Cross section of nursing mothers at a safe motherhood programme in Port Harcourt.

Amina Daerego is a typical
normal girl in one of the riverine areas of the Niger Delta in Nigeria. She was forced into early marriage against her wish at 14 for the singular reason that her parents needed someone to relieve them of the burden of catering for her.
Three times shortly after the marriage, she ran home, only for her parents to bring her back on each occasion with apologies to her husband, seeking his understanding of her feeling homesick.
Her husband, fondly called “Big Bros” by the locals, is a 58 year old male chauvinist who has 13 children with five women through concubinage, and eight grandchildren, six of whom are senior to Amina. He has never been officially married.
Four months into the marriage, Amina got pregnant and became even more embittered about her situation. Her husband, who claims to have all the experiences of child bearing, did not want to hear anything about ante-natal, but believed in traditional medicine. Meanwhile, he is known to have been nonchalant in catering for all the women he had children with, both during and after childbirth.
On several occasions, Amina attempted aborting the pregnancy through the use of various concoctions and cassava stems with advice from peers and friends. After several attempts without success, she gave up and decided to have the baby.
Being innocent and obedient, Amina faithfully patronised Traditional Birth Attendants (TBAs) for ante-natal services until she delivered, only to find that her baby boy was deformed. His right leg was far shorter than the left, and his left ear was sealed.
In another scenario, Tochukwu Ihaenacho, a 28 year old house wife in Nsukka, Enugu State, accessed neither ante-natal nor TBA services all through her pregnancy. When she was due, she and her husband went to a quack nurse who placed her on herbal concoctions preparatory to her delivery.
After some days, she started stooling and vomiting. The quack nurse explained to the husband that these were signs of labour, not knowing that his wife was gradually dying. When it became very obvious and getting out of hand, the woman referred them to a hospital.  Tochukwu and her baby died on the way to the hospital.
These scenarios are very common in Nigeria, especially in the hard-to-reach areas, popularly called rural areas. The circumstance surrounding the health of the girl/woman before, during and after delivery is what has come to be referred to as Safe Motherhood in modern day.
Safe motherhood means ensuring that all women receive the care they need to be safe and healthy throughout pregnancy and childbirth. This, in practice, means addressing all the factors that make pregnancy unsafe.
Ordinarily, having a baby is a natural process: after a full-term pregnancy, which usually lasts for nine months, a woman goes into labour on or near her due date, also known as Expected Date of Delivery (EDD), and gives birth to a healthy baby. A day or two later she leaves the hospital to begin day-to-day life with her growing family. But not all pregnancies go smoothly. Some women experience what doctors refer to as high-risk pregnancy.
A pregnancy is considered high-risk when there are potential complications that could affect the mother, the baby, or both. High-risk pregnancies require management by a specialist to help ensure the best outcome for both the mother and baby.
Factors that constitute high-risk and hence makes pregnancy unsafe can be categorised into Maternal Age, Medical conditions that exist before pregnancy, and Medical conditions that occur during pregnancy.
Naturally, women who will be under age 17 or over age 35 when their baby is due are at greater risk of complications than those between their late teens and early 30s. The risk of miscarriage and genetic defects further increases after age 40.
In the same way, conditions such as high blood pressure; breathing, kidney, or heart problems; diabetes; autoimmune disease; sexually transmitted diseases (STDs); or chronic infections such as HIV can present risks for not only the mother, but also her unborn baby.
For medical conditions that occur during pregnancy, even if the woman was healthy, when she becomes pregnant, it is possible for her to develop or be diagnosed with problems during pregnancy that can affect her and her baby.
Nigeria, regarded as the most populous African country, is said to have the highest maternal mortality ratio in the world. According to the newly revised estimates of the World Health Organisation (WHO), there are 576 maternal deaths in every 100,000 live births in the country, and a woman’s life time chance of dying during pregnancy, child birth or the postpartum period is 1 in 18.
WHO also estimates that annually, 59,000 Nigerian women die in childbirth, which is the second highest in the world, after India. Many factors have contributed to the above scenario. They include: severe bleeding (haemorrhage), which accounts for 25% of deaths; infection (15%); unsafe abortions (13%); enclampsia (12%); and obstructed labour and other direct diseases (16%).
Maternal deaths from direct causes accounts for the remaining 20% of deaths. These deaths, according to WHO, results from diseases (usually present before or during pregnancy) such as malaria, anaemia, hepatitis, heart disease and HIV/AIDS that are not complications of pregnancy, but complicate pregnancy, or are aggregated by it.
In a recent presentation on safe motherhood, titled “Women’s Sexual and Reproductive Health and Rights”, organised by Ipas, Nigeria, in Port Harcourt, Mrs. Mikiai Amachree, Desk Officer, Safe Motherhood in the Rivers State Ministry of Health, said only 10% of women deliver in government-owned health care facilities in the State.
According to her, “statistics show that out of 237,114, which is 80% of our target pregnant women, estimated to register for antenatal services, in 2011, only 120,990, which is 62.8%, came for antenatal care services.
The Tide’s investigation revealed that out of this number only 11,878, which is 10% of them, delivered in the health care facilities. This reveals gross under-utilisation of the services. Such records cannot be easily ascertained in the secondary, tertiary and private health facilities as well as Traditional Birth Attendants (TBAs).
One way to check the trend of poor record keeping as it concerns the secondary, tertiary, private and TBAs, according to Mrs. Amachree, is to make the Ministry of Health a record bank of all deliveries in Rivers State.
Impliedly, where to begin to keep records would be ensuring that all health facilities involved in deliveries in the country are made to submit their records bi-annually to the State Ministry of Health.
“The implication of this is that the State Government need to make it mandatory, including enacting a law to that effect, for such health facilities to submit their records of deliveries and deaths to their various state ministries of health”
Also, a study of deliveries that occurred in Kano State, Northern Nigeria, for instance, revealed a very high maternal mortality ratio of 2,420 deaths per 100,000 live births. The Tide gathered that about half of these deaths were caused by enclampsia, rupture of the uterus, and anaemia.
A research carried out by Shiffman J. and Okonofua F. identified  key challenges faced by safe motherhood practices in most parts of developing countries, where it is more common, to include institutionalising political priority for safe motherhood in Nigeria.
A critical look at these challenges, however, reduces them to three key areas: bringing about coalescence of the existing network of champions, developing strategies to increase federal budgetary resources, and promoting attention for the cause at state and local government levels.
How to transform the existing network of champions into a potent political force is the ûrst challenge. There are numerous networks working on safe motherhood that have many capable individual members but still not as functional as they should be, and have no overarching strategy and do not act in unison.
Members have numerous responsibilities within their own organisations, and these organisations themselves have multiple mandates, making it difûcult to bring about this coalescence.
Developing a unified common political strategy for safe motherhood promotion in Nigeria is possible, but would not only require a lot of resources and time, but also a leader or set of leaders at various levels of governance to appear, backed by a supportive organisational structure.
The second challenge is to generate significant federal budgetary resources for the cause. The relatively minimal amount the Federal Government has devoted to the cause, compared to those of donor agencies and the like raises questions about the meaningfulness of its commitment.
For instance, the 2014 Nigerian budget for health was N262 billion (about1.7 billion USD). The bulk of this amount was used in such areas as HIV/AIDS, immunization, capacity building programmes, etc. Safe motherhood was not given the attention it required, in spite of the high rate of maternal and infant mortality in the country.
Since HIV/AIDS has begun to attract signiûcant federal resources, it is not impossible for other health challenges, including maternal mortality reduction, to be adequately funded.
The implication is that the budgetary circumstances for safe motherhood should improve as the Federal Government, in response to national legislative and international pressure to achieve the maternal mortality reduction aims of the MDGs, may augment funding for the cause.
A major key towards the actualisation of this possibility is for safe motherhood advocates to pressurise the Federal Government, which also needs to view such pressure as nothing more than it truly is.
The third challenge is to generate meaningful political priority in state and local governments. This challenge has several components: the first is to generate reliable information on the scope of the problem so that ofûcials come to understand and appreciate it as a problem.
Secondly, there is the pressing need to re-orientate the political priorities of these officials, recognising that they operate as much from political self-interest as from a desire to promote social welfare.
This is mostly because many see little political value in making safe motherhood a policy priority. They, therefore, prefer to devote resources to other causes that they understand to be more visible and hence to be capable of generating greater political capital for themselves.
The challenge for safe motherhood advocates is, therefore, to frame the issue in such a way that it would convince governors and other elected officials that they can gain political support by acting on the problem and that they will lose political support by ignoring it.
Third is encouraging the diffusion of policy attention among state-level officials themselves. It is only through these means that the hope of the Nigerian mother can have meaning in terms of Safe Motherhood.

Sogbeba Dokubo