Maternal Mortality In Nigeria

Search Strategy

Databases Used

Multiple journal databases, book databases and online databases will be used for this assignment so that an in-depth study of the maternal mortality, including beliefs and cultural practices, of Nigerian women can be made. This will enable a greater understanding of Health Literature to be ascertained.

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Search Terms

• ‘Nigerian Women’
• ‘Maternal Mortality’
• ‘Beliefs and Cultural Practices’ and ‘Nigerian Women’
• ‘Measuring Maternal Mortality’

Inclusion/Exclusion

A broad range of research reports will be searched from different jurisdictions so that diverse views and opinions can be found. Recent data will also need to be used and will consist of reports from the past 15 years.

Outcomes of the Search

A Total of 30 research articles were found relating to the topic, yet only 20 were found to be relevant.

In order to decide which articles were the most applicable for this study, the Critical Appraisal Skills Programme (CASP) was used in order to decide the best available evidence from health research (CASP, 2012, p. 1).

Statistics Known of Maternal Mortality in Nigeria

The Maternal Mortality Rate (MMR) was reported to be 608 deaths per 100,000 live births in 2008 (Hogan, et al; 2010, pp. 1609-1623). Despite this, it also made clear in the report that maternal deaths have in fact reduced on a global level by 35% from 1980 to 2010, which seems to illustrate that maternal mortality is actually declining. This does not appear to be the case for Nigerian women, however, since the MMR in 1990 was 473 (Hogan, et al; 2010, pp. 1609-1623). As such, the elimination of maternal mortality has been slow (Hill et al; 2007, pp. 1311-1319). Many have questioned the accuracy of such figures, however, since it cannot be said that all deaths in Nigeria are actually registered (Schuitemaker et al; 1997, p. 78). Therefore, MMR does actually remain underreported which impacts the accuracy of these findings.

Knowledge and Attitudes of Nigerian Women to Maternal Mortality

Maternal mortality is defined by the World Health Organisation (WHO) as “the death of a woman while pregnant or within 42 days of termination of pregnancy” (WHO, 2004, p. 1). It is apparent that maternal mortality is one of the main causes of death in developing countries which is especially so in Nigeria where maternal mortality is prevalent amongst Nigerian women. Many challenges in relation to this thereby exist and it is thus believed that more should be done in order to tackle these problems and therefore reduce or even eliminate maternal mortality (Elijah, 2012, p. 1). Brabin et al; (2001, p. 6045) argue that anaemia is one of the leading causes of maternal mortality amongst Nigerian women which should therefore be dealt with first.

Interventions

Given that the MMR in Nigeria has increased rather than decreased, it is evident that any interventions that have been made in order tackle this problem have been unsuccessful. Nevertheless, the reduction of maternal mortality was in fact included into the Millennium Development Goals (MDG 5) so that MMR can be reduced by 75% from 1990 to 2015 (United Nations General Assembly, 2000, p. 55). Whilst there are another two years to go, it is unlikely this figure will be attained.

Research Question

• To establish what maternal mortality is;
• To determine whether maternal mortality us widespread;
• To consider the impact maternal mortality has on Nigerian women in comparison to those women from other jurisdictions;
• To consider the beliefs and cultural practices of maternal mortality within Nigeria;
• To determine the current attitudes towards maternal mortality within Nigeria;
• To review the steps already taken to tackle maternal mortality;
• To establish whether the interventions used to reduce maternal mortality have proven effective.

Study Design

Overview of the Study

In undertaking this study, it is important to first review the statistics that currently exist on maternal mortality on a global level. This will help one to decide whether maternal mortality is a global phenomenon or whether it is just Nigerian women who appear to be suffering. Once this has been done, applicable data will then be collected from various States within Nigeria providing an overview of the MMR within Nigeria including an estimation of the risks associated with maternal death. The methods adopted for assessing maternal mortality will thus be reviewed in order to illustrate the reliability of these statistics. Primary data that has been collected directly from women within Nigeria will also be used in order to attain an overview as to how effective the health system within Nigeria is. This will be followed by a review of secondary data in order to gain an insight into the current views and opinions of maternal mortality amongst Nigerian women. Consequently, part of this study will consist of a retrospective audit using a large population sample from an existing design. This will be based upon the most recent statistical data available including professional documentation as well as international standards.

A retrospective audit will be more suitable for this study than a prospective audit since a prospective audit is based upon “the collection of information about patients during their process of care” (Optimal Blood Use Project, 2013, p. 1), whilst a retrospective audit is based on a review of the records of patients that have already been discharged. This type of information will be a lot easier to attain since it may consist of data from computer databases. In using this particular type of data, nonetheless, it is important that the quality is adequate since this will otherwise be detrimental to the outcome of the study. This is because, a pre-test, post-design is being used and if any of the information is not adequate, the overall results will be impaired which will affect the whole of the study. Essentially, because the study aims to provide a greater understanding of the maternal mortality in Nigerian women, it is important that a paired data analysis can be conducted. Hence, as put by Bonate (2000, p. 1); “paired data arise when the same experimental unit, such as a person or laboratory animal is measured on some variable on two different occasions or at the same time under different testing conditions.”

This will allow a determination to be made as to whether there is a difference from the first testing to the second testing which is necessary in order to decide whether the intervening measures aimed at tackling maternal mortality have been effective. It is important that information is attained from patient and public involvement (PPI) as this will enable a more accurate study to be conducted. Furthermore, PPI will also ensure that applicable changes are made to the ways in which women in Nigeria are being treated and will allow such women to have an influence in the ways in which they are being cared for and treated. They will also be able to “have a say in the way services are planned and run” and will thus “help bring about improvements to the way care is provided” (NHS, 2012, p. 1). This is important given that patients within Nigeria have not been receiving appropriate care. PPI is thus a significant element of any study relating to the health of individuals since it is vital that specific measures are being implemented which ultimately serve the public’s interest (Burton and Ormrod, 2011, p. 43).

Sample

Because it would be impossible to study every single woman within Nigeria who has an interest in maternal mortality, it is important that only a pool of participants is selected for this particular research. This is because; whilst it is essential that the findings do not merely consist of those participating in the study, it would be impracticable to study a large proportion of the population within Nigeria. This study will therefore investigate Nigerian women from four different Nigerian states using the so-called ‘sisterhood method’. The sisterhood method will be used in this assignment because of the problems that are associated with the collection of data from developing countries. This method consists of asking a woman four simple questions about her sister/s and then deciding whether maternal mortality is widespread. The Investigation of maternal mortality by the sisterhood method is an indirect approach and “entails asking respondents about ever-married sisters: how many have died, and how many have died while they were pregnant or during childbirth or six weeks following the end of the pregnancy” (World Bank, 2006, p. 225). This is a frequently used method in this type of study and will help to provide a clear overview as to whether maternal mortality is increasing or decreasing. It also allows a greater amount of data to be collected from the person questioned. However, the downside to this method is that there is a danger of multiple results being produced where two sisters are asked the same questions.

Approximately 400 women will need to be studied between the ages of 16 and 45 so that an accurate estimation of maternal mortality can be gathered. In deciding whether this is a sufficient amount of people however, a power and sample size estimation will need to be made in order to ensure that there is a sufficiently large amount of data subjects to embark upon the study in question. Consequently, it will need to be considered whether “there is the possibility of harmful effects from participating in the study” (Taylor and Kermode, 2006, p. 207). ‘Power’ thus relates to the likelihood that the study will achieve the desired outcome, whilst ‘sample size’ relates to the number of people needed to achieve this result. The data collected must be of the “same scale of measurement” and the sample size must not be extortionate since this would otherwise incur unnecessary expense and would evidently waste time. Since the data is of the same scale of measurement and the sample size appears to be applicable for this assignment, it is evident that the sisterhood method is appropriate. This is a cheap and convenient way of gathering information from developing countries and is a useful way of attaining relevant information.

Hence, the studies will be undertaken a number of years subsequent to maternal mortality surveys being carried out which will allow greater accuracy to be provided. This method also enables small sample sizes to be used and is widely effective when it comes to sampling from large families were the respondents are likely to have a number of siblings. The processing of data is also relatively simple which ensures that the calculation of estimates is also simple (Maternal Mortality Measurement Resource, 2007, p. 1). Conversely, the sisterhood method does have some drawbacks and problems often emerge in those states were families have fewer siblings. Furthermore, it also “gives retrospective estimates, it assumes no major trends in family, it is difficult to get additional information about deaths and there are no established demographic techniques to permit evaluation and adjustment” (Maternal Mortality Measurement Resource, 2007, p. 1). Arguably, it is evident that whilst the sisterhood method is applicable for this study, caution should also be made in light of the problems that are associated with this since the findings may not be as accurate as first anticipated.

Data Collection

Applicable secondary data for this study will be collected from journal articles, text books, online databases and governmental reports which will be attained by undertaking online and paper-based research. This will require a search of library and online databases, which is considered to be the quickest form of data collection required for this study. Secondary research for this assignment is integral in finding out what the current attitudes and opinions are in relation to maternal mortality of Nigerian women. Furthermore, any changes and interventions that have been made over the years will also be capable of being identified as well as any previous statistics. In addition, censuses, organisational records and both qualitative and quantitative data will be included under this method of research and will thus reduce time and expense. The data collected will also be of a higher quality and will support the findings that will have been acquired through primary research. Secondary data is also important in helping to determine the changes that have been made over the years, which is vital in deciding whether maternal mortality is being tackled adequately. In order to collect data using the sisterhood method, however, primary research will also need to be utilised which will be accomplished through the conduction of a questionnaire as well as direct observations.

Questionnaires are highly advantageous in addressing the specific issues surrounding maternal mortality and will allow a proper assessment to be made as to whether changes to the healthcare of Nigerian women are still needed. Greater flexibility as to the ways in which the information is to be collected will also be ascertained which will enable the researcher to decide on the most applicable research approaches to take. Nevertheless, it is important that both secondary and primary research is used for this study since the “secondary research can be done from outside a Third World country and then followed up with primary research adapted for local cultural and material circumstances” (Luck et al, 2000, p. 280). This will ensure that the findings are accurate and will enable a proper estimation of the population attributes to be made through the undertaking of a sample survey. Because of the fact that the population in Nigeria is large, it is necessary for a mere sample survey to be carried out since this will reduce the costs that would be incorporated from the collection of census data. Problems associated with sample surveys include interference since the respondents may be chosen according to the desired outcome. As a result certain respondents may be specifically chosen which could cause problems and affect the data that is produced.

Data Analysis

Once all of the data has been collected, it will then be analysed in order to decide which data is more applicable for the study in question to ensure a proper conclusion can be drawn. Essentially, it is important at this stage to clean the data by inspecting each source thoroughly and then deciding whether or not it ought to be used. Hence, “the quality of the research should be judged in relation to the resources available and the effectiveness with which those resources have been used to investigate the particular topic in question” (Denscombe, 2009, p. 53). Since both quantitative and qualitative research methods will be used for this study, it is important to analyse both types of research thoroughly in order to prevent inaccuracies from transpiring. Quantitative methods of research are those methods which are concerned mainly with numbers and frequencies, whilst qualitative methods are more concerned with meaning and experience. These provide a more in-depth analysis into the subject matter and will therefore enable a proper determination to be made as to the effects maternal mortality has on Nigerian women. Whilst some prefer one method over another, it is more effective to adopt a combination of the two as this will allow “statistically reliable information obtained from numerical measurement to be backed up by and enriched by information about the research participants’ explanations” (Holah, 2012, p. 1). Consequently, by incorporating both methods of research into the assignment, a more in-depth account of maternal mortality will be provided.

Ethical Issues

Whilst it is important for any study to undertake both secondary and primary research, there are a number of ethical considerations that need to be taken into account. Essentially, whilst fewer problems arise with secondary research because of the fact that the data already exists, the re-using of data can cause problems in itself. This is because informed consent is often required and compliance with the data protection rules must be ensured. Primary research essentially causes greater concern than secondary research because of the fact it involves the collection of data from individuals. This is certainly the case for this study and because of this it is vital that care is taken when gathering information. Hence, the data that is being gathered is highly sensitive and in order to ensure the confidentiality and anonymity of the individuals concerned, all participants need to be fully informed of how the data will be used so that their direct consent can be provided (Dawson, 2009, p. 150). In addition, an assurance that the ethical rules of conduct is being complied with also needs to be made which means that any data which is produced must be “honest, unbiased, sincere, free from errors or negligence, open to critique and it must protect confidential communications” (Rensik, 2011, p. 1). Arguably, in order to ensure that the ethical rules of conduct are being utilised, a risk-analysis approach will be adopted and all participants will be made aware of how any data being collected will be used and their permission will be obtained. The approval of the College Research Ethics Panel will also be obtained so that any ethical issues can be avoided.

Conclusion

If the study works and the desired outcome is achieved it is likely that changes to the healthcare of Nigerian women will be made. This is because at present it seems as though there are a number of risks associated with the health of female Nigerians which leads to maternal mortality and in order to eliminate this problem, it is vital that the health system is vastly improved. In conducting this study, the problems associated with the health of Nigerian women will be highlighted and the ways in which this can be tackled will be elucidated. This may lead to the reduction of maternal mortality and will ensure that the beliefs and cultural practices of Nigerian women are respected. Accordingly, the lives of Nigerian women should be improved by these findings as a greater emphasis will be placed upon the Nigerian health system as well as any interventionist techniques that will be likely to reduce maternal mortality.

References

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8. Hill, K. Thomas, K. and AbouZahr, C. (2007) Estimates of Maternal Mortality Worldwide Between 1990 and 2005: An Assessment of Available Data, The Lancet, Vol. 370, no. 9595.
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13. NHS. (2012) What is Patient and Public InvolvementNHS Foundation Trust, [Online] Available: http://www.wwl.nhs.uk/Internet/public_involvment/what_is_PPI.asp [04 January 2013].
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16. Scuitemaker, N. Roosmalen, J. V. Dekker, G. Dongen, P. Geijen, H. and Gravenhorst, J. B. (1997) Underreporting of Maternal Mortality in the Netherlands, Obstetrics and Gynecology, Vol. 90, no. 1.
17. Taylor, B. and Kermode, S. (2006) Nursing Research 3e, Cengage Learning in Australia, 3rd Edition.
18. United Nations General Assembly. (2000) United Nations Millennium Declaration. United Nations, New York USA, A/RES/55/2.
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20. World Bank. (2006) Disease and Mortality in Sub-Sahara Africa, World Bank Publications, 2nd Edition.

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