized severe abdominal pain that was independent of posture and with no known relieving factor, started almost immediately. No history of abdominal trauma. LNMP was 5 weeks earlier. No bleeding par vaginum. Systemic review was not contributory. Patient was taken to the church where the pastor diagnosed poisoning (from the concoction she took) and gave an antidote. Thence a non-projectile vomiting started but she was not relieved of the pains. A concerned neighbor took her from the church to the hospital to have the poison flushed out. Patient was a housewife married to a civil servant. Findings on presentation: ill-looking young woman in painful distress with some pallor. VE revealed a severe cervical excitation tenderness, palpably enlarged and tender right adnexa. Four quadrant abdominal tap was dry however blood pregnancy test was positive and a pelvic scan showed an ectopic gestational sac. Other systems were within limits of normal. Diagnosis of ruptured ectopic pregnancy was made and patient was worked up for an emergency laparotomy. It was successful. Post op PCV was 23% for which she was built up. She was discharged home 8 days later.

Mrs E.A, a 28yo old para 1+0 (1 alive) woman was rushed into the ER at 0250hours after a day history of labour pains. Her last confinement was 30 months ago when she had an emergency section for CPD. For the index pregnancy, she booked at a Tradomedical clinic on the advice of her friend who had delivered successfully at the clinic. Patientʼs height was 1.5m. She presented at the Tradomedical clinic immediately she started draining liquor. After a day of non-progress in labour, the husband took her to the General Hospital but she was rejected for unknown reasons. They eventually brought her back to the hospital where she had had the first operation. Significant findings were on the abdomen and the genital tract: old Pfannenstiel scar with some tenderness, term pregnancy with a singleton lying longitudinally with cephalic presentation, fetal tones heard and regular. Fully dilated and well effaced anterior os, severe molding and caput. Other systems were essentially normal. An assessment of CPD in a previous scar with ??ruptured uterus was made. She successfully had an emergency section done to deliver a live male baby weighing 3.5kg.

 Nigeria has the 2^nd highest MMR in the world after India; it is about 800-1500/100,000 but then India has a population thrice Nigeriaʼs. In reality we have the highest MMR in the world. Reduction of the MMR by three quarter by 2015 is one of the cardinal points of the UN Millennium Development Goals. Nigeria is a signatory to the MDG and this is 2009; we have SIX more years to go!

Robot  # 1 | 10.01.2009 21:43

Maternal mortality is defined as the death of a woman while she is pregnant or within 42 days of termination of pregnancy irrespective of the duration and site of the pregnancy and from any cause related to or aggravated by the pregnancy or its management but not from any accidental or incidental causes. Maternal mortality ratio is the number of maternal deaths divided by the total number of births per 100,000 deliveries. The stories below are just a tip of the iceberg of the maternal mortality story in Nigeria - they highlight the causes, the sociodemographic milieu, the sequelae and some medical approach to the issue: Mrs O.M, a 34yo para1+0 (1 alive) unbooked woman whose last confinement was 2 years, presented in the emergency room with a 3-hour history of bleeding par vaginum 20 minutes after a delivery conducted by an auxiliary nurse. ANC was poor and no investigation...Read the full article.

Oluwato  # 2 | 10.01.2009 21:56

Thank you for this wake-up call article! I have been out of "circulation" for too long! We are now in reality number one in the world! Lord Jesus have mercy! Nigeria, my Nigeria!

Marin  # 3 | 11.01.2009 01:38

WOW. Mind numbing....where does one even start in that country?:cry2:

aleroann  # 4 | 16.01.2009 03:33

I confess that in the face of the stark reality, it appears hopeless. Where indeed do we start? educating women and families to recognise danger signs? telling them the importance of proper antenatal care? the hospitals and health centres? the underpaid, overworked healthcare workers? It truly seems impossible. But...there are baby steps towards the solution. One of the simplest strategies that can be immediately employed is the use of home-based medical records. Just think...What if a woman who gets pregnant goes to register at the clinic and when all her biodata is taken and she is first examined, all the relevant information is recorded in her personal health record book? Whenever she goes to the clinic - or any other clinic anywhere else - she simply presents her book and all the important relevant information is there. Whatever else the health staff do is also similarly captured. We have all seen the success of the green immunisation card that all the babies get; this is just a little more comprehensive and also at delivey, records details of the delivery, the post-natal period and goes on to record the neonatal growth and development of the child. Prof Morley proved the usefulness of this in our own Ijeshaland. Mothers have shown over the decades that they don't lose them. In fact, I daresay if you asked your mom, she can produce yours!!!! :lol: Its simple, proven effective and affordable. Japan, Malaysia and several countries with similar disease and socio-economic patterns as ours have successfully introduced similar documents. As Margaret Mead once said - "Never doubt that a small group of thoughtful committed people can change the world; indeed it is the only thing that ever has..." We can do it.... even perhaps in the 6 remaining years. It only requires a will to make a way

Dr. Fil-Gud  # 5 | 21.01.2009 11:15

Brilliant! Short of some detail but altogether gives a vivid picture of the myriad of obstacles we are yet to overcome in our blessed country. It's still a mystery to me however, how solutions, to these countless but simple problems of over three decades seem to elude our leaders. We need to brace up and take a bold stance in overcoming these challenges. And it all starts by sticking out :no: and speaking up! ITS A HOME RUN WITH THIS ONE. Gracias