International Journal of Innovation, Creativity and Change. www.ijicc.net Volume 9, Issue 10, 2019

Estimation of Maternal Mortality using Sisterhood Method in ,

Muhammad abdulkadira*, Ruslan Rainisb, a,bGeography Section Universiti Sains Malaysia Pulau penang 1800 USM, Email: a*[email protected]

The study was conducted to calculate (estimate) the maternal death and life time risk and the ratio of the maternal death in Jigawa State Nigeria. 96 respondents were selected randomly from cluster communities of which 7,069 (women) of age 15-49years were interviewed from 27 of 24 local government areas. Ratio of maternal mortality was calculated using the current state total fertility rate and the results indicate that about 1,026 maternal deaths, 29.2% (300), occur during child delivery, after termination of pregnancy and or during pregnancy. The life time risk of 6.6% was found with a 1,012 (95% CI: 898-1,126) ratio of maternal death per 100,000 live births. This research also revealed that 10,957 women reached their reproductive age. The study was conducted in consideration of eleven years of reference and determined that a high ratio of maternal mortality exists in the state which needs to be addressed through improvement of obstetric care and intervention.

Key words: Fertility rate, Jigawa, maternal death, Sisterhood method, vital registration, women.

Introduction

Death of women at some stage within pregnancy, childbirth and up to 42 days after delivery remains a serious world problem (De‐Regil, Palacios, Lombardo, & Peña‐Rosas, 2016; Joseph et al., 2017). In 2015 about 303,000 such deaths were recorded globally, unfortunately developing countries registered approximately 99% of world maternal mortality (Bell et al., 2018). The sub Saharan Africa is seriously affected, as indicated by the fact that of the 20 countries with highest ratio of maternal mortality, 17 are African (Alkema et al., 2016; EGBUNIKE & OKOYE 2017). The majority of the caused for this problem are preventable if necessary action is taken. Maternal mortality was listed number 5 of the Millennium

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Development Goals set amid in the context of decreasing the death rate by at least 75% by 2015 (Organization, 2016) and, to date, this has not been achieved.

Nigeria is one of the nations with the highest global maternal death rate contributing to approximately 50% of world-wide maternal death (Ishola, Owolabi, & Filippi, 2017; Oladapo et al., 2016). The rate of maternal death reduction is inconsistent in Nigeria, about 473 (95% CI: 360–608) per live births, in 1990, 608 (95% CI: 372–946) per live births in 2008 and currently estimated at 576 (95% CI: 500–652) per live birth (AWOTIDEBE et al., 2017). In Sub Saharan African countries, maternal death is complex as well as difficult to measure because of its high burden (Graham et al., 2016). In order to have accurate and reliable data on maternal mortality, the record of the number of pregnant females, location, death time, and causes of death most be adequately kept and recorded, and this is very difficult if not impossible in developing countries like Nigeria (Bland, 2015; Knight et al., 2015). Thus for the reason a strong registration system is vital in contrast to the current situation in developing countries where the registration system is very poor or does not exist at all. The maternal mortality estimation therefore is based on hospital recorded data and this data dos not reflect community maternal risk. To measure maternal mortality using direct estimation is very difficult due to the fact that it requires a large sample size and a number of deaths occur at home (Koblinsky et al., 2016; Lawn et al., 2016).

Literature review

Maternal death measurement as an indirect method was an alternative developed in a setting were vital registration is not well coordinated and organised, and where indirect method is practical and less expensive. Measuring maternal mortality by using sisterhood method is more ideal and a better fit in developing countries as a very small number of respondents are required and collection of data is simple and expedient (El Ayadi, Hill, Langer, Subramanian, & McCormick, 2015; Mbaruku, Vork, Vyagusa, Mwakipiti, & van Roosmalen, 2017). The sisterhood is the method used to measure the ratio of maternal mortality whereby information on deaths (maternal death) among sister respondents is collected. The method has been adopted and validated successfully in some countries in sub Saharan Africa as well as Asia. However, the sisterhood method cannot give estimates based on the current year in which the survey was conducted, and further does not give or measure short term and only long term trends (Scrafford & Tielsch, 2016; Woldegiorgis, Hiller, Mekonnen, & Bhowmik, 2017).

The ratio of maternal death varies between regions in Nigeria and is lower in the southern part of the country and higher in the Northern part (Adedini, Odimegwu, Imasiku, Ononokpono, & Ibisomi, 2015; Akinyemi, Bamgboye, & Ayeni, 2015; Graham et al., 2016). In Nigeria mothers’ health outcomes are very poor especially in the north, where society and economy is characterized by low educational background, distance of health facilities and inadequate skill

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in birth attendance (Shamaki & Buang, 2017). The delivery of babies at health institutions is abysmally low with only about 13% women who deliver in the presence of health personnel (Amakom & Ekeocha, 2017). In addition, the vital process of registration is virtually absent in the northern part of the country and many women die at home without any official report or record. Further, by implication, existing health facility data on maternal death is not accurate or is under reported. Therefore it is very important to introduce a method which will involve the community (a community based approach) to measure the ratio of maternal mortality in a similar manner to that of sisterhood (Lopez & Setel, 2015; Mikkelsen et al., 2015).

Two studies previously conducted estimated the ratio of maternal mortality in the north part of the country (Nigeria) by using sisterhood method. The research revealed a maternal mortality ratio of 1,049 (95% CI: 1021–1136) per live births in Zamfara State and also about 1,271 deaths (maternal) per 100,000. This occurred in the state of Katsina, Jigawa, Yobe and Zamfara(Findley et al., 2015; Gulumbe, Alabi, Omisakin, & Omoleke, 2018). Other studies conducted do not consider estimates at state level and therefore are not population based. The fundamental objective of this research therefore is to calculate the ratio of maternal mortality in Jigawa state and estimate maternal death lifetime risk by sisterhood method because lack of data is a major setback in policy implementation of the state’s safe motherhood programmes.

Methods and Study area

Jigawa state is situated in the North western part of Nigeria and lies between 11.000N latitude and 13.000N of latitude and 8.000E to 10.150E of longitude (Ibrahim et al., 2012; Ramyil et al., 2015). The state shares a boundary from the west with Katsina state, to the east Bauchi and Yobe to the north eastern as illustrated in Figure 1 below. The state also shares a border line with Niger republic in the north and is one of the 36 states of the federal republic of Nigeria (Kadiri, 2014; Okereke et al., 2015). Jigawa state contributes close to 3.11% of the country population and is ranked 8th in terms of national population. According to the 2006 population census the state has 4,360,002 total population with about 50.4% males and 49.6% females (Anosike, Enenmoh, Nkeleme, & Mosaku, 2016). In the most recent projection, the state has approximately 5,562,000 populations and the composition is slightly higher than in the 2006 population census (Mohammed, Alawad, Zeinelabdein, & Ali, 2015).

Jigawa state has a high ratio of maternal death, in 2009 the ratio was estimated to be 1,500 deaths per 100,000 live births, the figure dropped to nearly 950 in the 2013 (Eto, 2016). Maternal deaths in the state are mainly caused by; haemorrhage, anaemia, sepsis and eclampsia (Eto, 2016). Home delivery, low antenatal visit and low delivery by skilled personnel at health facilities are amongst the leading factors in maternal death in Jigawa State. Antenatal visits in 2013 were recorded at only 49.7% and delivery at facility level by health professionals at 10.2%. The Jigawa is one of the states in the country that still records a poor health indices

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indicator even though this has now improved. The percentage of access to health facility services increased from 24% to 70% from 2008 to 2013. However, accessibility to health facilities is still not facilitated in some areas of the state (Sharma, Leight, AbdulAziz, Giroux, & Nyqvist, 2017).

Figure 1. Jigawa State Nigeria

Study design and sampling method

This study covered the entire 24 local government areas of the state and found that each local government has a primary health centre, a state government service scheme of midwives and also a 24 hours health centre operation. Out of the 27 local governments only , and were not eligible to participate in the research. In the research approximately 3,000 participants were randomly selected which comprised a total of 96 clustered settlements. The settlement cluster was mapped and 15 percent of households were randomly chosen to take part in the research. Selected household wives were interviewed and if more than one identified participant per household was found eligible to take part in the study, a table of randomization was used to select the respondent. Thus this research used community based intervention randomized cluster data. The intervention was aimed at reducing or curtailing the maternal death in the state.

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Data collection and analysis

The survey (baseline) was conducted from December 2015 to May 2016. For the purpose of this study, data was retrieved from 7,069 women by using a Hausa (Local language) translated questionnaire specific to child and maternal health. The researcher recruited female research assistants as interviewers who speak the local language fluently and a programmed smart phone together with the electronic kit software for data collection were given to the interviewers. The sisterhood standard questions were incorporated in the questionnaire for the ratio of the maternal mortality estimation. Questions included: how many sisters do you have? how many are alive? how many dead? and how many died during pregnancy, during childbirth and after delivery?

Statistical software for social science (SPSS) was used to analyze collected data. The study calculated the maternal death exposure risk of sisters of each group and exposure duration was also calculated. A sister’s numbers were multiplied by specific age factor adjustment to determine the risk exposure. The total number of maternal mortality was multiplied by sisters exposed estimation for the maternal death life time risk. The state fertility rate is 6.7. The following formula was used for the calculation of lifetime risk:

MMR=100,000 X (1-(1-LTR)(TFR)) Where MMR = Maternal mortality ratio LTR= Lifetime risk TFR= Total fertility rate

Hanley et al’s method was used to calculate the maternal death confidence level of interval at 95%. The following equation was used to estimate the period to which the time refers and was calculated using the below: T = Σ (T(i)*ꞵ(i))/ΣB(i) Where T = the global estimate time location point T(i) = each age group time location ꞵ(i) = each age group exposing unit

Ethical procedure was duly followed since approval was obtained from the Jigawa state research ethical committee. A letter was taken to the various communities leader and verbal consent was obtained from the respondents.

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Results and discussion

Average years of respondent was 27.9 with standard deviation of 8.5. 7,096 women were the participants of the study. 64.8% of the participants had never attended formal education and percentage of literate respondents was only 9.6%. Due to the nature of the state about 99.9% of the respondents were Muslim. In terms of polygamy 30.5% were part of a polygamous family. About 4.0 births on average were reported by the respondents (SD=3.1). There were about 10,957 sisters who survived maternal death and 1,026 sisters who were dead as reported by the participants, about 9.4%. The research determined that about 29.2% (300) of deaths occurred during pregnancy, child birth or after delivery as presented in Table.1 below.

Table 1: Scio-demographic variables of respondents Variables Percentage Number Age of the respondents 15-19 19.8 1397 20-24 20.9 1476 25-29 18.8 1328 30-34 14.7 1039 35-39 12.9 915 40-44 9.1 646 45-49 3.8 268 Education Yes 2488 35.2 No 4581 64.8 Educated Yes 675 9.6 No 6394 90.5

Religion Muslim 7060 99.9 Christian 5 0.07 Others 4 0.06 More than 1wives Yes 2159 30.5 No 4910 69.5 Ownership of latrine Yes 5803 82.1 No 1266 17.9 Delivery at health facility Yes 319 8.5 227

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No 3423 91.5

Vital status of sisters is presented in Table 2 below reflecting the entire cohort of maternal death life time risk and age group (5 years). The maternal death, life time risk was 1 in 15 or about 6.6%. The ratio of the maternal mortality of the Jigawa state using total fertility rate was found to be 1,012 per 100,000 live births (95% CI: 898 – 1,126). The ratio of the maternal mortality reference time was eleven years.

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Table 2: Estimation of the maternal mortality using Sisterhood method

Age Respondents Survived sisters Dead sisters Maternal Death Age specific Sister expose Lifetime Risk k e c r f ꞵ=ef q=r/ꞵ n % N % n % n % 15-19 1397 19.8 1786 16.3 143 13.9 30 10.0 Q107 191 Q157 20-24 1475 20.9 2234 20.1 200 19.5 64 2.3 Q206 460 Q139 24-29 1328 18.8 2092 19.1 157 15.3 45 15.0 Q343 718 Q063 30-34 1039 14.7 1718 15.7 158 15.4 43 14.3 Q503 864 Q050 35-39 915 12.9 1632 14.9 177 17.3 61 20.3 Q664 1084 Q056 40-44 646 9.10 1093 9.9 146 14.2 44 20.3 Q802 877 Q050 45-49 268 3.8 402 3.8 45 4.4 13 4.3 Q900 362 Q086 Total 7069 100 10957 100 1026 100 300 100 4555 Q066

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Table 3 below depicts the analysis at local government level which shows the proportion of the variability of the mortality was accredited to maternal causes. 29.2% of the recorded deaths were due to child bearing and labour as reported by Sule Tankarkar, and local government.

For the estimation of the ratio of the maternal mortality, Table 2 above was used, this is because it calculated the recent ratio estimate and 4,201 women of less than thirty (30) years of age were respondents. A total of 6,112 women were reported by 4,201 respondents and of these, close to 8.2% (500) were dead and 27.85% (139) of those deaths were as a result of the maternal causes of death. The maternal death life time risk for women of less than thirty (30) years is 1 in 10 (10.2%). The ratio of the maternal death of this group was calculated at 1,586 per 100,000 live births, equivalent to approximately 7.3 years before the survey (95% CI: 1,326 -1,849).

Table 3: Local Government vital status of sisters LGAs Number Survived Sisters Number Of Dead Sisters Maternal Deaths Number Percentage Number Percentage 289 494 32 6.5 11 34.4 288 568 88 15.5 14 15.9 355 710 56 7.9 19 33.9 Birniwa 261 293 29 9.9 11 37.9

Buji 330 613 51 8.3 19 37.3 307 387 39 10.1 7 17.9 278 567 80 14.1 15 18.8 Garki 259 482 65 13.5 18 27.7 Guri 315 607 39 6.4 19 48.7 294 539 43 8.0 15 34.9

Gwiwa 271 389 18 4.6 10 55.6 284 385 53 13.8 11 20.8 183 312 29. 9.3 14 48.3 317 377 38 10.1 7 18.4 Kirikasamma 313 377 38 10.1 17 18.4 Kiyawa 347 402 37 9.2 20 54.1 223 396 48 12.1 11 22.9 Mallam 257 244 33 13.5 16 48.5 Madori Miga 355 457 33 7.2 10 30.3

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Ringim 351 508 53 10.4 16 30.2 Roni 323 673 57 8.5 9 15.8 Sule 257 224 8 3.6 4 50.0 Tankarkar Taura 337 526 56 10.6 12 21.4 275 269 9 3.3 32 22.2 Total 7069 10957 1026 9.4 300 29.2

The ratio of maternal mortality of 1,012 was reported by this research and unfortunately this is much higher than the national figure (estimate) as revealed by the sisterhood. The proportion of 576 per 100,000 live births was suggested, using 2006 as a time reference (Leight et al., 2018). The study also revealed high maternal death burden within the northern part of the country. This finding corroborated with other sisterhood methods previously conducted in the northern part of the country

The type of research was conducted first in 2009 and found a 1, 049 ratio of maternal death per 100,000 in the state of Zamfara (95% CI: 1021–1136)(Henry Victor Doctor et al., 2012). The latest and second research, in 2011, conducted in Katsina, Jigawa, and Zamfara and Yobe state revealed that the rate of maternal death is 1,271 per 100,000 live birth (95% CI: 1152– 1445)(Doctor, Findley, & Afenyadu, 2012). Although the research included Jigawa state this is not a state estimate but rather a regional estimate. Additionally, the research used the project site specifically to collect the data and this may not represent others area of the state. This research therefore is the first estimation evidence based on the ratio of the maternal mortality in the state (Jigawa). The sampling procedures of the research randomly selected the households within the randomly sampled communities and covered 24 local government areas within the state.

This study also revealed maternal mortality variation among the local government area within the state. Guri, Sule Tankarkar, Kaugama and Gwiwa local government areas were found to have the highest maternal death among women and all the deaths were related to the above identified causes of maternal death. This is a remote rural region and there is an absence of health facilities and long distances must be covered in order to access to facilities. This work corroborates other studies which reported that maternal deaths were more frequent for women who were younger when married and consequently younger when pregnant (Rai & Tulchinsky, 2015; Sauer, 2015).

This research has some limitations; the reported ratio of maternal mortality during the reference period is more than ten years prior to this research. Therefore it was very difficult to estimate ratio of maternal mortality using sisterhood method within the communities. The researcher only used the respondent village as proxy because the location data was not available; this 231

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method is consistent with other studies (Hanson et al., 2015; Kassebaum et al., 2016; Ren, Song, Theodoratou, Guo, & An, 2015).

Conclusions

The findings of this research revealed the high ratio of maternal mortality (95% CI: 898–1,126), with the ratio 1,012 per 100,000 live births in Jigawa state. Therefore the need for Jigawa state to strengthen obstetric care and both motherhood programmes and maternal intervention is a necessity as this much needed expansion will reduce the maternal mortality in the state.

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