COMMENTARY
The covid-19 is a
public health challenge that has affected the world’s stage in all aspects -
economically, socially and health wise.1 The pregnant women are no
exception as regards morbidity and mortality in relation to covid-19 especially
in countries with a high prevalence of the disease burden.2-4 The
reasons being that in pregnancy there is reduced immunity as pregnant women are
predisposed to infections.3,4 In addition, in developing countries
like Nigeria, the challenges of poverty, ignorance, denial, access to health
care as well as the availability of skilled birth attendants at delivery are
all factors that contribute to the alarming maternal mortality in the country.1,5
In these
trying times with the global covid-19 pandemic, the brain drain in Nigeria
makes it more difficult for pregnant mothers to receive adequate care from
obstetricians and midwives who are not enough to serve the Nigerian populace of over 200 million people.7-9
Having introduced the
topic in the above paragraph it will be necessary to throw more light on one of
the key words of this letter to editor and that is “Maternal Mortality”.
Maternal mortality is defined as the death of a woman while pregnant or within
42 days of delivery or termination of pregnancy, regardless of the site or
duration of the pregnancy from any cause related to or aggravated by the
pregnancy or its management but not from accidental or incidental causes.10-18
Late maternal death is the death of a woman due to direct or indirect obstetric
causes more than 42 days but less than 1 year after termination of pregnancy.10-14,19-24
Pregnancy related death is the death of a woman while pregnant or within 42
days of termination of pregnancy irrespective of the cause of death.12,21
There are
different classifications of maternal mortality. Two of these for discussion
are the direct obstetric causes and the indirect obstetric causes or the major
causes of maternal mortality and minor causes of maternal mortality.12-14,21-24
The direct
obstetric deaths results from obstetric complications during pregnancy, labour or puerperum fromomissions, interventions, incorrect treatment or a
chain of events resulting from any of the above.9,12-18They are due
to haemorrhage (mainly post-partum), sepsis or
infections, hypertensive diseases in pregnancy mainly severe pre-eclampsia/eclampsia, obstructed labour or labour dystocia,
complications of abortions (especially unsafe abortion), interventions,
omissions, incorrect treatments or events resulting from any of these.12,13
The
indirect causes of maternal mortality occurs from previously existing diseases
or from diseases emanating during pregnancy, these diseases are aggravated by
the physiological effects of pregnancy.18-21 Common in the
developing countries like Nigeria aremalaria, anaemia, HIV/AIDS and cardiovascular diseases (heart
diseases).12
Measures
of maternal mortality are maternal mortality ratio and maternal mortality rate
(MMR).12,21The maternal mortality ratio is the obstetric risk faced
by a woman each time she becomes pregnant.21When women have many
pregnancies the risk of maternal death ismagnified.12 MMR is
calculated as the number of maternal deaths during a given year per 100,000
live birth during the same period.21 The appropriate denominator for
MMR would be the total number of pregnancies (live births, still births,
abortions, ectopic and molar pregnancies).12 These figures are
seldom available especially in developing countries where most births take
place, so the number of live birth is most often used as denominator.6 For
this reason, in developing countries like Nigeria deliveries is used(live +
still births). 7-9
Maternal
mortality rate (MMR) measures both obstetric risk and the frequency with which
women are exposed to this risk .8,9 This is calculated as the number
of maternal deaths in a given period per 100,000 women of reproductive age (15
– 49 years).7 Often used interchangeably (rate or ratio). It is
essential for the sake of clarity to specify the denominator used when
referring to either of these measures.10
Life time
risk of maternal deaths takes into account both the probability of becoming
pregnant and the probability of dying as a result of the pregnancy cumulated
across a woman’s reproductive age.11 Example of which is the risk of
dying in the developing countries compared to the developed countries.9-10
Worldwide,
approximately 303,000 women between the ages of 15 – 49 years died as a result
of complications of pregnancy and childbirth.12 Most of which occur
in the developing countries of the world.11-12In Nigeria the
Maternal Mortality Ratio (MMR) was 576 per 100,000 live births in 2013, an
increase from 545 in 2008.13-17Majority of developing countries of
the world are yet to meet up with MMR of the developed countries,which was 230 per 100,000 live births. The MMR in the developing countries of the
world is 20 times or more when compared to the developed countries.10-12
In Nigeria,chances of dying
in pregnancy is between 1:16 to 1:22.13Every minute every day,
somewhere in the world a woman dies as a result of pregnancy and child birth.
Nearly 2/3 of 8 million infants die annually as a result from poor maternal
health.13Majority of these women diefrom preventable
causes.14 For every woman who dies, research indicates that millions
of women will suffer disabilities and sometimes for the rest of their life.15
The suffering goes beyond the physical but affects the woman’s ability to
undertake their social and economic responsibilities.15,16 Maternal
death is a tragedy to the woman, their family, community and the nation.16
Researchers have shown that 90% of children do not live up to their 5th birthday on
demise of their mothers.9-10 For the girl child the demise of the
mother is more devastating as it increases the chances of death of other
children 2-4 times as a result of
absence of care and support.14-16 By reducing the maternal mortality,
the dominant effect on perinatal and infant morbidity is reduced.14-15
This clearly shows that there is a correlation between the mothers health and
that of their children.14-16
The
question to be asked is where do maternal deaths occur? Maternal mortalities
occur in places where it is least expected or difficult to measure its indices
accurately.1-4 Developing countries of the world exemplified by
Nigeria record over 80% of maternal deaths globally.6-8 Scholars
first documented estimate of maternal deaths around the world in late 1980’s.17
Why do
women die? Maternal mortality is the concluding story of woman from birth until
pregnancy, delivery and puerperium due to failure in
obstetric care or unsafe motherhood.16-18 Annually, over 200 million
women get pregnant.19 Of the estimated 7.8 billion people in the
world, over 2 billion are mothers.19-20 Although pregnancy is not a
disease, it is potential risk of mortality.19 Researchers have shown
that obstetric complications are unforeseeable or unpredictable.6-8
Globally 80% of all maternal mortalities are direct results of complications
arising from pregnancy, delivery and puerperium.9,10 Basically, the aetiological factors for maternal death are the same
globally.20 Bleeding or haemorrhagethis
happens suddenly and is unpredictable, most often occurring after delivery
referred to as post-partum haemorrhage leading to
death.19-20Puerperial sepsis in myriad of cases linked to unskilled
birth attendant and poor hygiene severe after delivery if not managed properly
with antibiotics.18-20 Hypertensive disorders of pregnancy,
especially severe pre-eclampsia/eclampsia.19,20Prolonged
obstructed labour or difficult labour
which is a continuum of cephalopelvic disproportion
in labour.20Labour dystocia is common in the developing countries of
the world due to the endemicity of poverty and
malnutrition.20 In addition, in these regions of the world, in
traditional settings there are taboos concerning foods which aid in the growth
and development of the girl child.18-21 The vetting of early
marriage in these traditional settings is an aetiological
factor of labour dystocia in situations where the
girl child is made to prove her fertility despite her poorly developed pelvis.16-20Complications
of unsafe abortion (13%) contribute to approximately one third of maternal
deaths in some developing countries of the world.16-18
Literatures
have revealed that approximately 20% (indirect cause) of maternal deaths are as
a result of pre-existing diseases complicating the pregnancy or pre-dating the
index pregnancies and there management.20-21 Examples of such
diseases are anaemia, HIV/AIDS and cardiovascular
diseases.19-20
What are
the factors responsible for maternal mortality? In the developing countries of
the world the factors that are associated with maternal mortality are linked to
the girl child and women.1,4-8 These factors are socio-cultural and
economical.9-11 Due to the low status of girls and women in the
society, they are denied access to basic education which results in their poor
economic state.18-20 The effect of this is poor decision making
concerning their health andnutrtion.17-18 Furthermore, girls are
discriminated with respect to the allocation to resources of the family.4-8
In some remote villages in Sub-Saharan Africa, girls are subjected to the
position of subordination from the cradle as they over work, denied nutritious
foods and basic education.17-20
Prevention of
maternal death should be the responsibility of all because without women, there
will be no procreation and the continuity of the human race.22 This
is the reason why some researchers have described maternal mortality as a
tragedy.14-16 For this reason, both the developed and developing
countries of the world should synergize to prevent maternal mortality.23
Different authors have approached prevention of maternal mortality from myriad
perspectives.24 Some viewed it from addressing the obstetricconditions such as haemorrhage,
hypertensive diseases, puerperialsespsis,
complications of unsafe abortion and obstructed labour.19-20 Other
authors have looked at the medical conditions that pre-date or aggravate
pregnancies examples of which are anaemia, HIV/AIDS
and cardiovascular diseases.20-21 However, some other researchers
have looked at it more comprehensively by combining the former with addressing
the issues of the 3 types of delay that predispose to maternal death, as well
as reproductive health issues, child spacing and harmful traditional practices
such as early marriage and female genital mutilation.25
This
aspect of prevention of maternal death will beam the search light on primary
prevention, antenatal care and clean/safe delivery.20-23As a
follow-up of primary prevention of maternal mortality, the place of advocacy
for basic education for the girls and women cannot be over emphasized in line
with the Sustainable Developmental Goals.16-20 This is because an
educated girl and woman will be able to take the right decision concerning her
reproductive health, when to get pregnant, how to space her children, the
number of children to have, the right nutrition and the importance of ante
natal care.24 Family planning service is one of the pillars of safe
motherhood, preventing unwanted pregnancies, too early pregnancies, too close
together pregnancies, too many or too latepregnancies.26 Studies
have shown that 1 in 4 maternal deaths could be prevented by family planning.
At present the world’s population is 7.8 billion with approximately 60% of
unintended pregnancies in the developing countries of the world.27It
has been projected that if the corona virus pandemic continues for the next 6
months over 40 million women will not gain access to contraception/family
planning services.27
Basic
maternity care comprising of ante natal care (ANC) and clean and safe delivery
has been proven to reduce maternal mortality.20-24 Accessibility to
ANC which is also a pillar of safe motherhood reduces incidence of obstetric
complications and morbidity associated with pregnancy, hence maternal
morbidity.16-20 Studies have revealed that women who attend regular
ANC have privilege to early detection and treatment of diseases.10-12
In addition, they have adequate information on place of delivery, prophylactic
administration of iron, folic supplement, malaria prevention and tetanus
toxoid.18-20 Clean and safe delivery comprising of aseptic
procedures, oxytocics,antibiotics cover and
post-partum have been revealed to reduce maternal mortality.19-21
The
question is how can we reduce maternal mortality during the corona virus
(covid-19) pandemic?
Ø Enlightenment
on the ante natal mothers on the preventive measures of corona virus as
recommended by the centre for disease control (CDC).
Ø Emphasis
on the importance of ante natal care for pregnant women at 8 weeks after the
last menstrual period as emphasized by the World Health Organization (WHO).
Ø Disabuse the
populace on the superstitious believes about covid-19.
Ø Advocacy
for the support by the Government, Non-Governmental Organizations,
Ø International
agencies on the need to provide testing kits for ante natal mothers especially
in communities with increasing numbers of covid-19.
Ø Training
and re-training of obstetricians and mid-wives on preventive measures on
covid-19.
Ø Non-stigmatization
of positive mothers for covid-19 ante natal mothers.
Ø Multidisciplinary
approach in the management of covid-19 positive mothers involving the
obstetrician, mid-wives, paeditrician, internist,
pathologist, pharmacist, psychologist and social workers.
Ø The need
for grants in the support of research amongst ante natal mothers in communities
with high prevalence of covid-19 infections especially in the area of vaccines
for disease prevention. The emphasis should be on pre-conception care.
Ø Formation
of community participation groups to help support pregnant women that are
positive for covid-19 especially from survivors of covid-19 in pregnancy.
CONCLUSION
Prevention of
maternal mortality during this corona pandemic is beyond the confines of the
consulting room. The issues to be addressed are social, economic, religious and
cultural. The woman should be empowered economically, cultural barriers that
hinder safe motherhood should be discouraged which entails proper decision
making. In addition, education of the girl child is paramount in the prevention
of maternal deaths because this will help her take the right decision on
accessing family planning services. This will further strengthen her choice of
when to get pregnant, the number of children to have and the spacing of the
children.
Keywords: Update,
maternal, mortality, Nigeria, COVID-19.
Conflict
of Interest:
There was no conflict
of Interest
Acknowledgement
Mother and Baby Care
Global Foundation (Mother, Baby and Adolescent Care Global Foundation)
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