More than 600,000 women die due to childbirth or pregnancy related complications around the world annually. Nigeria is solely responsible for close to 10% of that figure. Africa has the highest maternal mortality ratio with an estimated average of 800 deaths per every 100,000 births. The estimated average maternal mortality rate in Nigeria, however, is 1,000 for every 100,000 births (2), but this figure varies according to regions of the country. Maternal mortality is much higher in the North Eastern region of Nigeria, accounting for 75% of the country’s maternal deaths (3), compared to the South East and South West regions (4).
The United States Agency for International Development (USAID) indicates that most of the victims of maternal deaths are women between the ages of 15 and 45. After India, Nigeria has the second highest maternal death rate in the world - 52,000 Nigerian women die every year (5). Unsafe practices of childbirth cause on average the death of 144 Nigerian women (6). This means that every 10 minutes one Nigerian woman dies due to childbirth and pregnancy related causes (7). This CAI brief discusses the causes of and Governmental responses to Nigeria’s high maternal mortality rate and argues that it is a clear reflection of women citizens’ national status.
What causes high maternal mortality rates in Nigeria?
Some of the common causes of maternal mortality include: haemorrhaging; infection; eclampsia; obstructed birth (8); bleeding; hypertension (9); unsafe abortions; malaria infection during pregnancy; HELLP syndrome (10); and female genital mutilation and cutting (FGM/C) (11). Two of the major causes, namely FGM/C and the medical condition known as eclampsia, will be discussed here.
Globally, approximately 120 million women and girls have fallen victim to FGM/C. FGM/C is commonly performed on girls between the ages of 4 and 12, however in certain cultures it may be performed on girls just after birth or prior to marriage. In Nigeria, FGM/C is still practiced for reasons including tradition, religion, the belief that it is more hygienic for women, the maintenance of virginity, morality, as well as a better chance to get married. Mothers force their daughters to undergo the procedure to safeguard them from being banished and disgraced from their community. FGM/C is more prevalent in Nigeria’s urban areas (12) and the alterations to female genitalia during the process often interfere with the process of giving birth. FGM/C drastically reduces the birth canal’s normal functions and women who have undergone the procedure can die from the severe bleeding and infections caused by the tears that result from giving birth. According to Nigerian midwife, Chief Muratu Adebayo, women who have undergone the procedure have greater difficulties during labour compared to women who have not (13). FGM/C’s interference with the female reproductive organs is a major contributor to the country’s high maternal mortality rate.
Eclampsia is the most common cause of maternal mortality in Northern Nigeria, while haemorrhage and unsafe abortions are the most common causes of maternal mortality in South Nigeria. Eclampsia is characterised by convulsions that appear in a person with high blood pressure and protein in their urine, and is regarded as an acute life threatening complication of pregnancy. It may appear prior to, during or shortly after labour. If eclampsia appears following labour in Northern Nigeria, it is often treated with certain harmful traditional practices such as “hot bath” or swallowing of Kunun Kanwa, which is salt from a lake and very rich in sodium (14). Women who suffer from this condition have epileptiform convulsions, headaches, nausea, abdominal pain, vaginal bleeding, liver and kidney failure. Due to the lack of or low levels of education in rural regions of Nigeria, pregnant women who display the symptoms of eclampasia are often believed to be possessed by evil spirits. The ill women are usually put in the care of a traditional healer, which delays their access to medical treatment and often causes death (15).
The Nigerian Government’s limited efforts to stop FGM/C, the fact that it leaves so many people uneducated about healthcare for pregnant women, and the lack of modern, accessible medical services for women everywhere, shows that women’s health and therefore women as citizens and indeed mothers of the nation, do not rank very high on the list of national concerns.
Take healthcare to mothers’ homes
Nationally, nearly 45% of Nigerian women and 95% of women from Northern Nigeria give birth in their homes with the assistance of traditional healers, mainly due to the fact that they do not have access to modern professional health care services. Breakthrough medication known as Misoprostol was recently launched in Nigeria by health agencies with the aim of making home childbirth safe. Its main advantage is its ability to stop bleeding almost instantaneously, thus allowing women to deliver their children without assistance from professional medical staff (16).
The Population and Reproductive Health Partnership, which includes the University of California Berkley and Venture Strategy innovations, and Ahmadu Bello University in Zaria, Nigeria, has established a training and awareness programme to educate communities on the correct use of Misoprostol. Dr. Ndola Prata of Venture Strategies Innovations praised the drug’s ability to resolve Prevention of Postpartum Haemorrhage (PPH), stop excessive bleeding during childbirth and prevent bleeding complications following labour (17). Misoprostol is fairly simple to administer: three tablets should be ingested after labour. However, the Federal Government has limited its distribution to medical centres and the medication is administered exclusively by medical practitioners. Dr. Prata has urged the Federal Government to reconsider its policy and allow women from rural communities the opportunity to administer Misoprostol themselves in their own homes, as this would significantly reduce maternal mortality in the country (18).
Midwives and health centres are essential
Hajiya Hajara, Special Assistant to the Governor of Bauchi State, Malam Isa Yuguda, has noted that the recorded increase in the maternal mortality rate may be attributed to an inadequate health care system. She stated that a lack of experienced staff, adequate medication and medical equipment in Nigerian health centres is part of the reason for the country’s escalating maternal mortality rate. Governor Yuguda’s administration established Bauchi State Primary Health Care Agency with the aim to deliver specialised and proficient primary health care services to the Nigerian population, specifically those people in the rural areas. This agency focuses on controlling HIV & AIDS, Tuberculosis, Malaria, as well as other pregnancy and childbirth-related diseases, all in order to decrease the country’s maternal mortality rate (19). The fact remains, however, that substantial Governmental investment in the establishment of many more health centres and healthcare staff across the country would be an investment not only in women as mothers, but ultimately also in their families and the well-being of every citizen.
The National Primary Health Care Development Agency (NPHCDA) recently organised a Training of Trainers Workshop on Life Saving Skills for Midwives (20) after which 2,819 midwives were deployed to 652 primary health care facilities in all 36 states of Nigeria, including Abuja, the Federal Capital of Nigeria. Midwives were trained on life saving skills, childhood illnesses, as well as educating the mothers on how to use the “mama” kits, each of which contain a health book to document their health information (21). The distribution of trained midwives across all regions of Nigeria, urban and rural, can drastically reduce the rate of maternal and infant mortality.
Prevention is better than cure
Of course, prevention is better than cure and one possible prevention strategy is family planning. At the International Conference on Population and Development (ICPD) held in Cairo in 1994, 179 countries agreed that reproductive rights are human rights, and that sexual health is a component of reproductive health. They collectively called for universal access to reproductive health services such as family planning by 2015; they envisioned equality between men and women in respect to reproductive decision-making, thereby promoting voluntary choice in determination of number and timing of children; and they endorsed freedom from sexual violence, coercion, discrimination and other harmful practices (22). According to Werner Harug, Director of Technical Division at the United Nations Population Fund (UNFPA), “family planning is the best documented practice to reduce maternal mortality.” (23) He further commented that maternal mortality rates may be decreased by 40% if women and men had access to the latest contraceptives (24).
Janet Museveni, First Lady of Uganda, considers family planning an effective, existing, and low cost prevention strategy. Family planning involves educating and assisting couples in planning for their next child while the mother recuperates from the prior childbirth and pregnancy. This prevention strategy decreases maternal mortality by encouraging parents to avoid pregnancies that are premature, unplanned, too close together, or too delayed. She urges men to support their women partners during pregnancies and discuss pregnancy related issues co-dependently (25). The Nigerian Government should adopt this prevention strategy in its States, as it could only reduce maternal and infant mortality rates among its citizens.
Education is considered another important factor in reducing maternal mortality. Women’s education should be prioritised so that their life course may exist more independently of men. Women who are educated will choose to attain medical attention from professionals during pregnancy, as well as gain knowledge about what to do and what to avoid during childbirth and the pregnancy period. “By educating a woman you empower her to make decisions to take care of herself.” (26)
Nigerian churches have recently started becoming more involved in the provision of healthcare to women, but Dr. Ezechi Oliver Chekwujekwu, consultant obstetrician and gynaecologist at the Nigerian Institute of Medical Research (NIMR), expressed concern about churches becoming involved specifically in childbirth. He urged churches to employ professionals and equip themselves with appropriate equipment, as well as to provide sanitary conditions in cases where they wish to provide maternal services on their premises. He further recommended that the Government abolishes all unorthodox traditional places that women go to give birth and rather promote hospitals. He feels that the Government needs to focus on sensitisation and awareness campaigns in order to battle maternal mortality in Nigeria (27).
The Nigerian Government’s efforts
Millennium Development Goals (MDGs) number 4 and 5 are targeted at reducing global maternal mortality by 2015; however Nigeria has not made notable progress toward achieving these goals yet. The Nigerian Government’s interest in curbing this problem is evident, however. In mid-June 2009, for example, the Nigerian Government assisted with the ‘Nigerian NGOs Workshop Toward a Consolidated Role as Maternal, Newborn and Child Health advocates,’ which was held in Abuja. The programme was also made possible by cooperation between ACCESS (access to Clinical and Community Maternal, Neonatal and Women’s Health Services), JHPIEGO (John Hopkins Programme for International Education in Gynaecology and Obstetrics). The country’s Government and these organisations agreed that primary health care facilities need to be sufficiently equipped and that Government needs to increase funding of the health sector in order to decrease maternal and infant mortality (28).
To reduce maternal mortality, Kaduna State Government has begun distributing free medication, treated mosquito nets, vector chemicals, anti-septics, sanitary pads, cotton wool, needles, syringes and detergents to pregnant women and women with children below the age of five (29). Kano State Ministry of Health (KSMOH) representatives, Alh Tajudden Gambo and Dr. Ashiru Rajab, in association with the Centre for Development and Population Activities (CEDPA) Nigeria, organised a meeting with civic society leaders and business and political leaders with the aim of reducing maternal mortality in Nigeria. During the meeting, Dr. Suleiman Sani Wali, a representative of the Kano State Hospitals Management Board, put forward a draft of the Free Integrated Maternal and Child Health Bill (FIMCH), which aims to enhance access to appropriate health care facilities to pregnant women and thus decrease maternal mortality (30).
Prioritise caregivers by prioritising maternal healthcare
Maternal mortality is an important issue that affects the citizens of developing countries on a daily basis. Governments should join forces with the World Health Organisation (WHO), the United Nations (UN) and local organisations to curb the current high numbers. The media should also become more involved in creating awareness of life-threatening conditions that pregnant women are exposed to during pregnancy and at the time of labour, not only in Nigeria, but across Africa where this problem thrives. In addition, organisations such as Action Health Incorporated (AHI), Society for Family Health (SFH), the Campaign Against Unwanted Pregnancy (CAUP), the Nigerian Red Cross Society, Grassroots Health Organisation of Nigeria (GHON) and the Women’s Health and Action Research Centre (WHARC) should be funded by the World Bank in order to reduce maternal mortality rate in Nigeria (31).
The state of women’s health inevitably ripples through their communities and it is a shame that Governments in Africa do not allocate more funds to support the reproductive health of their female citizens. In fact, if fewer millions were spent on ‘recreative’ events and flashy parties, much more would be available to care for the women who form the very heart of African society.
(1) Maya Zozulya is an External Consultant for Consultancy Africa Intelligence's Gender Issues Unit (