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Barriers to Safe Motherhood in Nigeria

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Barriers to Safe Motherhood in Nigeria March 2009 Barriers to Safe Motherhood in Nigeria Akinrinola Bankole, Gilda Sedgh, Friday Okonofua, Collins Imarhiagbe, Rubina Hussain and Deirdre Wulf HIGHLIGHTS ■ Nigeria has one of the highest maternal mortality ratios in the world: 1,100 maternal deaths for every 100,000 live births. ■ Although patterns vary by region, high-risk births persist in Nigeria. In both 1990 and 2003, two-thirds of all births were high risk because of the mother’s age, parity or spacing of births. ■ More than 40% of women giving birth do not receive prenatal care from a trained health care provider. This proportion did not improve during the 13-year period. It is above average in the North East and North West regions. ■ The proportion of women receiving health care from a trained provider at delivery has increased somewhat—from 30% in 1990 to 37% in 2003. Even so, it is still low and less than that in some other West African countries. ■ Increasing urbanization and education coupled with a drop in the proportion of women who are married have led to declines in fertility desires and childbearing. However, the desire for a smaller family appears to be outpacing reductions in fertility. This is evident in the increasing proportion of births that are unplanned, which largely reflects a low level of contraceptive use in Nigeria. ■ The Nigerian government has adopted several policies aimed at reducing maternal mortality by 75% by 2015. However, they lack effective implementation, largely because of the very low level of government spending on health care. Most programming on safe motherhood has been initiated by nongovernmental organizations working with funding from international donors. ■ Some recent programs and policies have the potential to improve the quality of maternal health care in Nigeria. To achieve this goal, the Nigerian government must make a commit- ment to provide adequate resources—trained providers, up-to-date equipment and, most importantly, sufficient funding—to end the many needless deaths associated with childbearing among Nigerian women. CONTENTS Introduction ...............................................................................3 Data Sources .............................................................................4 A Snapshot of Nigeria and Nigerian Women’s Characteristics ..........................................................................5 March 2009 Reproductive Behavior and Implications for Barriers to Safe Motherhood in Nigeria Maternal Health ........................................................................7 Akinrinola Bankole, Gilda Sedgh, Friday Okonofua, Policies to Reduce Maternal Morbidity and Collins Imarhiagbe, Rubina Hussain and Deirdre Wulf Mortality ....................................................................................14 Programs to Reduce Maternal Morbidity and Mortality ...................................................................................16 Funding of Services to Reduce Maternal Morbidity and Mortality ........................................................18 Discussion and Recommendations .....................................20 References ...............................................................................22 APPENDIX TABLE 1. Selected social and demographic measures, and measures of maternal morbidity and mortality among women in Nigeria, by region, ACKNOWLEDGMENTS 1990 and 2003 ...................................................................24 Barriers to Safe Motherhood in Nigeria was written by APPENDIX TABLE 2. Unweighted Ns for selected social Akinrinola Bankole, Gilda Sedgh and Rubina Hussain, and demographic measures, and measures of all of the Guttmacher Institute; Friday Okonofua and maternal morbidity and mortality among women in Collins Imarhiagbe, both of the Women’s Health and Nigeria, by region, 1990 and 2003 ..................................26 Action Research Centre; and Deirdre Wulf, independent consultant. The authors thank Babalola Adeyemi, Faculty of Health Sciences, Obafemi Awolowo University; Isaac Adewole, College of Medicine, University of Ibadan; Latifat Ibisomi, African Population and Health Research Center; and Boniface Oye-Adeniran, College of Medicine, University of Lagos, for providing insightful comments and suggestions on an earlier draft. The authors also thank David Ajanaku, Federal Ministry of Health; Jerome Mafini, Futures Group; Ejike Oji, Ipas; and Kole Shettima, The John D. and Catherine T. MacArthur Foundation, for meeting with us during our visits to their establishments in the course of our research. We also greatly appreciate the contributions of the other members of the project team—Susheela Singh, Ann Moore and Fatima Juarez, all of the Guttmacher Institute; and Olukunle Daramola, Women’s Health and Action Research Centre—to the development of this report. We acknowledge Suzette Audam and Alison Gemmill, both of the Guttmacher Institute, for help with data processing and analysis, and Patricia Donovan, of the Guttmacher Institute, for her © Guttmacher Institute, 2009 comments on an earlier draft. Susan London, independent consultant, edited the report. Suggested citation: Bankole A et al., Barriers to Safe The research on which this report is based was carried out Motherhood in Nigeria, New York: Guttmacher Institute, 2009. by the Guttmacher Institute and the Women’s Health and Action Research Centre with support from The John D. To order this report or download an electronic copy, go to and Catherine T. MacArthur Foundation. www.guttmacher.org Introduction Nigeria, the most populous country in Africa, has one In addition, at the global level, approximately 20 mil- of the highest maternal mortality ratios in the world.1 lion of the 136 million women who give birth each year Newly revised estimates of the World Health Organization experience pregnancy-related illnesses after childbirth. (WHO) indicate that there are 1,100 maternal deaths for Recovery from organ failure, uterine rupture, fistulas and every 100,000 live births in the country2(Annex 5) and that a other severe complications, and the sequelae of poorly woman’s lifetime chance of dying during pregnancy, child- repaired episiotomies or perineal tears, can have last- birth or the postpartum period is one in 18.2(Annex 3) WHO ing health consequences, such as urinary incontinence, further estimates that every year, 59,000 Nigerian women uterine prolapse and pain.5 If untreated, some of these die in childbirth—the second highest number in the world postdelivery complications can lead to chronic ill-health (after India).2(Annex 3) In fact, only seven other countries in or maternal deaths. A study of deliveries occurring in the Sub-Saharan Africa* have higher maternal mortality ratios. 1990s in the state of Kano in northern Nigeria found a very Unsafe abortion is a major contributor to maternal mor- high maternal mortality ratio (2,420 deaths per 100,000 tality. A study finds that more than 3,000 Nigerian women live births).6 Eclampsia, rupture of the uterus and anemia being treated in hospitals for complications from such were responsible for about half of these deaths. procedures die each year; however, since many women This report, which is based mainly on data from two having unsafe abortions die before reaching a facility, the national surveys complemented with data from other true number of such deaths is likely to be much higher.3 sources (see Data Sources), examines trends over a According to WHO, 13% of maternal deaths in 2003 in 13-year period (1990–2003) in selected factors that are West Africa, of which Nigeria is the largest country, were directly and indirectly related to maternal mortality in due to unsafe abortion.4 Nigeria—the educational and social status of women of Taken together, these findings are disappointing. childbearing age, average family size, patterns of contra- In 2000, Nigeria and 146 other members of the United ceptive use and unmet need for family planning, levels of Nations agreed on eight Millennium Development Goals unintended childbearing and proportions of births that con- (MDGs) to improve the health and socioeconomic well- stitute a high risk to mothers and their infants. The report being of the people in their countries in the 21st century. also looks at the use of health services by Nigerian women The fifth goal, MDG 5, calls for the reduction of maternal during pregnancy and childbirth, as well as recent esti- deaths by 75% by the year 2015. mates of levels and sources of overall health care expen- Most of the half million maternal deaths in the world ditures in Nigeria. In addition, it examines the policies and each year occur in developing countries. The major direct programs that affect maternal health in the country. causes of maternal death in these countries are severe This report could help policymakers and program plan- bleeding (hemorrhage, which accounts for 25% of the ners understand the factors associated with the very high deaths), infections (15%), unsafe abortions (13%), eclamp- levels of maternal morbidity and mortality in Nigeria. The sia (12%) and obstructed labor and other direct causes expectation is that the report might catalyze change and (16%).5(pp. 62–64) Maternal deaths from indirect causes inform the development and introduction of strategies and account for the remaining 20% of deaths. These deaths programs to end the many needless deaths and complica- result from diseases (present before or during pregnancy) tions associated with pregnancy and childbearing among
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