What type of ‘delay’ is considered a myth in its attribution to maternal mortality in Nigeria?

‘Every four hours, day in, day out, a jumbo jet crashes, and all the passengers are killed. The 250 passengers are all women, most in their prime of life, some still in their teen. They are all either pregnant or recently delivered of a baby… (WHO, 1986; 175)’

The above quotation captures the global enormity of the problem of maternal mortality in ‗real terms‘. Moreover, Studies by Thaddeus and Main (1994) focused on indirect factors that contribute to maternal deaths rather than direct causes such as haemorrhage. The result of this study showed that maternal mortality is attributable to three forms of delay. These delays include the delay in seeking care (type 1 delay), the delay in identifying and reaching medical facilities (type 2 delay) and the delay in the provision of adequate care (type 3 delay).  The rationale for this specific focus may be based on facts that the healthy state of a woman and her high socioeconomic status still predisposed women to deaths during delivery in developing countries.

These barriers associated with delay in seeking care (type 1 delay); include the socio-economic status of a woman, illness factors such as the perception of illness, cost, and quality of care and socio-cultural factors. However, it can be argued that type 1 delay based on cultural beliefs are the major cause of maternal mortality because maternal mortality in Nigeria varies across geographical locations, for example, studies have shown that maternal mortality is higher in the north than in the south of Nigeria and this has been attributed to the adoption of Islamic religion that encourages the practising of ‗’sharia law‘and ‘purdah‘(wife seclusion), in most northern states. Here, most women are disempowered by the emphasis which is put on various traditional beliefs such as squatting during labour, unassisted deliveries by women in order to show modesty during pain, for the sake of delivering a prestigious male child in the Hausa cultural group and also seeking permission from their spouse before a woman can attend a hospital facility for her delivery. In contrast, Stock (1983) and Egunjobi (1983) argued that distance is the major risk factor to the perception of seeking adequate health care in Nigeria. Where Stock (1983) demonstrated for example, that the number of mothers seeking treatment within one week of the onset of illness declined as the proximity to treatment facilities increased.

In addition, Thaddeus and Maine (1994) argue that Type 2 delays were attributable to the inaccessibility to adequate health care services after a decision to seek care. This may be because of travel distance resulting from the uneven distribution of health facilities in rural and urban areas and lack of transportation. However, the transportation may be available but the means of a mother getting to an adequate health care institution may be identified as a barrier for reaching the hospital on time. For example, Stock, 1983 asserts that in some northern parts of Nigeria, Muslim women are forbidden to ride bicycles or donkeys, even though these sources of transportation may be available. additionally, Type 3 delays may be caused by lack of qualified staff, and the unavailability of blood and essential drugs.

However, most top ranked health professionals in Africa may challenge that type 1 and 2 rather than type 3 delay may be the major attributary factor to maternal mortality in Nigeria. This may be because there has been no definitive observational study that have been carried out in hospitals and have been linked to the precise cause of maternal deaths. Therefore, this may insinuate that type 3 delays in actual fact may be a myth in Nigeria. However, one professional argues that based on personal experience type 3 delay is not a myth in its contribution to maternal mortality in Nigeria. This is her story.....

The story......

She strolled into the hospital as cheerful as she could be....this was her first day in her obstetrics and gynaecology posting as a medical student in a Edo state, Nigeria.

Suddenly, she was ignoring the unpleasant odour that filled the obstetric ward, which was the usual antiseptic smell that accompanied most governmental hospitals in Nigeria. This offensive odour may be deduced to be the locally enhanced antiseptic called dettol with a mixture of polluted water and bleach (jik), which is used by most cleaners to wipe the hospital floors. However, the spontaneous lack of recognition of this offensive smell in the supposed ‘hospital’ environment was precipitated by the unusual screams that overwhelmed the labour ward.  Furthermore, she realised that the spaces of her footsteps were increasing as she was approaching towards the direction of the abrupt cries of a woman. In addition, she noticed that her heart beat was increasing rapidly as her fingers came in contact with the unknown, which is the doorknob of the ward while Her other fingers were clenching on to her medical books.

In a few seconds, she found herself standing in front of her young colleagues who also appeared to be perplexed as they gazed at one of the naked patients in the wards. She was acknowledged to be a restless woman, in her early twenties, who appeared unkempt, with a gravid abdomen and her opened thighs were covered with ‘show’.   ‘Show’ can be described to be a brownish or blood-tinged mucus discharge which accompanies labour in pregnancy. However,   the first appearance of the blood stained mucous was not the cause of the apprehension that filled the room but rather it was the appearance of the obstructed head of the pink looking foetus that emerged out of the woman’s cervix. The gluteal region (buttock) and the legs of the fetus were also visible to her and the audience.

Now, she was confused as she studied at her environment. She could not comprehend that the elder doctors, so called registrars’ and senior registrars’, who must had taken the medical oath and sworn  to preserve both physical, mental and social health, paid no attention to the helpless mother that laid lifeless in the maternity ward. They attended to other deliveries. She turned towards the nurses and asked the obvious questions, that all her colleagues feared to ask.

’how long has she been here for and why is nothing been done?’

The harsh reply of the matron lingered in her head for several years and still present.

’she has been here for 24 hours from the time she was admitted and as you can see her obstructed labour cannot be induced because she has no money for oxtytocin’

0xytocin in an injectable form can be used for induction  of labour and to support labour in case of non-progression of parturition. Nevertheless, it was later to be learnt that the woman’s husband had absconded after dropping the patients in the ward. He had bailed because of the demanding hospital bill.  This was a frequent occurrence in this hospital and most hospitals in Nigeria. Therefore, the doctors had refused to induce the obstructed labour. In addition, this outrageous decision was also precipitated by the pay before service rule!  

‘oxytocin is  just  50 naira . Cant the hospital do something?’ she impatiently asked the nurse

           ‘if the hospital gives free drugs every day, believe me it would run down, this is not a charity case’ the nurse snapped  back at  her.

           She sadly left the ward.This is because 50 naira is equivalent to 3 dollars. She thought positively to herself, help would come. It would not be possible to leave the patient there all day.

           The next day she returned to the wards.  The patient still remained. This time she had been transferred to the extreme end of the wards. Her screams had reduced. Now she only gasped for breath, her eyes appeared sunken and was overflowing with lifeless tears; her skin looked dehydrated and pale. In addition, the foetus now was cyanosed, that is blue in colour and its exposed lower limbs dangled down the cervix of the inert patient. Again, all the doctors paid her no attention. The patient and her blue baby were left alone.  Sadly, She could render no help to the patient which was based on the fact that as a student she had no money to give the hospital to pay for the patients induction, plus the people who she looked up to such as the staffs in the hospital had built up a break wall in demonstrating any emotions or help towards this woman. She thought to herself. Was this because the doctors had no money too?   These facts may have been prompted by the way the doctors dressed. For example, most officials still dressed in clothing’s they had previously worn for two days and most of their shoes were worn out. Or perhaps being ‘nonchalant’ was the only way to become a true doctor in Africa- by showing no emotions to this humane act? And again, naively she thought help would come and to her as scarlet O’ Hara from Gone with the wind, would say ‘tomorrow was another day’.

           The next day she again returned, but this time it looked like if no one had ever occupied that empty bed space in the wards because there was no sound of gasping or cries that emerged from the direction of the maternity wards in which the patient had previously laid.  The bed appeared empty and the sheets were taken off.   Immediately, she knew the event that had occurred without attempting to make any enquires from the officials in the hospital. The woman and her baby had passed away and her husband never came to rescue her. She had been diagnosed with death from sepsis and obstructed labour.  Likewise, no documentations were made on her death based on nosocomial infection!

           At present.....

           Currently, She is a doctor in the developed world and that incidence still torments’ hers. She now realises the inhuman acts of that occurrence. In addition, she knows that that this type of maternal deaths still occurs in most health facilities in the undeveloped countries such as Nigeria. However, she can do nothing for change but only tell the untold story of the helpless mother.

          Moreover, this story may intensively challenge authors like Thaddeus S, Maine D., 1994 whom asserts that type 1 delay may be the major contributing factor to maternal mortality. Instead, it may be argued that type I and 2 delays may not always be the major cause of maternal mortality in the developing world. Instead, we may concur with Studies by Orji, et al (2002) whom illustrates that Type 3 delays are caused by the failure of health-care staff to identify an obstetric emergency early enough and refer the woman to an appropriate centre, as well as to a lack of ability by the referring hospital in executing an emergency caesarean section and to apprehension of caesarean sections.

Similarly, it may be argued that for there to be a successful reduction in the high rate of maternal mortality in Nigeria, interventions by the government should be based on a synergy between health and human rights based approach. For example, educating patients and health professionals and also, in cooperating penalties into the constitution for skilled birth attendants whom demonstrate negligence towards patients in health care facilities.

           In conclusion, this story may signify that the emerging interventions for maternal mortality in Nigeria are failing because most emphasis are placed on type 1 and 2 delays rather than diverting interventions towards type 3 delay. In summary, it may be denoted that type 3 delay should not be considered a mare myth in its contribution to maternal mortality but rather a mystery because similar stories are yet untold....

By Uraih Oby Nuala