Nigeria, Africa’s most populous country with nearly 200 million people, faces significant challenges in maternal healthcare. Shockingly, nearly 20% of all global maternal deaths occur in Nigeria, highlighting the urgent need for comprehensive improvements. The World Health Organization (WHO) emphasizes that high maternal death rates in certain regions reflect inequities in access to health services and a significant gap between the rich and poor.
In developing countries, the lifetime risk of maternal death is 1 in 4900, compared to 1 in 4900 in developed countries. The situation is particularly dire in sub-Saharan Africa and South Asia, where over half of these deaths occur. Poor women in remote areas are the least likely to receive adequate healthcare, especially in regions with a low number of skilled health workers.
The Nigeria Near-Miss and Maternal Death Survey revealed that intra-hospital quality of care issues and delays in accessing the adequate level of care play a major part in the occurrence of maternal deaths. Inequities in health services and gaps between the rich and poor remain significant obstacles. For instance, the wealthiest 20% of households are more than twice as likely to be attended by skilled health personnel compared to the poorest 20% (89% versus 43%).
Focusing on Nigerian maternity care and health system, the supplement helps readers understand the reasons for the high intra-hospital deaths associated with pregnancy-related complications such as abortion. An in-depth analysis of uterine rupture-a major sign of delays in managing obstructed labor-is also featured.
Team leaders, hospital managers, and policymakers should act on the information obtained from the survey to reduce maternal deaths and morbidity in Nigeria. Health systems often face challenges in reducing avoidable deaths and promoting health and well-being, particularly when data collection and analysis are not fully operational and unable to generate actionable information.
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WHO Response and Collaborative Efforts
Improving maternal health is one of WHO’s key priorities. There are many points at which something can go wrong during pregnancy and childbirth - so many factors that can determine whether a mother lives or dies while giving life. Action at the community level meant engaging local leaders to help spread the word about the importance of seeking antenatal care (ANC) during pregnancy, and delivering at a facility with a skilled birth attendant.
Action at the facility level included ensuring public and private providers were well educated to deliver quality maternity care, and that the facility had adequate infrastructure to support quality service delivery. By making private health providers true partners in improving maternal health, there was positive change at the state level too.
Today, with public and private facilities working in tandem, more than 90% of women in Cross River State have access to quality emergency obstetric care within the recommended 2-hr time frame. Mary Ekpo Eyo, the officer-in-charge at Atani Eki primary health center, reports that as a result of all collaborators working together toward a common goal, ANC visits had tripled in just a few months.
"Stronger ties between private providers and the state health ministry improves monitoring and oversight and transparency across the health system," project lead Dr. Farouk M. Jega, Nigeria Country Director for Pathfinder International, SMGL’s implementing collaborator in Nigeria, points out. "Before SMGL, only 20% of private facilities were reporting their health data to the state, and now they all do," Dr. Jega says. "If we can do all this in Cross River, we can do it in other parts of Nigeria, and beyond," Dr. Jega says. "But we will need all hands on deck.
In Nigeria, many mothers are at risk of getting pregnant before they are ready. Given low modern contraceptive use in Nigeria, Merck for Mothers and the Bill & Melinda Gates Foundation saw another opportunity to leverage private facilities - by integrating post pregnancy family planning (PPFP) services. In many rural and semi-urban areas, these private vendors are the primary if not only source of health care for women; they play a pivotal role at a critical moment in a women’s health journey.
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Our collaborators are working with private health facilities to deliver information to women while they are still pregnant, when they come in for antenatal checkups, and during other routine health visits. Daramola Oluwaseun, who owns and operates a local private drug shop in Alimosho, was one of the first to sign up. "The training has been an eye opener," she says. When customers come into her store, she can now counsel them on their options.
Mobolaji Temitope, 38, recalls how she first learned about the different modern methods of contraception during a routine health check while in the second trimester of her third pregnancy - an unplanned one - and was glad to receive her method of choice within 48 hours after delivery. "This change is very important to me, because it gives me peace of mind," Mobolaji says.
At Merck for Mothers, we are working with collaborators in Nigeria to help improve access to quality medicines as part of an overall strategy for improving maternal health. As you know, maternal mortality is still very high in Nigeria. Women are still dying from postpartum bleeding. So we have some work to do. We need to educate the patent medicine vendors and pharmacists about quality medicines.
Agreed. Merck for Mothers and our collaborators are taking that multi-stakeholder approach you are talking about with all our maternal health programs. My top priorities have been to establish a sound quality management system - making sure the internal workings of the agency are aligned and that every department is working together holistically. We are also working with local manufacturers, to make sure they are doing their part to ensure quality.
We are already doing that. We need to work to harmonize medicine regulation across West Africa and across the African continent. And we have to keep partnering with others -international partners like the Gates Foundation, the World Bank. This is inspiring. Yes, things are changing. We have a great culture. We have great people.
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Challenges and Disparities in Maternal Healthcare Services
Women of reproductive age are prone to face deaths and complications from maternal-related health issues if they do not utilize proper healthcare services. Certain challenges act as a disparity and hinder women of reproductive age from accessing maternal health care services leading to deaths and further complications. The study investigated the challenges in pregnancy and how they create disparities in the health of women through poor utilization of maternal healthcare services.
Results of the study revealed that the majority of the women had a good knowledge of maternal healthcare services. Still, there was poor utilization of these care services due to challenges resulting from poverty, distance, religious beliefs, and inappropriate staff attitude which leads to poor care of the pregnant mother and the fetus resulting in preventable deaths and complications. The study concludes that these challenges that affect the utilization of maternal healthcare services must be addressed in order to help promote women’s health and also improve the actualization of Sustainable Development Goals.
This study also recommends the continuous training of health workers to enable them to know how best to attend to these women. The low use of skilled health care during pregnancy, childbirth and postpartum indicates that Nigerian women are paying a heavy price as seen in the country’s very high maternal mortality rates.
Improving Maternal Health in #Nigeria | MSD for Mothers Partners & Global Roundtable Meeting
Stakeholder Perspectives on Skilled Pregnancy Care
Stakeholders identified barriers to pregnant women’s use of skilled pregnancy care and they include; financial constraints, women’s lack of decision-making power, ignorance, poor understanding of health, competitive services offered by traditional birth attendants, previous negative experience with skilled healthcare, shortage of health workforce, and poor financing and governance of the health system.
Study participants suggested health insurance schemes, community support for skilled pregnancy care, favorable financial and governance policies, as necessary to facilitate women’s use of skilled pregnancy care. Therefore engaging policy makers and healthcare providers is necessary to better identify challenges, improve implementation of maternal health interventions, and provide accountability of resources and results.
Coping Mechanisms During Pregnancy and Labor
Findings suggested that women utilized many non-pharmacological methods for coping. Various challenges have been reported among women during pregnancy. Farias et al. observed that many women in low and middle-income countries experience do not receive adequate information and psychological care during pregnancy.
Understanding labour pain is complicated, and several factors influence its perception; hence, women experience and deal with labour pain differently. In some Nigerian cultures, women are more concerned about delivering a healthy baby than the labour pain. Labour pain is caused by several physiological, psychosocial, and environmental factors.
A study conducted among women in Nigeria reported various forms of maltreatment by health providers during childbirth, including physical abuse, verbal abuse, and health system constraints. Evidence suggests that women’s coping mechanisms during labour could be environmental, physical, mental, and emotional. Little is known about coping experiences of Nigerian women with pregnancy and labour, which prompted this qualitative study which aimed at exploring their coping experiences during pregnancy and labor.
The inclusion criteria included mothers on routine postnatal clinic visits and mothers admitted to the postnatal wards, and women who underwent cesarean section having passed through the labour process. The results showed that Nigerian women had a wide range of coping mechanisms during pregnancy and labor, which were highly influenced by culture, religion, and family.
Satisfactory readiness and coping strategies can have numerous positive results, such as decreased labor pain and pregnancy complications. Participants used education from antenatal care to cope during pregnancy and labor. These findings suggest that early booking and attending the antenatal clinic, as they were given adequate antenatal education and support from health professionals, helped the participants cope with pregnancy.
The Dire Reality: Maternal Mortality Rates
Ms. Salahu's experience is not unusual. According to the most recent UN estimates for the country, compiled from 2023 figures, one in 100 women die in labour or in the following days. In 2023, Nigeria accounted for well over a quarter - 29% - of all maternal deaths worldwide. That is an estimated total of 75,000 women dying in childbirth in a year, which works out at one death every seven minutes.
Among the other common causes of maternal deaths are obstructed labour, high blood pressure and unsafe abortions. According to Martin Dohlsten from the Nigeria office of the UN's children's organisation, Unicef, Nigeria's "very high" maternal mortality rate is the result of a combination of a number of factors including poor health infrastructure, a shortage of medics, costly treatments that many cannot afford, cultural practices that can lead to some distrusting medical professionals and insecurity.
Ms Onwuemena explains that some women, especially in rural areas, believe "that visiting hospitals is a total waste of time" and choose "traditional remedies instead of seeking medical help, which can delay life-saving care". She believes that even if they managed to, their problems would not be over. "Many healthcare facilities lack the basic equipment, supplies and trained personnel, making it difficult to provide a quality service."
In 2021, there were 121,000 midwives for a population of 218 million and less than half of all births were overseen by a skilled health worker. It is estimated that the country needs 700,000 more nurses and midwives to meet the World Health Organization's recommended ratio.
The shortage of staff and facilities puts some off seeking professional help. The 28-year-old from Kano state is now expecting her fifth baby. The authorities hope that the country can eventually follow the trend of the rest of the world.
Adolescent Pregnancy in Nigeria
Adolescent pregnancy refers to pregnancy in females between ages 10 to 19 who become pregnant before completing their somatic development. Adolescent pregnancy is often unplanned and considered the most unfavourable outcome of adolescent sexual activity. In developing countries like Nigeria, adolescent pregnancy is considered the leading cause of newborn and maternal mortality, increased sexually transmitted disease, induced unsafe abortions etcetera.
Understanding the determinant of adolescent pregnancy in Nigeria is crucial to designing, developing, and implementing effective, country-specific interventions and policies. Papers on adolescent pregnancy in Nigeria published between January 2007 and December 2022 were searched.
One focus group discussions and four key informant interviews and one retrospective study. In Nigeria, the prevalence of adolescent pregnancy, as recorded by researchers, was 7.5%, 19%, 23%, 7.5-24%, 30%, and 49.50%. The prevalence was found to vary by region, with the Northcentral region having the highest prevalence of 14.3% and the South-south region having the lowest prevalence of 5.2%.
The attitudes and beliefs of individuals and society towards the education of the female child, public health campaigns and the promotion of contraceptive uptake, as well as religious and cultural norms, can significantly impact the prevalence of adolescent pregnancy. Early adolescent sexual activity has been identified as a significant factor contributing to the high prevalence of adolescent pregnancy in Nigeria.
Marriage is a significant factor associated with adolescent pregnancy in Nigeria, as married adolescents are more likely to get pregnant than unmarried ones. Educational attainment is a crucial factor related to adolescent pregnancy in Nigeria. However, poor education correlates with poor knowledge about reproductive health and practices, which leads to poor sexual and reproductive health outcomes.
Peer pressure has been identified as a significant factor influencing adolescent pregnancy in Nigeria, as evidenced by several studies. To address this issue, there is a need to educate adolescents on healthy relationships, sexual behaviors, and the risks associated with early sexual activity. Parents and caregivers can play a critical role in discussing sex and sexuality with their children and providing them with accurate information.
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