Professor Atiene Solomon Sagay - University of Jos Institutional ...

FACING THE CHALLENGES OF MOTHERHOOD; THAT THESE LITTLE
ONES MAY LIVE
Text of Inaugural Lecture
By
Professor Atiene Solomon Sagay
BSc, MBChB, FWACS, FICS, FRCOG (Lond)
Professor of Obstetrics and Gynaecology
Hon. Consultant Obstetrician and Gynaecologist
University of Jos / Jos University Teaching Hospital
PMB 2084, Jos, Nigeria
Mobile: 08034519740 e-mail: atsagay58@yahoo.com
The natural desire of a woman of any culture to bear a biological child of her own is usually
strong. It is the expression of a deep and compelling innate call to motherhood. The
processes of pregnancy, child birth and child rearing are unique life-transforming motherhood
experiences that a woman looks forward to as she comes of age. I intend to explore these
processes and discuss the numerous challenges women face in Nigeria, by examining five
basic questions:
1. What if a woman fails to conceive or keep pregnancies?
2. What if a pregnancy is unintended and unwanted?
3. How hazardous can pregnancy and childbirth be?
4. Are there any concerns about survival of the newborn?
5. Are there emerging challenges to motherhood in the HIV era?
1. What if a woman fails to conceive or fails to keep pregnancies?
Definition of infertility
Infertility primarily refers to the biological inability of a person to contribute to conception.
For a couple, infertility refers to the inability to achieve conception after 12 months of
unprotected sex. Infertility may also refer to the condition of a woman who is unable to carry
a pregnancy to a state of viability.
There are many biological causes of infertility and in general, it is estimated that in 30% of
infertile couples, the problem is with the woman, in another 30% the problem is only with the
man and in a further 30%, the defects are found in both parties while in the final 10% of
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couples, no abnormalities are found (unexplained infertility). It is estimated that one out of
every 6 couples in Nigeria are infertile.
We evaluated 1000 consecutive infertile women in Jos, Nigeria and found that 410 (41%) had
never ever conceived (primary infertility) while 590 (59%) have had at least one prior
pregnancy (secondary infertility) (Sagay et al 1998). More than 4 out of every 10 (42.3%) of
these women had blocked tubes on both sides (bilateral tubal occlusion). Of the 548 (54.8%)
of these infertile women who were found to have pelvic adhesive disease, two-thirds (66%)
had moderate to severe pelvic adhesions for which reconstructive surgical outcome is poor.
What this means is that a large proportion (about 40%) of infertile women in Nigeria have
badly damaged reproductive organs for which assisted conception in the form of in-vitro
fertilization and embryo transfer (a.k.a. test tube baby) is required. The prevailing cost of this
procedure in Nigeria (about 700,000 Naira) is however out of the reach of most infertile
couples in this country.
On the male side, we studied the semen quality of male partners of infertile couples in Jos
(Imade et al. 2000). In all, we analysed the semen of 428 male partners of infertile women
using the World Health Organisation (WHO) guidelines. The findings revealed that 124
(29%) of the men had normal semen parameters (normozoospermia) while 304 (71%) had
abnormal semen quality. The semen abnormalities comprised; 39 (9.1%) with complete
absence of spermatozoa (azoospermia), 89 (21%) with significantly reduced population of
spermatozoa (oligozoospermia), 22 (5.1%) with poor movement (asthenozoospemia) and 18
(4.2%) with abnormal physical forms (teratozoospermia). Another 134 (31.5%) men had
various combinations of these seminal abnormalities. The findings suggested that the male
partner is a significant contributor to the problem of infertility in Jos.
Psycho-social consequences of infertility
A Yoruba adage says “Omo laso”, meaning children are clothes, without them you are
naked. Infertile couples feel insecure and vulnerable to societal stigmatization.
The psycho-social challenge faced by infertile women is age-long. Evidence from
biblical time shows that women have contemplated suicide as a response to their
continued barrenness. Rachael, wife of Jacob considered live worthless without a
child of her own: [Gen 30:1 And when Rachel saw that she bore Jacob no children,
Rachel envied her sister. And she said to Jacob, Give me sons, or else I will die].
Anthropologists who worked in different communities in the South-south region of Nigeria
concluded that; "the necessity for a woman to have a child remains basic in this region.
Motherhood continues to define an individual woman's treatment in her community, her selfrespect,
and her understanding of womanhood" (Hollos et al 2009).
In focus group discussions on the social meaning of infertility in south-western Nigeria,
(Okonofua et al.1997) reported the following community perceptions;
that infertility is not often discussed, and if at all, must be discussed carefully and
privately. This was largely to avoid embarrassing those who were infertile.
that an infertile person would be extremely sensitive to any discussion about children
or pregnancy, and would assume that even comments in casual conversations were
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meant to make fun of them. This is in the context of the belief that a person without
children has failed in a fundamental way.
that women are most often blamed for the infertility problem. There are many who
believe that a man cannot be infertile, as fertility and potency are often thought to be
synonymous.
that a common consequence of a couple's infertility is the expulsion of the woman
from the husband's house, with or without divorce. People most commonly responded
by saying the husband would ‗send her packing‘. Thus, having children is clearly
more important than loyalty to one's spouse, which is evidenced by the common
practice of divorce because of childlessness, or forceful ejection of the wife from the
husband's home, either by the husband himself or by his family.
that infertile women are often excluded from inheriting property, from decisionmaking
in the family, and from any type of financial or social security.
that it is common for people to avoid those women known to be infertile, and women
often tell their children to avoid these women, either because they think the women
might harm their children because of their bitterness, or because they might not know
how to look after other children properly.
that there are strong beliefs that some infertile women were witches, had given birth to
children in another world, and taken a secret vow never to bear children on earth. This
belief justifies the attempt to ostracize these women, and to expel them from their
households.
that often, any subsequent misfortune of the woman or family which would ordinarily
be taken in isolation may instead be attributed to her infertility and/or witchcraft.
A woman‘s ability to make decisions within the family, and her ability to inherit her
husband‘s property are almost exclusively dependent upon fertility.
Clearly, infertile women in the Nigerian socio-cultural setting face tremendous challenges
and perhaps as a consequence, there is a high prevalence of psychological problems among
infertile women.
In a Nigerian study, nearly one-third of infertile women were found to have diagnosable
psychopathology, mainly depressive episode and generalized anxiety disorder. Compared
with the control group, the infertile women experienced poorer marital relationships and
polygamy was found to have a close association with psychopathology. (Aghanwa et al.1999)
A recent article in the Canadian Medical Association Journal reported the finding that
motherhood appears to protect against suicide, with increasing numbers of children
associated with decreasing rates of death from suicide. Having children may protect against
suicide because children may increase a mother's feelings of self-worth. Children may also
provide emotional and material support to a mother and provide her with a positive social
role. As well, motherhood may enhance social networks and social support.
Recurrent pregnancy losses (Habitual abortion)
There is no experience more difficult than having to go through a miscarriage during
pregnancy. Miscarriage is not only physically taxing, but very emotionally challenging, as
well. Yet, pregnancy loss can be even harder to deal with when it occurs time and time again.
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Known as recurrent pregnancy loss, repeated miscarriage is difficult for both partners
involved. It can also make fertility treatments particularly challenging.
Recurrent pregnancy loss occurs when a women loses three or more consecutive pregnancies.
The majority of recurrent pregnancy losses occur early in pregnancy, typically during the first
half of pregnancy. Recurrent pregnancy loss is very difficult for couples to experience,
especially because a cause for these miscarriages is often never determined. Nevertheless, by
undergoing specific fertility testing and treatment, there is hope that couples who have
experienced multiple miscarriages will go on to welcome a healthy child of their own.
Fortunately, recurrent pregnancy loss is relatively rare as fewer than 3% of couples go
through more than three miscarriages in a row. It is more likely to occur in older women who
have had two previous pregnancy losses and engaged in certain life-styles such as smoking,
heavy drinking and drug use.
Unfortunately, it is difficult to pinpoint the underlying cause of pregnancy loss. In fact, more
than 50% of couples that experience the problem never find out what is responsible for their
miscarriages. However, there are a number of conditions that do underlie some cases of
recurrent miscarriage. They include genetic factors, structural uterine problems, hormonal
imbalance and blood clotting disorders.
2. What if a pregnancy is unintended and unwanted?
Each year, thousands of Nigerian women have unintended pregnancies that end in illegal
abortion. Many of such procedures occur under unsafe conditions, contributing to maternal
morbidity and mortality. To highlight this challenge, permit me to share an experience
during my residency training.
It was about 9.00pm on a cold April night in mid-1980s, I was on my first call duty as a
resident doctor in the Jos university teaching hospital, Jos, and I was asked to review and
admit a young lady who was said to be having vaginal bleeding. She was a university
undergraduate. On the couch, I found a pretty, young lady with a stylish hair do, who was
very pale, cold, motionless and stiff. My examination confirmed that she was dead. I tried to
conceal my horror and politely told the porter to take her back to the casualty officer and
demonstrated to him that she was brought in dead and could not be admitted to the
gynaecology ward. The brief history suggested that she had a termination of pregnancy
somewhere in town that evening. That night, as I reflected on the scene, I realised I had just
witnessed an avoidable maternal death. This experience remained on my mind all through my
residency training and served as a constant reminder of how hazardous being a woman in
Nigeria can be.
Abortion in Nigeria is illegal except to save a woman‘s life. Of the estimated 6.8 million
pregnancies that occur annually in Nigeria, one in five is unplanned and half of these end in
an induced abortion. (Guttmacher Institute 2008) Abortion is therefore common in Nigeria
and most procedures are performed under unsafe, clandestine conditions. In 1996, an
estimated 610,000 abortions occurred (25 per 1000 women of childbearing age), of which
142,000 resulted in complications severe enough to require hospitalization. The number of
abortions is estimated to have risen to 760,000 in 2006 (Bankole et al. 2006). Unsafe
abortions are a major reason Nigeria‘s maternal mortality ratio – 1,100 deaths per 100,000
live births- is one of the highest in the world (WHO 2007). According to conservative
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estimates, more than 3,000 women die annually in Nigeria as a result of unsafe abortion
(Henshaw SK et al 2008).
In countries like Nigeria with low contraceptive uptake, a high rate of unintended pregnancies
and poor access to safe maternal healthcare services, each pregnancy puts a woman‘s life at
considerable risk. Women in Africa experience a 1 in 26 (1 in 18 in Nigeria) lifetime risk of
dying from pregnancy- or childbirth-related complications. This is compared to a 1 in 7,300
lifetime risk for their counterparts in developed countries. Among a total of 171 countries for
which estimates were made, the adult lifetime risk of maternal death (the probability that a
15-year-old female will die eventually from a maternal cause) was highest in Nigeria‘s
northern neighbour Niger (1 in 7 ), in stark contrast to Ireland, which had the lowest lifetime
risk of 1 in 48,000 (WHO 2005).
The likelihood of complications during pregnancy and delivery is increased in the face of: too
many pregnancies, too short an interval between pregnancies, having a pregnancy too early in
life, or having a pregnancy too late in life.
These conditions can negatively affect a woman‘s long-term health by depleting her
nutritional and overall health status— contributing to anaemia, fatigue, increased blood
pressure and decreased immunity to diseases such as malaria and reproductive tract
infections. These factors can also increase the risk of excessive blood loss immediately after
delivery, birth injury, miscarriage, or stillbirth.
Clearly, maternal and neonatal deaths can be prevented by (1) limiting the number of
pregnancies each woman experiences during her lifetime and (2) improving access to
reproductive and maternal healthcare—particularly antenatal care, skilled attendance at
delivery, emergency obstetric care, postpartum care, and post-abortion care. Making family
planning a component of safe motherhood programs, should help women limit their overall
fertility and reduce the number of times they are at risk for maternal death; space births,
thereby allowing their bodies to recover from previous pregnancies; and time their
pregnancies. These services must also be accessible to youths.
Over the last 25 years, the Jos University Teaching Hospital (JUTH), Jos has offered family
planning services to all comers and has built tremendous human and institutional capacity. In
the mid 1980s, the department of obstetrics and gynaecology at JUTH established a voluntary
surgical contraception unit principally for the provision of female sterilization services. The
unit remains one of the most active in the country and a number of reports have been
published (Otubu et al 1990, Aisien et al 2001, Aisien et al 2002). With the advent of novel
contraceptive implants in the 1980s and 1990s, and the instant popularity of this non-sex
related, long-term, reversible contraceptive method among our clients, a number of studies on
the safety profile among Nigerian women were undertaken in the department.
The effect of Norplant on serum lipids and lipoproteins (agents that are incriminated in heart
and vascular diseases) was studied by Otubu et al. (1993) Serum triglycerides and total
cholesterol were reduced. High density lipoprotein-cholesterol (HDL-chol) exhibited
statistically significant reduction and low density lipoprotein-cholesterol (LDL-chol) was
significantly elevated at 6 months. The changes in lipid profile with regards to cardiovascular
morbidity were mixed. Norplant use was not associated with adverse lipid profile.
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We studied the effects of Norplant® on the electrical activity of the heart and showed a
tendency to significant prolongation of ECG intervals (a tendency to cause heart blocks)
(Sagay et al 2002, Okeahialam et al 2004). Although these ECG changes appeared
innocuous, we advised that patients with pre-morbid cardiac conditions should use alternative
contraceptives until these effects are clearly elucidated. Norplant® did not show any
adverse effects on diastolic and systolic blood pressures over time.
Of additional note are the findings that Norplant use is associated with the depletion of
platelet counts (Aisien et al 2002), weight gain after 2 years of use (Sagay et al 2008 ) and
mild but reversible impairment of glucose metabolism (Sagay et al 2000).
The effect of Norplant® use on the bone quality of Nigerian women using quantitative
ultrasound measurements and serum markers of bone turnover (VanderJagt et al 2005)
We used calcaneal ultrasound to compare the bone quality of Nigerian women between 25
and 50 years of age who had Norplant implants for 1-4 years to that of women who were not
using any form of hormonal contraceptive. The mean stiffness index of women who had
Norplant implants for as long as 4 years was not significantly different from that of controls.
However, serum markers of bone turnover were significantly decreased in women with
Norplant implants compared to age-matched controls. Serum bone-specific alkaline
phosphatase was significantly decreased in subjects with Norplant implants for 1 year and
serum N-Telopeptidase was significantly decreased in subjects with implants for 3 years. We
conclude that although levonorgestrel contraceptive decreased overall bone turnover, it had
no deleterious effect on the bone quality of women using Norplant implants for up to 4 years.
(VanderJagt et al 2005).
Overall, Norplant® use in our women was not associated with any serious adverse effects.
Contraceptive implants have remained popular in our family planning clinics today.
3. How hazardous can pregnancy and childbirth be?
If a mother dies, the infant has little chance of survival
Maternal mortality: This is defined as the death of a woman while pregnant or within 42 days
of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any
cause related to or aggravated by the pregnancy or its management, but not from accidental or
incidental causes.
Worldwide, every minute a woman dies from pregnancy-related complications.
Maternal mortality ratio: The number of maternal deaths per 100,000 live births.
The maternal mortality ratio in Nigeria is 545 deaths per 100,000 live births. (NDHS 2010)
Maternal morbidity: Refers to serious disease, disability or physical damage such as fistula,
caused by pregnancy-related complications.
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For every woman who dies, 15 to 30 live but suffer chronic disabilities, the worst of
which is obstetric fistula.
The vast majority of women in Nigeria who desire to conceive will conceive within a year and
the pregnancies will develop normally and end with an uneventful vaginal delivery. However, a
number of factors conspire to endanger maternal lives in this country. Permit me to mention
these factors without much elaboration.
Risk factors for maternal mortality in Nigeria
1. Susceptible social context:
The social context that contributes to high mortality and morbidity includes a culture
that undervalues women; control of women by men; seclusion of wives that limits
access to medical care; female illiteracy; early marriage and pregnancy; high rates of
obstructed labor; directly harmful traditional medical beliefs and practices; inadequate
facilities to treat obstetric emergencies; a declining economy; and a corrupt, inefficient
political culture (Wall LL 1998), additionally, restrictive abortion laws and a
dysfunctional criminal justice system.
2. Non- booking for antenatal care.
3. Ineffective antenatal care.
4. Delivery without skilled attendant.
5. Delays in getting professional medical service.
a. Delay by patient in seeking medical care [Individual patient and community].
b. Delay in arriving at a medical facility [communication and transportation
system].
c. Delay in the provision of appropriate care at the medical facility [health
personnel and institutional].
Globally, each year there are at least half a million maternal deaths, 3.2 million stillborn
babies, 4 million neonatal deaths. The majority of these deaths are avoidable. A total of 11–
17% of maternal deaths occur during childbirth itself; 50–71% occur in the post-partum
period. The time spent in labour and giving birth, the critical moments when a joyful event
can suddenly turn into an unforeseen crisis, needs more attention, as does the often-neglected
post-partum period. These periods account not only for the high burden of post-partum
maternal deaths, but also for the associated large number of stillbirths and early newborn
deaths.
A total of 98% of stillbirths and newborn deaths occur in low- and middle-income countries:
obstetric complications, particularly in labour, are responsible for perhaps 58% of them. The
care that can reduce maternal deaths and improve women‘s health is also crucial for
newborns‘ survival and health.
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In developed countries, the advent of modern obstetric care in the late 1930s gradually moved
the process of childbirth from home to institutional settings, with post-partum follow-up and
care by a skilled health-care provider. In most developing countries including Nigeria, the
majority of women deliver at home without skilled health-care providers. The Nigerian
Demographic and Health Survey 2008 reported that in the North-central zone of Nigeria,
65% of pregnant women receive antenatal care while only 41% deliver in health facility
(NDHS 2010). In Plateau State, Nigeria in 2004, a total of 71,655 women attended at least
one antenatal visit but only 22,640 delivered in health facilities, indicating that over twothirds
of women who attend antenatal care still deliver at home. Little wonder that we
reported a maternal mortality ratio of 740 maternal deaths / 100,000 births (Ujah et.al 2005).
The challenges to be met are not new technologies or new knowledge about effective
interventions, because we mostly know what needs to be done to save the lives of mothers
and newborns. The real challenges are how to deliver services and scale up interventions,
particularly to those who are vulnerable, hard to reach, marginalized and excluded. Effective
health interventions exist for mothers and babies such as post-abortal care, emergency
obstetrics care, immunization, nutrition counselling and reproductive health services.
However, none will work if political will is absent where it matters most: at national, state
and local government levels.
A key constraint limiting progress is the gap between what is needed and what exists in terms
of skills and geographical availability of human resources at local, state and national levels.
The Midwifery service scheme which is being implemented by the federal government
through the national primary health care development agency (NPHCDA) is a commendable
step. The table below highlights the nursing personnel gaps in PHCs in all 17 local
government areas of Plateau State (Table 1).
Other challenges are how to address deteriorating infrastructures; how to maintain stocks of
drugs, supplies and equipment in the face of increased demand; lack of transport; ineffective
referral to and inadequate availability of 24-hour quality services – particularly emergency
obstetric care services – and weak management systems. We need to challenge our policymakers
and unit heads to refocus on the development of viable organizational strategies for
monitoring and evaluation that ensure a continuum of care and account for every birth and
death.
South Africa is one of the few developing countries with a national confidential inquiry into
maternal deaths. 164 health facilities obtain audit data for stillbirths and neonatal deaths, and
a new audit network does so for child deaths. Three separate reports have been published,
providing valuable information about avoidable causes of death for mothers, babies, and
children. The leaders of these three reports have united to prioritise actions to save the lives
of South Africa's mothers, babies, and children (Bradshaw et al 2008).
Nigeria should establish a national confidential inquiry into maternal deaths and mandatorily
obtain audit data for stillbirth, neonatal and child deaths. Although Edo and Ondo States have
already promulgated the enabling laws, I advocate a national buy in and leadership at the
national level.
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Table 1: Nursing personnel gaps in PHCs in Plateau State (2009)
As we plan to obtain these relevant data, clear framework and procedures for data use to
improve national vital health statistics should be developed. Audit is powerful, but only if the
data lead to action.
Nigeria‘s most recent maternal mortality ratio of 545deaths/100,000 live births gives the
impression that things have substantially improved.
Before we leave with such impression, let me outline the findings of two recent study by
Mairiga and Saleh (2009) and Kullima et al (2009) that reported maternal mortality in
Bauchi Specialist Hospital, Bauchi, Bauchi State and Federal Medical Centre, Nguru, Yobe
State.
Bauchi, Bauchi State:
Maternal Mortality Ratio (MMR) for the period under review was 1,732 per 100, 000 live
births. Six hundred and twenty one (621) of the deaths (81.0%) occurred in 12,067 unbooked
deliveries giving a maternal mortality ratio of 5,146 per 100,000 for unbooked mothers (11fold
increase in maternal mortality over booked mothers). The annual MMR was highest for
the year 2006 (2,586 per 100,000).
Nguru, Yobe State:
At Federal Medical Centre, Nguru, a total of 112 maternal deaths were recorded in 3,931
deliveries giving a MMR of 2849/100,000 deliveries in the 5-year period studied. The highest
MMR of 6234/100,000 was observed in 2003, with remarkable decline to 1837/100,000 in
2007. Eclampsia was the leading cause, accounting for 46.4% of the maternal deaths,
followed by sepsis and postpartum haemorrhage (PPH) contributing 17% and 14.3%,
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espectively. Lack of antenatal care (Unbooked status) and illiteracy were the significant
determinants of maternal mortality.
When we compare these maternal mortality figures with 3/100,000 deliveries in Sweden,
4/100,000 deliveries in Spain, 5/100,000 deliveries in Switzerland and 8/100,000 deliveries in
the United Kingdom (WHO 2005), they become terribly disturbing. These staggering
maternal mortality figures are a reflection of the premium placed on the lives of women in
this country. These women do not die of diseases that can’t be treated or complications that
can’t be prevented. To quote Mahmoud Fathalla, former president of the International
Federation of Obstetricians and Gynecologists, “they die because societies have yet to determine
that their lives are worth saving”. Sadly, if a woman does not survive, her child has little
chance of survival.
Vesico-Vaginal Fistula (VVF)
For every woman who dies at childbirth, 15 to 30 live but suffer chronic disabilities, the
worst of which is obstetric fistula. Each year some 50,000-100,000 women sustain an
obstetric fistula in the act of trying to bring forth new life. Fistula is a preventable and
treatable condition, one that no woman should have to endure. Yet more than two million
women remain untreated in developing countries.
Obstetric fistula is the most devastating of all pregnancy-related disabilities. It usually occurs
when a young, poor woman has an obstructed labour and cannot get a Caesarean section
when needed. The obstruction can occur because the woman‘s pelvis is too small, the baby‘s
head is too big, or the baby is badly positioned. The woman can be in labour for three days or
more without medical help. The baby usually dies. If the mother survives, she is left with
extensive tissue damage to her birth canal that renders her incontinent.
The results are life shattering. The woman is unable to stay dry and the smell of urine or
faeces is constant and humiliating. Nerve damage to her legs can also make it difficult to
walk. Rather than being comforted for the loss of her child, she is often rejected by her
husband, shunned by her community and blamed for her condition. Women who remain
untreated not only face a life of shame and isolation, but may also face a slow, premature
death from infection and kidney failure. While some women receive support from their
families, others are forced to beg or turn to sex work for a living.
During obstructed labour, the prolonged pressure of the baby‘s head against the mother‘s
bony pelvis cuts off the blood supply to the soft tissues of her vagina, bladder and rectum that
are trapped between the harder (bony) structures. The injured soft tissue soon rots away,
leaving a hole, or fistula. If the hole is between the woman‘s vagina and bladder, she loses
control over her urination, and if it is between her vagina and rectum, she loses control of her
bowels. Reconstructive surgery can mend this injury, but most women are either unaware that
treatment is available or cannot access or afford it. Fistula surgical repair has up to 90 per
cent success rates and costs between N20, 000 to N60, 000. In supported VVF repair and
rehabilitation centres, most services are provided free of charge. ECWA Evangel Hospital is
one such centre in Jos, Nigeria.
In the words of DR. ANDREW ARKUTU ―An obstetric fistula is more than a hole. For those
afflicted, it is a comprehensive social and psychological disaster, resulting from a dramatic
failure in obstetric care.‖
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The tragedy of an obstetric fistula is that it touches a young girl at the very essence of her
being - her childbearing capabilities. It touches her when she is too young to understand what
has happened. . . If not operated on or helped, recurrent urinary tract infections can lead to
kidney problems and eventual renal failure and death. So, though the girl with obstetric
fistula is a survivor of maternal mortality statistics in the first light, is she really, if she dies
later, unwanted, humiliated and lonely in some remote village hut?
Clinical Audit of Primary Health Centres in Jos, Nigeria
In 1978 at Alma Ata, the United Nations adopted primary health care, as a global strategy for
promoting health for all by the year 2000, a policy that was adopted by Nigeria in 1988. The
emphasis was on preventive rather than curative medicine. The federal ministry of health
through the states and local governments established Primary Health Centres (PHCs) in all
local government areas in this country. One of the aims was to improve access to affordable
antenatal care for pregnant women in order to achieve a substantial reduction in maternal and
perinatal deaths. Despite these efforts by government, maternal and perinatal death rates did
not decline. Pregnant women are frequently referred late from PHCs to tertiary institutions,
resulting in adverse obstetric outcomes (Kuti et al 2001). The high proportion of avoidable
maternal deaths in the maternity unit of JUTH resulting from late referrals from PHCs around
Jos prompted us to conduct a clinical audit of these centres (Sagay et al 2005).
The study evaluated the quality of antenatal care services in 12 randomly selected PHCs in
the Jos/Bukuru metropolis. The findings indicated that:
High risk obstetric cases (previous caesarean section, hypertension, and previous post
partum haemorrhage) were being booked and seen at the PHCs.
Over two-thirds of pregnant women receiving antenatal care at PHCs did not have
blood pressure surveillance through pregnancy.
Routine malaria prophylaxis during pregnancy was not given in any of the PHCs.
About two-thirds of pregnant women receiving antenatal care did not have any
documented attempt to ascertain the gestational age.
No pregnant woman was screened for sickle cell disease (sickling test or genotype).
The principal examination that almost all patients had was weighing which has been
shown to have little impact on obstetric outcome.
Undoubtedly, we considered antenatal care provided at the PHCs in the Jos area substandard
and capable of putting the health of pregnant women at unacceptable risk. We made the
following recommendations:
1. A periodic exchange of staff between primary, secondary and tertiary health
institutions should be encouraged as a way of improving the knowledge base and
skills of healthcare providers in these facilities.
2. Healthcare workers in PHCs should be encouraged to attend periodic update courses.
3. Regular internal and periodic external audit of the clinical activities at PHCs should
be considered.
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4. Posters of high-risk obstetric factors requiring referral should be placed in strategic
areas in the consulting rooms at PHCs to serve as reminders for the healthcare
workers.
5. Basic infrastructure in PHCs should be provided and maintained.
6. Each local government area should consider appointing a supervising consultant
obstetrician to maintain the standard of services in its PHCs.
PHCs in Jos are better staffed in comparison to PHCs in more rural communities in the State
(see Table 1). The poor antenatal services observed in PHCs around Jos are therefore likely to
be a more generalized problem. Sub-standard care in this situation does not only put pregnant
women‘s lives at risk but it represents a missed opportunity to impact positively on the poor
maternal and perinatal health statistics in the area.
4. Are there any concerns about survival of the newborn?
The global burden of newborn illness shows that a disparity of up to 30-folds exists between
countries with highest and lowest newborn death statistics. Four million babies die in
developing countries annually and about 42% of these deaths are due to infections. Other
major causes include perinatal asphyxia (21%), birth injuries (11%), prematurity and low
birth weight (10%) and congenital abnormalities (11%). It was also observed that two-thirds
of the deaths in the neonatal period occur in the first week; among these deaths, two-thirds
occurred within the first 24 hours.
skilled care at facility levels such as emergency obstetric care services are
recommended for saving maternal and newborn lives (Bhutta et al 2008).
scale-up of community and household care are necessary for improving
newborn and child survival
Programmes that are necessary for the reduction in neonatal morbidity and mortality rates are
for countries to employ rational mix of quality clinical services, effective public health
measures and inexpensive community-based interventions in public and private sectors and to
scale-up known cost-effective interventions such as the mother-baby packages. (Sule and
Onayade 2006). Strengthening Maternal Newborn and Child Health services at the primary
health-care level should be a priority for countries to reach their Millennium Development
Goal targets for reducing maternal and child mortality.
5. Are there emerging challenges to motherhood in the HIV era?
Trend of HIV prevalence in women in Plateau State
Our study of the HIV epidemic in pregnant women in Nigeria started in 1999 when we
reported the yearly trend of HIV sero-prevalence among pregnant women in Jos over a 10year
period (1989 – 1998). A total of 11,059 pregnant women were screened and 134 (1.24%)
were HIV positive. The yearly trend showed a rise in HIV sero-prevalence from 0.25% (1 in
394) in 1989 to 3.69% (1 in 27) in 1997(Sagay et al 1999). The trend of yearly HIV
prevalence among pregnant women from 1989 to 2001 is shown in Figure 1.
12

Figure 1: Diagram shows rising trend of HIV infection in pregnant women in Jos, Nigeria
% HIV Positive
6
5
4
3
2
1
0
0.25
Yearly HIV Seroprevalence Among Pregnant
Women in Jos, Nigeria 1989-2001
0.38 0.4
0.71
1.71
2.21
Year
We believed that the 16-fold rise in prevalence of HIV infection among pregnant women in
Jos over a 10-year period was a reflection of the trend in the general population. In the
absence of interventions, 30% to 40% of HIV- exposed infants will become HIV infected
through mother-to-child transmission. The implications of this rising prevalence of HIV in
pregnant women and what it portends for child survival in the absence of interventions to
prevent mother-to-child transmission (PMTCT) provided the impetus for our further studies
to identify local risk factors and possible intervention strategies.
Documentation of higher prevalence of cervical abnormalities in Jos
Another challenge that we documented was the higher prevalence of cervical abnormalities
which could not be directly attributed to the increasing HIV epidemic. Cancer of the cervix is
essentially a sexually transmitted disease and it occurs more commonly among women who
have delivered many children. Cervical pre-cancer lesions are more common among HIV
infected women when compared with HIV negative controls (40% versus 17%) (Massad et al
1999) and it correlates with lower CD4+ cell counts (Schafer et al 1991). We reported the
doubling (7.7% in 1990 vs 14.6% in 2002) in prevalence of CIN in Jos over a decade of
expanding HIV epidemic (Sagay et al 2008.) Recently, we also reported a much higher rate
of CIN (24.6%) among female sex workers in Jos (Sagay et al 2009). These findings
highlight anticipated challenges with cervical cancer in the near future if prevention,
screening and treatment interventions are not implemented. With the advent of human
papilloma virus vaccine, the prospect of achieving wide spread primary prevention cannot be
brighter. The quadrivalent human papillomavirus (HPV) vaccine, marketed under the name
Gardasil®, is a recombinant vaccine that is effective against HPV types 6, 11, 16, and 18.
The vaccine received approval for the prevention of cervical, vulvar, and vaginal
intraepithelial lesions and genital warts associated with the vaccine HPV types. The vaccine
is administered to girls aged 9-26 years in 3 doses over a 6-month period. The complete cost
per client is about 400USD or N60, 000.
13
3.21
3.28
3.69
3.92
4.13
4.56
4.82

Risk factors for HIV infection in pregnant women in Jos
As part the national program for prevention of mother-to-child transmission (PMTCT) of
HIV, the AIDS Prevention Initiative in Nigeria (APIN) developed HIV voluntary counselling
and testing services at JUTH antenatal clinic in October 2001. Between April 2002 and
November 2003, we conducted a study to determine the risk factors for HIV and other
sexually transmitted infections (STIs) among pregnant women participating in the PMTCT
programme at JUTH. During this period, antiretroviral (ARV) intervention for PMTCT using
single-dose Nevirapine was introduced. This study documented risk factors of HIV infection
in pregnant women which are outlined below in tables 2a, 2b, 2c and 2d.
HIV Risk Factors in Pregnant Women in Nigeria:
a. Age, religion and alcohol
Among pregnant women in Jos, Nigeria, HIV prevalence was lowest in teenagers and the
over 40s. Women aged 20 to 29 years had a 4-fold higher prevalence of HIV infection.
Compared to women who reported to be Moslems, women of all Christian denominations had
significantly increased risk of HIV. This was more so among Pentecostals and Catholics.
Women who admitted to taking alcohol had significantly increased risk of HIV.
Table 2a: The associations between age, religion and alcohol use and HIV-1 infection
among pregnant women in Jos, Nigeria (Sagay, Kapiga, Imade, et al 2005)
Predictor
Age (years completed)
40
Don’t know
Religion
Moslem
Catholic
Pentecostal
Protestant
Traditional/other
Missing
Do you drink alcohol?
No
Yes
Missing
N (%) % HIV
positive
182 (6.8)
618 (23.3)
887 (33.4)
607 (22.8)
276 (10.4)
54 (2.0)
33 (1.2)
802 (30.2)
477 (18.0)
383 (14.4)
953 (35.9)
15 (0.6)
27 (1.0)
24 (93.8)
125 (4.7)
41 (1.5)
b. Marital Status and Husband’s Occupation
14
2.2
8.3
10.9
7.7
5.4
1.9
6.1
5.1
9.6
10.2
9.3
0.0
0.9
7.9
13.6
4.9
Crude OR (95% CI) a Adjusted OR (95%
CI) b
1.00
4.00 (1.43-11.22)
5.46 (1.98-15.03)
3.73 (1.33-10.50)
2.56 (0.83-7.82)
0.84 (0.09-7.67)
2.87 (0.50-16.34)
1.00
1.98 (1.28-3.07)
2.10 (1.33-3.32)
1.91 (1.30-2.80)
-
1.48 (0.34-6.48)
1.00
1.83 (1.07-3.10)
0.59 (0.14-2.48)
1.00
4.57 (1.3-15.46)
4.44 (1.32-14.88)
3.00 (0.86-10.40)
1.69 (0.44-6.43)
0.47 (0.04-5.38)
1.05 (0.01-11.39)
1.00
1.72 (1.01-2.95)
2.57 (1.46-4.52)
1.50 (0.93-2.44)
-
-
Women who were married only once had a low risk of HIV. In comparison, the risk of
HIV was increased among women who reported multiple marriages and in unmarried
women. The risk of HIV was also increased among women whose husbands were

ankers or accountants.
Table 2b. The associations between marital status and husband’s occupation, and HIV-1
infection among pregnant women in Jos, Nigeria (Sagay, Kapiga, Imade, et al 2005)
Predictor
Marital status
Married only once
Married more than once
Not married (single/div/sep)
Missing
Occupation of husband/partner
Civil servant
Banker/accountant
Business
Drivers (truck, taxi, motorcycle)
Other
Missing
Not married
N (%) % HIV
positive
2429 (91.4)
161 (6.1)
39 (1.5)
28 (1.1)
830 (31.2)
72 (2.7)
858 (32.3)
181 (6.8)
557 (21.0)
120 (4.5)
39 (1.5)
15
7.4
16.1
23.1
7.1
8.6
20.8
6.9
5.5
7.4
10.0
23.1
Crude OR (95%
CI) a
1.00
2.41 (1.54-3.76)
3.75 (1.75-8.02)
0.96 (0.23-4.08)
1.00
2.81 (1.51-5.22)
0.79 (0.55-1.13)
0.63 (0.32-1.24)
0.85 (0.57-1.27)
1.19 (0.62-2.26)
3.21 (1.46-7.02)
c. Circumcision, No. Of Sex Partners, Sex Network and Perceived Risk of HIV
Adjusted OR (95%
CI) b
1.00
3.06 (1.74-5.39)
2.08 (0.67-6.47)
_
1.00
2.88 (1.28-6.45)
1.10 (0.71-1.70)
0.87 (0.40-191)
0.97 (0.60-1.57)
_
_
Women who reported to be circumcised (13.3%) had relatively reduced risk of HIV
(OR=0.59, 95% CI=0.36-0.96). Women’s level of education and occupation were not
associated with HIV. The risk of HIV increased with increasing number of sex partners
in the past 5 years. Women who were aware that their last male partner had other sex
partners were at increased risk of HIV. About 51% of women knew someone who was
living with HIV or died from AIDS, while 17.6% had a close relative who was living with
HIV or died from AIDS. These women had increased risk of HIV. Compared to women
who perceived themselves to be at no risk of HIV, the risk of HIV was significantly
increased in all other women. Women who had abnormal vaginal discharge in the last
12 months were also at increased risk of HIV infection.

Table 2c. The associations between selected potential risk factors and HIV-1 infection
among pregnant women in Jos, Plateau State, Nigeria. (Sagay, Kapiga, Imade, et al 2005)
Predictor
Number of sex partners in the last 5 years
1
2
>3
Missing
p-value, test for linear trend
Last male partner has other partners?
No
Yes
Don’t know
What are your chances of contracting
HIV/AIDS?
No risk at all
Minimal/small risk
Moderate risk
Great risk
Don’t know
p-value, test for linear trend
Had abnormal genital discharge during the
last 12 months
No
Yes
Don’t know
N (%) % HIV
positive
2003 (75.4)
349 (13.1)
128 (4.8)
177 (6.7)
1680 (63.2)
162 (6.1)
815 (30.7)
1607 (61.7)
388 (14.9)
68 (2.6)
25 (0.9)
518 (19.9)
8866 (70.2)
661 (24.9)
130 (4.9)
16
5.7
13.2
19.5
17.5
5.8
22.8
10.2
4.1
7.2
17.6
20.0
11.0
6.3
14.1
5.4
d. Sexually Transmitted Infections (STIs) and HIV Risk
Crude OR (95% CI) a Adjusted OR
(95% CI) b
1.00
2.49 (1.73-3.85)
3.98 (2.48-6.41)
3.49 (2.27-5.36)
0.001
1.00
4.83 (3.17-7.35)
1.85 (1.36-2.51)
1.00
1.82 (1.15-2.87)
5.00(2.56-9.78)
5.84 (2.12-16.03)
2.89 (1.99-4.18)

Table 2d. The associations between selected potential risk factors and HIV-1 infection
among pregnant women in Jos, Plateau State, Nigeria. (Sagay, Kapiga, Imade, et al 2005)
Predictor
Had genital ulcer during the last 12
months or at the time of exam.
No
Yes
Don’t know or not examined
Candida albicans
Negative
Positive
Samples not provided
Trichomonas vaginalis
Negative
Positive
Samples not provided
Active (recent) syphilis
Negative
Positive
Samples not provided
Disturbance of vaginal flora
Normal flora
Mild disturbances
Moderate disturbances
Severe disturbances (Bacterial Vaginosis)
Samples not provided
N (%) % HIV
positive
2422 (91.2)
132 (5.0)
103 (3.9)
2226 (83.8)
391 (14.7)
40 (1.5)
575 (96.9)
41 (1.5)
41 (1.5)
627 (98.8)
7 (0.3)
23 (0.9)
185 (7.0)
1677 (63.2)
288 (10.8)
466 (17.5)
41 (1.5)
17
7.0
28.8
9.7
7.3
13.0
10.0
8.0
14.6
12.2
8.0
42.9
17.4
7.6
6.5
10.4
12.7
12.2
Prevention of Mother-to-Child Transmission of HIV
Crude OR (95%
CI) a
1.00
5.39 (3.58-8.10)
1.43 (0.73-2.80)
1.00
1.91 (1.37-2.67)
1.41(0.5-4.03)
1.00
1.97 (0.82-4.74)
1.60 (0.62-4.11)
1.00
8.63 (1.92-38.82)
2.42 (0.82-7.19
1.00
0.85 (0.48-1.51)
1.42 (0.73-2.76)
1.77 (0.96-3.26)
1.70 (0.57-5.01)
Adjusted OR (95%
CI) b
1.00
3.35 (2.00-5.61)
-
1.00
2.23 (1.49-3.36)
-
1.00
16.88 (2.88-98.76)
-
1.00
1.68 (0.78-3.62)
2.40 (1.03-5.60)
2.77 (1.25-6.13)
-
Mother-to-child transmission (MTCT) of HIV is the most significant source of HIV infection in
children below the age of 10 years. To prevent mother to child transmission of HIV, World
Health Organization recommends a four-pronged strategy. This includes: (i) the primary
prevention of HIV infection among parents to be; (ii) the prevention of unwanted pregnancies
(including safe abortion where permitted by law) in HIV-infected women; and (iii) the
prevention of HIV transmission from infected women to their infants and (iv) the treatment,
care and support of infected and affected women, their infants and young children, partners and
families.
Nigeria national response
The expanding HIV epidemic nationally prompted the establishment of a national prevention of
mother-to-child transmission (PMTCT) of HIV program in 2001. The program started with a
formative research in 2001 while counselling, testing and the administration of single-dose
Nevirapine intervention regimen commenced in 8 tertiary health facilities in July 2002. With
funding support from Center for Disease Control (CDC), Atlanta, USA in2003, interventions
started in 3 additional tertiary facilities, bring the total to 11 sites. Evaluation of the program in
2004 showed a national coverage of about 1% of eligible pregnant women and this poor

coverage was the impetus for scaling up efforts. The national PMTCT Program expansion efforts
enjoyed substantial donor support, and services have currently reached about 650 sites.
Expansion of PMTCT services in Plateau State
With support from APIN, we embarked on the expansion of PMTCT services in Plateau State in
2004. This project was my sabbatical leave assignment with APIN. We adopted a stepwise
approach as outlined below:
Mapping of maternity care services in Plateau State.
Selection of phase 1 implementation sites based on; HIV prevalence in facility, volume of
ANC clientele and geography.
Engagement of institutional leadership through advocacy to promote buy-in., Facility
assessment, Renovation, Personnel capacity building (trainings), provision of necessary
equipment and commencement of PMTCT services using national guidelines and
registers.
Figure 2: New Antenatal Care Bookings by LGAs in 2004
18

Figure 3: Health Facility Deliveries by LGAs in 2004
Figure 4: Health Facility HIV prevalence rates in Plateau State by LGAs in 2004
19

Figure 5: Level of PMTCT Services by LGAs in Plateau State 2004
In 2006, this drive snowballed to HIV/AIDS comprehensive treatment and care program
through additional funding from Harvard PEPFAR. Services were decentralization to all the 17
local government areas of Plateau State. Service provision in the following areas were
supported: Adult antiretroviral therapy, PMTCT, Paediatric antiretroviral therapy, Infant
feeding and nutrition counseling, Family planning, Cervical cancer screening, Malaria
prophylaxis interventions, Tuberculosis screening and Orphans and vulnerable children (OVC)
support. The diagram below shows the activity pyramid of the program.
47
Activity Pyramid
14
1
20
APIN
JUTH
SATELLITES
SITES
PRIMARY HEALTH
CARE FACILITIES
COMMUNITY
Figure 6: Activity Pyramid of PMTCT Decentralization in Plateau State, Nigeria

Figure 7: Hub and Spoke Illustration of PMTCT Sites in Plateau State, Nigeria
The mapping exercise reported that in 2004, 71,655 pregnant women booked for antenatal care
and 22,640 women delivered in the 193 health facilities providing maternity services in the 17
LGAs of Plateau State. In 2004, only 5,500 pregnant women in 2 LGAs accessed PMTCT services,
giving PMTCT coverage of 6.5%. Subsequent PMTCT expansion efforts supported principally by
APIN and also by other partners, led to the availability of PMTCT services in all 17 LGAs by
2007. In 2008, 42,120 pregnant women accessed PMTCT interventions across Plateau State
giving coverage of 47.5% according to 2006 population census. From conservative estimates
based on these figures, about 300 infant HIV infections were averted in Plateau State in 2008
alone.
About 300 infant HIV infections are averted each year in Plateau State
through PMTCT interventions
HIV testing and counseling in labour as entry point for PMTCT
The highest risk of mother-to-child transmission (MTCT) of HIV-1 infection occurs during
labour and delivery. Findings from clinical trials show that antiretroviral (ARV) prophylaxis,
given to the mother during labour and delivery and to the neonate immediately after birth, can
reduce MTCT of HIV by as much as 50% (Moodley D et al 2003).
Thus, provision of routine HIV testing to women with unknown HIV status during labour and
delivery can contribute in reducing MTCT. We demonstrated the feasibility of providing rapid
HIV testing and counselling, using the “opt out” approach, in the labour ward of JUTH (Sagay et
al 2006). Among 164 women with unknown HIV status before labour, 14 (8.6%) were detected
to be HIV positive in labour. In all, a total of 340 (99.8%) of the 431 pregnant women who were
offered HIV testing in labour accepted testing. Of the 235 women who previously tested HIV
negative during pregnancy, 5 (2.1%) were found to be HIV positive in labour (see Table 3). The
practice of rapid HIV testing and counselling in labour provides a final opportunity to detect
21

pregnant women with HIV infection, who may require interventions to prevent MTCT. This was
the first study to demonstrate the feasibility of this practice in labour ward settings in Nigeria.
Table 3: HIV status prior to labour and HIV status after testing in labour (Sagay et al 2006).
HIV Status prior to Labour Tested HIV Neg in
Labour
22
Tested HIV Pos in
Labour
Negative 230 5 (2.1%) 235
Positive 1 27 28
Unknown 150 16 (9.6%) 166
Indeterminate 0 1 1
Total
381 (88.6%) 49 (11.4%) 430
HIV Sero-discordance among couples in PMTCT settings in Nigeria
In 2005, we conducted this study to determine the pattern of HIV sero-status of Partners of
HIV Positive Pregnant Women in three different regions of Nigeria and to explore the
implications for HIV prevention interventions. The study was conducted in Benin City, Jos
and Kano after consideration of their ethnic, religious and cultural representation of Nigeria.
The city-by-city results showed that in Benin City (Southern Nigeria), 78.8% (104/132) of
the partners were HIV negative (sero-discordant), Jos (Middle-Belt) had 48.4% (103/213)
sero-discordance while Kano (Northern Nigeria) recorded a sero-discordance rate of only
7.7% (12/155) (see Figure 8).
Figure 8: Prevalence of HIV Sero-discordant Couples with
Positive Female Partners in Nigeria
Oyo
Ogun
Lagos
Kebbi
Osun
Kwara
Sagay AS, et al AJMMS 2006
Sokoto
Ekiti
Ondo
Niger
Edo
Delta
Zamfara
Kogi
78.8%
FCT
Anam
bra
Imo
Bayelsa Rivers
Katsina
Kaduna
Abia
Akwa
Ibom
Kano
Nasarawa
Ebonyi
7.7%
Benue
Cross
River
Jigawa
Bauchi
Plateau
48.8%
Taraba
Gombe
Yobe
Adamawa
Borno

The study documented a high prevalence of prevalence of HIV sero-discordance in marital
settings in Benin and Jos and substantiated the observation that unlike most sexually
transmitted diseases (STDs), HIV is not very infectious in heterosexual relationships, unless
the transmission is assisted in some way. The chance in one sexual act of transmission
between partners who are disease-free except that one is HIV-positive may be as low as one
in 1000 from woman to man and one in 300 from man to woman (Caldwell et al. 1995).
These are not levels of infection which give rise to epidemics, and this is the reason why most
societies with STD control programs are not at risk of a heterosexual epidemic. In the United
States only 7% of transmission is heterosexual, as is 10% in Europe (Way et al. 1994).
These results also indicate that the dynamics of HIV transmission in marital settings in
Nigeria are different in the various regions of the country. We concluded as follows, that:
HIV sero-discordance rates in marital settings in Southern Nigeria are among the
highest globally
Studies to unravel the high rate of HIV sero-discordance in Benin-City may yield
dividends in the prevention of heterosexual transmission in Nigeria. This may not be
unconnected to the almost 100% male circumcision in childhood and easy access to
medical treatment of sexually transmitted infections.
In cultures where women are emancipated (Benin), the general direction of
heterosexual transmission of HIV in marital settings is from women to men while the
reverse situation occurs in cultures that are restrictive on women (Kano).
Primary HIV prevention strategies in predominantly Christian communities where
women are emancipated should target young women while Moslem communities
must target the males
Disclosure of HIV sero-status in PMTCT settings in Nigeria
Partner consent and support can substantially enhance adherence to PMTCT interventions. This
is particularly true of the Nigerian setting where significant others such as mother-in-laws have
a big role in determining postnatal interventions. In this study, we explored the issues
concerning disclosure of HIV status to partners of HIV sero-positive mothers in our PMTCT
programme in Jos, Nigeria.
A total of 570 HIV positive mothers in the PMTCT clinic were studied. Eighty nine percent
(500/560) of the women have disclosed their HIV status to their partners. Of these, about
40% (199/502) required the assistance of health workers while 60% (298/502) did it by
themselves. Following disclosure of HIV status, 86.9% (430/495) of the partners were
supportive, 5.7% were indifferent, 6.7% were quarrelsome and abusive while 1.0% were
violent. Seventy four percent (419/563) of the mothers were aware of their husband‘s HIV
sero-status. Of these, 65.4 %( 274/419) of the partners were HIV positive while 34.6% were
sero-negative.
Based on these findings, we concluded that the reactions of partners of HIV positive mothers
to disclosure of their wives‘ HIV status are predominantly supportive and felt that this should
strengthen strategies to promote partner disclosure (Sagay et al. 2006).
23

Outcome of PMTCT interventions in Nigeria
We have analysed the mother-to-child transmission (MTCT) rates following various
interventions at JUTH and these are shown in green bars in figure 9 above. The transmission
rates at 6 weeks of age are compared with MTCT rates in Botswana, a country that can boast of
some of the best PMTCT programs in Africa.
15%
10%
5%
0%
Figure 9: ARV Interventions and
MTCT [Nigeria vs. Botswana]
BOTSWANA
JOS, NIGERIA
0.7%
0.9%
2.3%
3.3%
2.9%
Pre-preg During 4wks
HAART AZT+sdNVP
4.7%
24
7.0%
5.2%
sdNVP
alone
12.3%
12.6%
No ART
Clearly, outcomes in our programme are comparable indicating that our interventions are
working like elsewhere in the world.
Infant feeding and MTCT between 6wks and 6months
One of the strategies to reduce postnatal mother to child transmission (MTCT) of HIV is the use
of replacement feeding (BMS) which is expected to eliminate transmission through breast milk.
To achieve this goal, BMS must be practiced in a setting where it is culturally acceptable,
feasible, affordable, sustainable and safe (AFASS), otherwise, there is increased risk of infant
morbidity and mortality.
The vast majority of our HIV infected mothers are provided with infant formula (BMS) to
prevent HIV transmission to their babies. Our recent unpublished study compared the risk of
postnatal transmission of HIV at 6 months among infants who are HIV negative at 6 weeks of
age and were exclusively breast fed or given exclusive replacement feeding in the PMTCT
program at JUTH, Jos, Nigeria. The difference in transmission risk between the two feeding
methods was not statistically significant (1.8% vs 2.2%; P value =0.785). This finding showed
that many mothers in the BMS group were practicing mixed feeding. New guidelines endorse
administration of antiretroviral drugs to make breast feeding safer. It is hoped that this strategy
will improve child survival without increasing HIV transmission to the infant.

Evidence of declining prevalence
The last three HIV sero-sentinel surveys have consistently showed a declining trend in HIV
prevalence among pregnant women. HIV prevalence in Plateau State has declined from 8.5%
in 2001 to 2.6% in 2008 (see Figure 10). The reasons are not unconnected with the State-wide
interventions by all stakeholders. I am proud to continue to be part of these efforts.
Prevalence (%)
Figure 10: HIV Prevalence trend in States that showed a
defined consistent pattern 2001 - 2008
8.5
8.2
6.8
3.5
3.2
3.3
Key points and Conclusions
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
6.8
6.3
4.8
3.7
3.3
2.0
2001 2003 2005 2008
Year
25
4.9
Plateau Bauchi Ekiti Gombe Zamfara Abia
Infertile women in Nigerian face tremendous socio-cultural challenges and perhaps as
a consequence, have a high prevalence of psychological problems. Government
support for assisted reproductive technologies, as obtainable in developed countries
like the United Kingdom, may mitigate the impact of this widely prevalent malady.
There is no experience more difficult than having to go through a miscarriage time
and time again. Miscarriage is not only physically taxing, but very emotionally
challenging, as well. A small proportion of couples in Nigeria experience recurrent
pregnancy losses (when a woman loses three or more consecutive pregnancies). The
management of this condition remains a challenge for gynaecologists.
Each year, thousands of Nigerian women have unintended pregnancies that end in
illegal abortion. Many of such procedures occur under unsafe conditions, contributing
to maternal morbidity and mortality. Substantial investment in culturally appropriate
family planning messaging and making contraception services available, affordable
and accessible to all women (including youths) as a component of safe motherhood
programs is required.
4.0
3.4
3.0
1.6
5.0
4.0
3.1
2.6
2.1
1.0

References
Too many mothers and newborns are dying in Nigeria. We know what needs to be done
to save these lives. The real challenges are how to deliver services and scale up interventions,
particularly to those who are vulnerable, hard to reach, marginalized and
excluded. Innovative, non-governmental ways of reactivating, supervising and
monitoring services in primary healthcare centres across Nigeria should be a top
priority.
The HIV epidemic is an emerging threat to maternal and newborn lives. Existing
prevention and treatment interventions are efficacious but must be scaled up to
achieve the desired impact.
In Nigeria, the HIV epidemic is driven by heterosexual transmission. In heterosexual
settings, HIV does not stand alone. It requires the support of other STDs to stand. This
is why most societies with STD control programs are not at risk of a heterosexual
HIV epidemic. In addition to existing HIV interventions, resuscitation of STD control
programs nationally is required to control the present HIV scourge.
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