Insights from a yearlong investigation into Nigeria’s maternal health crisis shows the need for community-driven solutions that empower women and show accountability.
Prolonged obstructed labour is what killed Amina, Majin and Nwakego. For Ebiladei, it was excessive bleeding after delivery. Obiageli died after suffering seizures brought on by eclampsia, another serious yet treatable childbirth-related complication. All of these women’s deaths were preventable.
These women’s stories are just a few of the many dozens that were recorded as part of a yearlong investigation into why women are dying while giving birth in Nigeria. What happened to these women and why is now part of the narrative propelling the national movement to solve Nigeria’s maternal health crisis.
According to UNFPA, in 2017,67 thousand women died from pregnancy or childbirth-related causes in Nigeria, the highest number of maternal deaths compared to any other country in the world, and about a quarter of the global total. One of the biggest issues is that barely 40 percent of all women in Nigeria give birth in health facilities with the assistance of a skilled birth attendant, a factor that significantly decreases their risks of a poor outcome. The ongoing COVID-19 pandemic has exacerbated the weaknesses and challenges within the healthcare system, resulting in more poor maternal health outcomes.
Like many other countries in Africa, Nigeria’s healthcare system faces significant challenges: quality of service delivery, poor attitudes of healthcare staff toward their patients, lack of expertise, inadequate equipment, shortages in essential medicines and an unstable supply of power and clean water. All of these issues will have to be addressed to improve maternal health care. But there is a confluence of other factors — cultural, societal, and financial — that must also be considered and addressed, forces within communities that discourage or even preclude women from seeking, reaching and receiving the care they need when they are at their most vulnerable.
The consortium in this effort, Africare, EpiAFRIC and Nigeria Health Watch, conducted the maternal death review from May 2019 through May 2020 with funding support from MSD for Mothers, dispatching teams to communities, rural and urban, across six states, each representing a geopolitical zone (Bauchi in the North East, Bayelsa in the South South, Ebonyi in the South East, Kebbi in the North West, Lagos in the Southwest and Niger in North Central). The teams interviewed women, men, youth, traditional and religious leaders, health workers and others. According to the team, they documented 133 maternal deaths in 18 communities, 133 tragedies that had previously gone unrecorded and unexamined.
From these accounts and their related research, the teams draw a number of useful insights and recommendations, detailed in a new report. What this report makes clear is that there are ample opportunities for collaboration by decision makers at every level; a reminder that we are all stakeholders in the fight to help mothers survive and thrive and that we all have a role to play in helping to end preventable maternal deaths in Nigeria.
In particular, the report highlights the need to:
Take a bottom-up approach: Though the leading direct causes of maternal deaths are essentially the same across all localities and regions of the country, there are different underlying causes and factors that affect women’s health-seeking behaviors and contribute to their health outcomes, the teams found. A woman from Bayelsa State, for example, faces the challenge of navigating through the high tides surrounding her riverine village just to access maternal care and so is more likely to turn to a local “massager” for care instead, someone who is not trained in managing obstetric emergencies.
Due to prevailing cultural and religious attitudes, a woman in Ebonyi State is more likely to entrust her delivery to an unskilled birth attendant than to go to the nearby primary healthcare center to “prove her worth” as a “Hebrew woman”. In Niger and Kebbi States, functioning health facilities are few and far between and not easily accessible, giving most women little choice but to give birth at home. For those that do have access to a health facility, in some northern states their husbands are resistant to them receiving care from a male healthcare worker.
Overcoming these barriers will take community-based approaches, developed and implemented with buy-in from religious, traditional and other community leaders
Enlist the help of traditional birth attendants (TBAs) in effecting positive change: Many women in Nigeria turn to TBAs, traditional healers, herbalists and “massagers” for support and services during pregnancy and childbirth; any community effort to shift toward safer birth practices must include them. In some states, TBAs are already being trained to recognise danger signs of maternal complications, so they can refer women to health facilities for appropriate care at the first sign of a complication. The national government can help by establishing guidelines for TBAs and other unskilled birth attendants. States can help by enforcing those guidelines and otherwise regulating their activities.
Ensure that all 774 local government areas (LGAs) have a functioning primary healthcare center (PHC) that is well-equipped to provide maternity care services. Every woman must be within reasonable distance from a functioning PHC, with no prohibitively long and arduous journey required. This is a matter of states identifying local needs — with local input — and leading efforts to revitalise PHCs that are in disrepair or otherwise non-functional. The federal government must facilitate and support this effort, including setting requirements for each state and enforcing those requirements through consistent monitoring.
Eliminate affordability as a factor in whether women seek facility care: A major barrier to women seeking facility-based care during pregnancy and childbirth is cost. Nigeria has the highest out-of-pocket health spending at more than 70 percent. Health insurance schemes, while they exist, have not been fully implemented across states and coverage is extremely low, nationwide only 3 percent of women aged between 15 and 49 have health insurance. In addition, these schemes do not include comprehensive provision of maternal health services. State and federal government must address cost barriers by investing in innovations that encourage women to plan and save for childbirth and linking them to health insurance schemes. One such solution is MomCare– a mobile platform under the Lagos Health Insurance Scheme that helps link women to quality maternal health care services that are both affordable and high quality. The delayed implementation of the Basic Health Care Provision Fund (BHCPF) has meant that the basic package of services, which includes free maternal care for all mothers in rural areas, is not being delivered.
Address the chronic shortage of health workers: Training community health workers to provide basic maternity care services can help make up for the dearth of skilled maternity care providers in under-served areas. Poor treatment by overworked staff is often cited by women as a reason they avoid going to health facilities to give birth, investigators found. State governments should collaborate with professional associations (e.g., Nigerian Medical Association, National Association of Nigeria Nurses and Midwives) to ensure that practitioners are available in every LGA, are adequately remunerated and are protected. In addition, the role of midwives needs to be elevated and better integrating them in the continuum of care for maternal health. A broader national strategy is needed, one that includes incentives such as hazard pay and free housing to encourage midwives to serve in hard-to-reach areas.
Expand maternal death and perinatal surveillance and response (MPDSR) activities to communities so that every death is counted and investigated: All maternal deaths must be fully investigated and understood to inform improvement measures and policies. This requires instituting a multi-step, systematic process that is community-owned and executed, and includes an in-person visit with the family to get the full story behind the woman’s death, followed by a thorough exploration of all contributing factors.
The Why Women Are Dying in Nigeria report recommends that the federal government, through the Ministry of Health, work with state governments, local governments and ward councils to facilitate this community MPDSR process; that every state has a functioning and fully-funded MPDSR steering committee and that surveillance teams can easily submit their data as part of a nationally integrated health information system so that learning’s lead to better quality maternity care.
It is time for Nigeria’s maternal health community to deliver on its commitment to changing what it means to give birth in Nigeria. The fight to end preventable maternal deaths is a fight for all of us. Our country’s future prosperity depends upon us winning that fight, together.
MSD for Mothers is MSD’s $500 million initiative to help create a world where no woman dies while giving life. MSD for Mothers is an initiative of Merck & Co, Inc Kenilworth, NJ, and U.S.A.
Iyadunni Olubode is the Nigeria director, MSD for mothers