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High Maternal Mortality in Jigawa State, Northern Nigeria Estimated

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High Maternal Mortality in Jigawa State, Northern Nigeria Estimated Sharma et al. BMC Pregnancy and Childbirth (2017) 17:163 DOI 10.1186/s12884-017-1341-5 RESEARCH ARTICLE Open Access High maternal mortality in Jigawa State, Northern Nigeria estimated using the sisterhood method Vandana Sharma1* , Willa Brown1, Muhammad Abdullahi Kainuwa2, Jessica Leight3 and Martina Bjorkman Nyqvist4 Abstract Background: Maternal mortality is extremely high in Nigeria. Accurate estimation of maternal mortality is challenging in low-income settings such as Nigeria where vital registration is incomplete. The objective of this study was to estimate the lifetime risk (LTR) of maternal death and the maternal mortality ratio (MMR) in Jigawa State, Northern Nigeria using the Sisterhood Method. Methods: Interviews with 7,069 women aged 15–49 in 96 randomly selected clusters of communities in 24 Local Government Areas (LGAs) across Jigawa state were conducted. A retrospective cohort of their sisters of reproductive age was constructed to calculate the lifetime risk of maternal mortality. Using most recent estimates of total fertility for the state, the MMR was estimated. Results: The 7,069 respondents reported 10,957 sisters who reached reproductive age. Of the 1,026 deaths in these sisters, 300 (29.2%) occurred during pregnancy, childbirth or within 42 days after delivery. This corresponds to a LTR of 6.6% and an estimated MMR for the study areas of 1,012 maternal deaths per 100,000 live births (95% CI: 898– 1,126) with a time reference of 2001. Conclusions: Jigawa State has an extremely high maternal mortality ratio underscoring the urgent need for health systems improvement and interventions to accelerate reductions in MMR. Trial registration: The trial is registered at clinicaltrials.gov (NCT01487707). Initially registered on December 6, 2011. Keywords: Maternal mortality, Sisterhood method, Jigawa, Nigeria, Northern Nigeria, Sub-Saharan Africa Background Development Goals (MDG 5), with the aim of reducing Maternal mortality, defined as the death of a woman maternal deaths by 75% from 1990 to 2015 [3]. However, during pregnancy or within 42 days after birth, remains progress towards this objective has been slow in many a major global health problem [1]. In 2013, there were sub-Saharan African countries. an estimated 293,000 maternal deaths worldwide, with In Nigeria, for example, one of the six countries that 99% of these occurring in low income countries [2]. The together contribute >50% of the total maternal deaths African continent is disproportionately affected; 17 of worldwide, reductions in the maternal mortality ratio the 20 countries with the highest maternal mortality ra- (MMR; number of maternal deaths per 100,000 live tios in the world are in Africa [2]. Most maternal deaths births) have been inconsistent. The most recent national are avoidable and the goal of preventing maternal mor- data estimates the MMR for Nigeria to be 576 deaths tality has received increasing attention. Maternal mortal- per 100,000 live births (95% CI: 500–652) [4]. Previous ity reduction was included as one of the Millennium estimates of MMR in Nigeria ranged from 608 deaths per 100,000 live births (95% CI: 372–946) in 2008, to * Correspondence: [email protected] 473 deaths per 100,000 live births (95% CI: 360–608) in 1Abdul Latif Jameel Poverty Action Lab, Massachusetts Institute of 1990 [5]. Technology, 30 Wadsworth St, Cambridge, MA 02142, USA Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Sharma et al. BMC Pregnancy and Childbirth (2017) 17:163 Page 2 of 6 Maternal mortality is difficult and complex to measure MMR for Jigawa State in the northeastern region of the especially in the settings where the highest burden ex- country is available. This lack of reliable state-level data ists. Data on the number of deaths of women of repro- poses a challenge to the planning and implementation of ductive age, their pregnancy status at the time of death safe motherhood programs in the state. The primary ob- and the medical cause of death is required for accurate jective of this study, therefore, was to estimate lifetime measurement. This can be particularly difficult to obtain risk of maternal death and calculate the MMR in Jigawa in low-income settings where vital statistics are often in- State, Northern Nigeria using the Sisterhood Method. complete or do not exist. Estimates are frequently based on hospital data, which often do not reflect the maternal risk within communities [6]. Community based studies Methods using direct estimation to measure maternal mortality This study utilized baseline data from an ongoing face numerous challenges including large sample sizes cluster-randomized controlled trial of community-based required to produce reliable results, and the fact that interventions to reduce maternal mortality in Jigawa most deaths occur at home and follow up is therefore State, Northern Nigeria. The trial is being implemented time consuming and costly. by the Abdul Latif Jameel Poverty Action Lab (J-PAL) in Indirect methods for measuring maternal mortality partnership with the Planned Parenthood Federation of have been developed to provide practical, less expensive Nigeria (PPFN) to evaluate the impacts of three separate alternatives for estimating the MMR in settings were interventions: 1) training local women as Community data on vital events are not routinely collected or are Resource Persons (CoRPs) who provide education and unreliable. The Sisterhood Method for estimating MMR, referrals to pregnant women and their families, 2) the which involves collecting data on maternal deaths CoRPs program plus distribution of safe birth kits to among sisters of respondents, is an ideal method for pregnant women, 3) the CoRPs program plus commu- such settings because it requires a smaller number of re- nity dramas to change social norms around maternal spondents than cohort studies, and data collection is health. quick and relatively simple [7]. The Sisterhood Method has been validated and applied successfully in a number Study area – of countries in Africa and Asia [8 11]. However, this Jigawa State, located in North-Western Nigeria, had a method does not provide a current estimate of MMR for population of 4.3 million inhabitants during the 2006 the year the survey is conducted and cannot be used to census [22]. The state is divided into 27 Local Govern- measure trends in the short term [12]. Longer term ment Areas (LGAs), with 80% of the population residing trends in MMR, however, have been assessed using the in rural areas. Sisterhood Method [13]. In Nigeria, there is significant variation in the MMR between regions in the country, with the highest ratios Study design and sampling method in the north [14–19]. The extremely poor health out- LGAs were included in the study if they had a Primary comes for mothers in Northern Nigeria are linked to fac- Health Center (PHC) that had received the government’s tors such as weak health infrastructure, low literacy and Midwives Service Scheme (MSS) and was thus providing large distances from health facilities [20]. Skilled birth 24-h maternity care at the time of the study start. Of the attendance (SBA) is extremely low with only 13% of 27 LGAs in Jigawa State, the following 3 were ineligible women delivering with skilled personnel [21]. In for participation in the study: Jahun, Hadejia, and addition, vital event registration is virtually non-existent Gumel. Using a list of settlements and their populations in the north and most maternal deaths occur at home in each LGA, 96 clusters of settlements with an average and are unreported. This suggests that maternal mortal- population of approximately 3,000 people per cluster ity data collected at the facility level may not be accur- were randomly selected. Each of the 96 population clus- ate, and community-based approaches to assess MMR ters were mapped during a partial census, and 15% of such as the Sisterhood Method may be essential. households were randomly selected to participate in the Two previous studies estimating MMR in Northern baseline study. Wives of the household head or female Nigeria using the Sisterhood Method reported an MMR household heads in sampled households who were of re- of 1,049 maternal deaths per 100,000 live births (95% CI: productive age (between 15 and 49 years of age) were 1021–1136) in Zamfara State, and 1,271 maternal deaths eligible to be interviewed. In cases where a household per 100,000 live births (95% CI: 1152–1445) across Zam- had more than one eligible respondent, one respondent fara, Jigawa, Katsina and Yobe States [18, 19]. The sec- was randomly selected using a randomization table. ond study was not powered for state-level estimates, and Households that declined to participate were replaced thus, to date, no reliable population-based estimate of with back-up households. Sharma et al. BMC Pregnancy and Childbirth (2017) 17:163 Page 3 of 6 Data collection Table 1 Characteristics of respondents in study sample The baseline survey was conducted between December Variable N (%) 2011 and May 2012. Data were collected from a total of Age (years) 7,069 women of reproductive age using a structured 15–19 1397 (19.8) questionnaire translated to Hausa, the local language, fo- 20–24 1476 (20.9) cused on maternal and child health.
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