The state of Antenatal care in Nigeria

This is an excerpt from my fourth year research thesis

In the summer of 2019, I was privileged to volunteer at a primary healthcare centre in anticipation of finding a research thesis for my final year project. I attended a Wednesday antenatal session and seeing up to 60 women waiting in line to see one doctor for their ANC baffled me. How is it that for an important visit during pregnancy, a woman spends only an average of 8 minutes for an occasion that has long lasting effects for a lifetime. Well, the effects of this shows as statistically, Nigerian women are 500 times more likely to die from childbirth than a woman in a developed country.

"Image from Merkformother.com"

WHO (World Health Organization) requires that quality ANC provided by PHC must consist of risk identification, prevention and management of pregnancy-related and concurrent diseases as well as health education and promotion, to achieve positive pregnancy outcomes. In that space of 8 minutes, a doctor is unable to adequately assess the possible risks or danger a woman may pose during her pregnancy or child birth experience. Quality antenatal care is essential to locate possible pregnancy risks and preparation to manage these risks.

Globally maternal mortality rates are at an alarming rate with 830 women dying daily from various factors, which majorly include obstetric complications. In 2015, the mortality rate in Nigeria was 814 per 100,000, contributing to 14% of the global maternal mortality rates. With Nigeria contributing to 14% of the global maternal mortality rates, there is a need to assess the efficiency of communication in ANC provided by PHC and devise possible solutions that influence evidence-based policies that are successful in reducing maternal mortality rates. WHO defines maternal mortality as when a woman dies while being pregnant or within 42 days of pregnancy termination, irrespective of the site or length of the pregnancy, and its cause is related to the pregnancy or pregnancy management but not from incidental or accidental causes . The two leading causes of maternal mortality in Nigeria are preeclampsia and postpartum hemorrhage. Preeclampsia is characterized by symptoms like proteinuria and decreased urine output, while early symptoms of postpartum hemorrhage include decreased blood pressure and decreased red blood cell count. With the detection of these early symptoms through ANC, this decreases the risk of a woman dying from obstetric complications during pregnancy or child labor.

"Image from WHO"

The Nigerian Federal Ministry of Health takes the initiative of campaigning for the importance of ANC in reducing maternal mortality rates in Nigeria, especially in PHC settings. The WHO recommends that a minimum of four visits for ANC is required for a woman with normal pregnancy. During the ANC visits, health prevention and promotion initiatives are taken to inform women about positive pregnancy behaviors that reduce the risk of obstetric complications. The doctor also performs risk identification measures by screening for possible risks of pregnancy like high blood pressure which can lead to preeclampsia and reduced red blood cells, which is a risk for postpartum hemorrhage. If risks are detected, the doctor observes the prevention and management of pregnancy-related and concurrent diseases by ensuring treatments are available for these symptoms. However, when there is no effective communication between the woman and her healthcare personnel on possible symptoms or ways to prevent her risks, quality ANC is not attained.

Effective communication in ANC requires that healthcare providers detail as much information to the woman about her pregnancy, including risks and risk prevention and ensuring she understands this information. A study that assessed the satisfaction of patients with ANC provided by PHC in Nigeria discovered that 36% of patients reported that healthcare providers in their PHC were non-empathetic towards them when they sought their services. Another study on the quality of ANC in Southwest Nigeria that sampled over 400 women concluded that two-thirds of the women reported not receiving as much information as they wanted during their visits. The study also found that only 60% of the women received information on recognizing the symptoms of pregnancy complications. Evidence from these studies shows that ineffective communication in ANC is a very common problem in Nigerian PHC settings and it hinders the delivery of quality ANC services.

"Image taken by me at the doctor's office in Nigeria"

From the conversations I had with the doctor pictured above, he was one of the few doctors that stayed back working in the PHC, despite being over worked and under paid. Instead of travelling abroad or moving to a private clinic, his passion for his community keeps him going everyday where he works. Nigeria's battle with brain drain is a major factor that contributes to poor services provided ANC users. The unemployment rates in Nigeria in 2018 was 23.1%, and this has led to the increased emigration of skilled workers, especially health personnel to developed countries in search of better working conditions and higher-earning capacities. In an estimated population of 200 million, there is an average of 5000 people per doctor, which is over the recommended number of one per 600 people by the WHO. Like most PHC settings in Nigeria, the Awoyaya PHC center is equipped with only one doctor who works a minimum of 10 hours a day, 7 days a week, and has stewardship over all the patients who come in for healthcare services that range from ANC to pediatric care and trauma. This doctor consults an average of 70 women who seek ANC from this PHC center in a week. The overwhelming amount of women that these health professionals have to care for limits effective communication, and this affects the fulfillment of WHO’s criteria of quality antenatal, thereby increasing these pregnancy risks which leads to high mortality rates in the country.

"Image from Pep Bonet / NOOR"

What is the solution to providing quality antenatal care, and tackling the rising maternal mortality rates you may ask? Well it's a very simple solution, but it must be willingly adopted for visible change. The WHO recommends that Nigeria allocates 13% of its annual budget to health care, but in 2017, only 4.16% of the budget was allocated towards health care infrastructure. Rwanda an east African country, spent 18% of its total budget on health care in 2016 and this country has been able to reduce its maternal mortality rates over the years because of the prioritization of their health care. The maternal mortality ratio in Rwanda reduced by 77% between 2000 and 2013, and this was due to the prioritization of their health care. This framework that Rwanda has used to achieve a reduction in maternal mortality, can be modeled by the Nigerian government focusing on increasing the quality of care provided by antenatal care providers.