Jane Kim is a senior at the University of Southern California studying Biology, Social Sciences emp. Psychology, and French. She enjoys doing community service, traveling, reading, drawing, and watching Netflix. In the future, she plans on attending medical school and working with underprivileged communities in Los Angeles. Her favorite animal is the elephant.
THE STATE OF MATERNAL HEALTH IN NIGERIA
In the year 2000, the United Nations established eight international development goals to be achieved by 2015 called the Millennium Development Goals (MDG). MDG 5A set out to improve maternal health, aiming to reduce the maternal mortality ratio (MMR, given in number of maternal deaths per 100,000 live births) by three quarters between 1990 and 2015.
MDG 5A also hoped to ensure that 100% of all deliveries be assisted by a skilled birth attendant, which is defined as a medical doctor, nurse, or midwife. Figure 1 depicts the progress in reducing MMR in Nigeria. The labeled points are actual numbers taken from available data while the points in between were filled in using a simple slope formula to show general trends (Nigeria Demographic and Health Survey, 2013). The blue line represents real data, while the red line shows what progress needs to be made in order to reach the target. While Nigeria has made significant progress in reducing MMR, achieving a 52% decrease since 1990, Figure 1 shows that from 2008 to 2013, there was no statistically significant change in MMR, and Nigeria is not on track to achieve MDG. In fact, the efficacy of maternal health improvement efforts seems to have plateaued.
As a country of great economic diversity, it is important to note that these aggregate numbers gloss over any disparities in Nigeria’s progress. Nigeria is divided into six geopolitical zones: North East, North West, North Central, South West, South East and South South.These geopolitical zones are further divided into 36 states which are, in turn, divided into local government areas (LGAs). Despite progress in the nation as a whole, a 2012 study showed that MMR decreased in only 2 zones, remained relatively stable in 3, and markedly increased in the NE where Boko Haram has been active since 2009 (Global One, 2012).
Nigeria’s large population is divided along more than just geopolitical lines. To start, the southern half of the country is predominantly Christian while the northern half is almost uniquely Muslim. In addition to the religious disparities, several states have adopted (to varying extents) some form of sharia law. Furthermore, there are over 500 ethnic groups living in the country, many with unique language and cultural beliefs. Figure 2 shows that the burden of disease is much higher in the northern states, which are significantly poorer and where women have less autonomy and education than in the southern states (UNICEF, n.d.).
OBSTACLES TO BETTER MATERNAL HEALTH
In general, wealth, or the lack thereof, is an indicator of maternal health, so it is initially surprising that Nigeria, which has the largest economy in Africa by nominal GDP according to the World Bank, has the second highest MMR in the world (UNICEF, 2008). However, a closer analysis shows that over half of the population lives under the poverty line. Additionally, the rural poverty rate in 2004 was 64%, or 1.5 times higher than the urban poverty rate of 43%. These socioeconomic differences among Nigeria’s regions may help explain the disparities in MMR throughout the country. Figure 2 shows the estimated MMR in four of Nigeria’s six regional zones. A UNICEF study showed that 67% of the North East population lived in poverty but only 34% in the South East Zone. This coincides with the higher instance of maternal deaths in the North East (MMR 1549) compared to the South East (MMR 165).7 But economic inequality alone between Nigeria’s geographic zones does not fully explain the differences in MMR.
The differences in MMR between regions are much greater than would be predicted based on wealth disparity alone, indicating that there are other obstacles to maternal health. Four main obstacles to maternal health have been identified and are often classified as follows:
The delay in deciding to seek care may be due to lack of education about care, mistrust of the government or health systems, and family constraints.
- The delay in reaching care is often associated with distance from health facilities, lack of roads, and inadequate means of communication. In Nigeria, 73% of women age 20-34 reported having at least one problem in accessing healthcare (see Table 1). Some of these numbers would vary depending on the woman’s level of education, wealth, authority within her household, and whether she lives in an urban versus rural area.
The delay in receiving appropriate care on arrival is a result of inadequate or incompetent manpower and shortage of drugs and supplies.
- The delay in referral, which is related to the third delay,occurs when complications beyond the local facility’s capacities arise and there isn’t an efficient emergency response system in place to administer more specialized care. Table 2 lists the immediate causes of maternal mortality in Nigeria (Cooke and Tahir, 2013). Approximately 80% of these causes can be prevented or treated relatively simply if only women had proper access to care. These complications can be difficult to predict in any particular individual, but a woman’s risk of dying from these causes falls dramatically if she seeks and has access to effective antenatal care and if she delivers her baby in the presence of a skilled birth attendant (Cooke and Tahir, 2013).
PROGRAMS INTENDED TO IMPROVE MATERNAL HEALTH
Maternal health is not a novel problem to Nigeria, and it “has been of particular interest to President Goodluck Ebele Jonathan” (Federal Republic of Nigeria and UNDP, 2013) In the past decade, and especially since the publication of the 2008 Demographic and Health Survey, several new initiatives have been introduced in order to meet the MDG goals.
The earliest of these solutions is the Midwives Services Scheme (MSS), which sought to address the issue of unattended deliveries by training and deploying 4,000 midwives to 1,000 primary healthcare centers. In these targeted facilities, there was an average reduction of 26% in maternal deaths. Under MSS, midwives were promised a small salary from the federal government, supplemented by a stipend from state governments and housing from LGAs. However, due to corruption at the local and state level and the government’s refusal to prioritize maternal health, the midwives weren’t properly compensated and they left the program (Cooke and Tahir, 2013).
Started in 2009, the Abiye Program is a pilot program in the Ondo state (South West zone). This program focused on addressing the aforementioned delays and introducing a surveillance system in order to ensure evidence-based planning. The delay in seeking care is offset by appointing, training and posting health rangers to rural areas to act as intermediaries between pregnant women and the designated Abiye maternity health centers. Twenty-five pregnant women are assigned to each health ranger who visits them regularly. The health ranger is responsible for customizing a pre-natal checklist, detecting potentially high-risk pregnancies, carrying out a birth plan, educating and advising on family planning, ensuring the use of chemically impregnated bed nets, etc. The delay in reaching care is addressed by giving each health ranger a locally-manufactured, low-tech tricycle ambulance to transport women who are in labor and may not be able to sit on the back of a motorcycle. The delay in receiving quality care is addressed by constructing and refurbishing existing facilities, training more midwives and health workers, and task-shifting. Task-shifting gives more responsibility to less skilled health workers so that highly-trained doctors and nurses can focus on more exigent cases.
Another measure taken by the program to address these delays is the provision of non-pneumatic shock garments, which help redirect blood flow to the vital organs and can keep a woman suffering from postpartum hemorrhage alive for up to several hours, thus giving her time to be moved to more specialized care and compensating for the delay in referral. But perhaps the most innovative aspect of the Abiye program is their focus on data collection and evidence-based planning. The program itself was preceded by four months of surveys to see what interventions would be most cost-effective; it also implemented a better data system in order to assess and amend the impact of the program.
The Abiye pilot program was carried out in one LGA, Ifedore. Prior to the program, Ifedore only saw about 100 deliveries per year in a health facility, but that number grew to 2,000 by the first year and 6,000 by the second year. Furthermore, the number of women registered for antenatal care that eventually delivered in the hospital increased from 16% to 60% by the second year. When the program was expanded to several other LGAs between 2010-2012, they saw a 45% reduction of maternal mortality cases, 58% increase of registered patients, and 96% increase in number of live births (Cooke and Tahir, 2013).
In 2012, the Subsidy Reinvestment and Empowerment Program (SURE-P) funded the expansion of MSS and a new conditional cash transfer program (CCT). CCT’s are social programs that conditionally grant regular cash payments to poor households for their use of certain health services and school attendance. The goals of such programs are to 1) provide a safety net for the extreme poor and 2) increase human capital investment of poor households. The SURE-P Maternal and Child Health initiative (SURE-P MCH) offers the equivalent of 32 USD to women who follow through on at least 3 antenatal care visits, deliver their children in the presence of a skilled birth attendant, have one postnatal visit, and have their children immunized. The program is still in its pilot phase as MMR requires a very large sample size since it is measured in deaths per 100,000 live births, so it is difficult to measure the program’s impact on maternal health. However, there was a positive impact on infant health and a definitive increase in attended births (Cooke and Tahir, 2013).
It is important to note that more women delivering in health facilities does not necessarily mean better maternal health. For example, India’s Janani Suraksha Yojana (JSY) program compensated women for delivering in a healthcare facility, but there was no positive impact on maternal health because of the inadequate quality of care (Lim et al., 2010). The Nigerian health system “has been plagued by problems of service quality, including unfriendly staff attitudes to patients, inadequate skills and chronic shortages of essential drugs. Electricity and water supply are irregular and the health sector as a whole is in a dismal state” (Mojekwu and Ibekwe, 2012). In order to avoid similarly disappointing results as JSY, it is essential that the Nigerian government work to improve access to care and quality of care concurrently.
On the other hand, Brazil’s Bolsa Família welfare program is considered the most successful CCT program in history. Like in Nigeria’s SURE-P MCH program, women are paid for getting ANC visits, delivering with a skilled birth attendant, postnatal care, and immunization of their children; however, families continue to receive money for other things such as children’s attendance in school. Not only does this help impoverished families stay out of debt, but it also helps them escape the vicious cycle of poverty by providing children with an opportunity to become educated (Soares, 2010). Although Nigeria’s CCT program is specifically focused on maternal and infant health and not poverty, promoting education can help in the long run for several reasons. First of all, families will be encouraged to keep their girls in school, curbing the incidence of child marriages (which are linked with poor maternal health). Secondly, girls will be educated, empowered, and thus more able to assert authority in the home and in society. Finally, more educated women are more likely to seek care, use family planning, and have less children, all of which reduce the risk of maternal complications. These positive effects on the lives of women are due to the positive correlation observed between higher levels of education and healthier behaviors (Cooke and Tahir, 2013).
Though CCT programs have lots of potential, there are many obstacles. For example, delayed implementation, which can be caused by financial crisis, natural disaster, changes in program administration, or political leadership, can lead to decreased efficiency and even program termination (Rawlings and Rubio, 2003). Moreover, often the neediest and poorest populations can’t follow through with the conditions because of transportation costs (to schools and hospitals) or because the mother can’t miss work to register or accomplish all the conditions. As mentioned before, poor quality of care and government corruption are issues. Lastly, corruption and lack of adequate information can lead to distrust in the program; so even if the other issues were to be resolved, people wouldn’t take advantage of the program.
Improving maternal health is a daunting task, and can be even more overwhelming for Nigeria due to its size, diversity, and plethora of political and economic issues it faces. It is imperative that Nigeria implement multiple initiatives simultaneously to address different issues regarding maternal health. One must consider horizontal vs. vertical programs and top-down vs. bottom-up initiatives. Horizontal delivery refers to services delivered through public financed health systems and are commonly referred to as comprehensive primary care, whereas vertical delivery of health services implies a selective targeting of specific interventions, not fully-integrated in health systems (Msuya, 2004). In this context, a top-down initiative refers to programs conceived at the national level (e.g. India’s JSY program) and implemented throughout the whole country; a bottom-up initiative refers to programs starting in the lower arms of government (e.g. Nigeria’s Abiye Program) or among the people (e.g. traditional birth attendants).
As a vertical, bottom-up approach, I would propose expanding the Abiye program, tailoring it to the specific needs of each LGA and state. This can be supplemented with horizontal, top-down initiatives such as improving infrastructure (e.g. building roads, refurbishing hospitals) and implementing a CCT program that focuses on healthcare as well as continued education for children. In order for this to be effective, provisions need to be made for working women and those in remote communities to allow them a fair chance to follow through on the conditions.
Championing a single issue, such as malaria or maternal health, appeals more to the pathos of a sympathetic donor than, per se, the building of roads. Moreover, progress with singular issues such as these can be more easily demonstrated using concrete data. Therefore, vertical programs that target specific interventions should primarily be funded by foreign aid, and government funding should be allotted to horizontal programs because it is harder to garner financial support for a general, overarching program than one specific issue. In this way, the general health infrastructure of the country is produced by sustainable means, whereas the need for vertical programs and foreign aid should decrease as infrastructure is improved.
Additionally, government funds should be allocated using a top-down funding system. In other words, instead of LGAs or state governments raising and using their own funds, all financial resources should be distributed by the national government. This will fight the huge socioeconomic disparities by reallocating funds to the neediest areas and reduce corruption found in the lower tiers of government, as seen in the MSS program.
While it may be evident that investing in health, education, and human capital is not a waste of money, it is important to find concrete sources of funding. One existing source is the 53 million USD of the federal Debt Relief Fund directed to building primary health infrastructure and strengthening training and procurement for maternal and child health (Cooke and Tahir, 2013). However, Nigeria must streamline its initiatives in order to optimize the use of this limited fund. In the future, it would be ideal for Nigeria to allocate a percentage of its oil revenues to building health infrastructure. In the past, a bill that would direct 2% of oil revenues to primary health care faced much resistance from legislators and health professional associations alike (Cooke and Tahir, 2013). Foreign stakeholders, including the USA and the EU, should put pressure on the Nigerian government to pass such public policies.
Finally, Nigeria must establish a multi-tiered surveillance system. On the government level, incorporating a policy of transparency will help stop corruption and garner the people’s trust. Hospitals and other facilities should be rewarded for quality of care, but also integrate mechanisms to help subpar hospitals improve. On the individual level, a basic data system (including birth, death, and health history) should be created. Not only is this basic information that all governments should have, but it will also help assess the impact of programs and make adaptations based on evidence.
It is necessary to discuss the limitations and scope of this paper. The conclusions are based almost solely on MMR, which does not account for the maternal deaths that never enter the system, near-misses (these occur when women survive life-threatening conditions arising from complications related to pregnancy and childbirth), or morbidity. For example, in Nigeria alone, 40,000 maternal deaths occur annually, but another 1-1.6million women suffer from serious disabilities from pregnancy and birth-related causes, obstetric fistulas being a specific problem (Cooke and Tahir, 2013).
Nigeria is an important target for MDG 5 because it accounts for about 15% of maternal deaths worldwide (UNICEF, 2008). Success on this front would be a critical step forward in improving global maternal health. However, specific issues regarding the cultural, religious, and ethnic diversity in Nigeria were not explored.
Maternal health is important because it is correlated to good infant health, it is an indicator of a good overall health system, and (unlike diseases) pregnancy cannot be eradicated. If maternal health isn’t improved, millions of women will continue to die each year from easily preventable causes.
Cooke, J.G. & Tahir, F., Maternal Health in Nigeria: With Leadership, Progress is Possible (Washington, D.C., Jan 2013).
Federal Republic of Nigeria and UNDP, Nigeria MDG Acceleration Framework: A Commitment to Improved Maternal Health (Aug 2013), p.8.
Global One, Maternal Health in Nigeria: A Statistical Overview (2012), p. 10.
Lim, Stephen S., Lalit Dandona, Joseph A. Hoisington, Spencer L. James, Margaret C. Hogan, and Emmanuela Gakidou. “India’s Janani Suraksha Yojana, a Conditional Cash Transfer Programme to Increase Births in Health Facilities: An Impact Evaluation.” The Lancet 375.9730 (2010): 2009-023. Web.
Mojekwu, J. & Ibekwe, U., Maternal Mortality in Nigeria: Examination of Intervention Methods (Oct 2012), p. 136.
Msuya, J., Horizontal and Vertical Delivery of Health Services: What are the Trade Offs? (Washington, D.C., 2004), p.2.
National Population Commission (NPC) [Nigeria] and ICF International. 2014. Nigeria Demographic and Health Survey 2013. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF International.
“Nigeria.” The World Bank. The World Bank Group, n.d. Web. <http://data.worldbank.org/country/nigeria>.
Rawlings, L. & Rubio, G., Evaluating the Impact of CCT Programs: Lessons from Latin America (Aug 2003), p. 23.
Soares, F.V., Evaluating the Impact of Brazil’s Bolsa Família: Cash Transfer Programs in Comparative Perspective (Pittsburgh, PA, 2010).
World Health Organization, UNICEF, UNFPA, The World Bank & the United Nations Population Division. (2014). Maternal mortality in 1990-2013: Nigeria. Geneva: WHO.
UNICEF. MOTHER, NEWBORN AND CHILD HEALTH AND MORTALITY IN NIGERIA – GENERAL FACTS. Abuja: UNICEF, n.d. Advocacy Brochure. Federal Ministry of Health. Web. <http://www.unicef.org/nigeria/ng_publications_advocacybrochure.pdf>.
UNICEF, The State of the World’s Children 2009: Maternal and Newborn Health (New York, NY, Dec 2008), p. 19.