Maternal, neonatal and child mortality are still very serious health challenges in Africa despite decades of efforts by governments and other stakeholders to address them. Nigeria has one of the highest maternal and infant mortality rates in the world. In terms of the actual number of maternal deaths, Nigeria is ranked second in the world behind India! Nigeria is part of a group of six countries in 2008 that collectively accounted for over 50% of all maternal deaths globally.

In terms of maternal mortality ratio (MMR), Nigeria is ranked eighth in Sub-Saharan Africa, behind Angola, Chad, Liberia, Niger, Rwanda, Sierra Leone and Somalia. The situation in the Northwest and northeast geopolitical zones is significantly worse than the national average; the MMR is 1,025 per 100,000 live births compared to the national average of 800 per 100,000 live births. The Northwest and Northeastern states continue to lag behind in educational and health indices. According to World Health Organization statistics, these places are some of the worst places to get pregnant and give birth in the world!

With its current fertility rate, tradition of short birth intervals (with very low usage of family planning of course), harmful cultural practices, high rate of poverty and illiteracy, it is no wonder northern Nigeria is a major contributor to the national maternal mortality burden.

Maternal mortality, simply put, is dying while giving birth. The International Classification of Diseases, Injuries and Causes of Death defined maternal death as “the death of a woman within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.”

From this definition, it would seem Nigeria is not only getting it wrong with keeping women alive while giving life, we continue to fail in accurate documentation of death of women who die giving birth. Mostly, only deaths that occur in health facilities and at the point of delivery are reported leaving out thousands more that occur far away among communities most of which are not covered by the basest of health services. This is credence to the fact that we are even yet to fully understand the enormity of the problem let alone find the right solutions to them!

It is on record that lots of resources have been invested to reduce or eradicate maternal mortality in Africa without corresponding results. In Nigeria for instance, the health system is still too weak to respond to the very low demand for skilled health services, and where services are available, people still refuse to use them due to apathy. Stakeholders have attempted to strengthen the health systems to respond adequately to health needs of ordinary Nigerians but nothing seems to be changing despite the length of time and resources expended. Obviously, lots of things are still not being done right. Please, note that reference is made here to the entire health system because nothing can be done to improve maternal/child health in isolation of the entire nexus of health systems.

Despite increasing knowledge on the dangers of doing so, Northern Nigerian women have increasingly sought the services of traditional birth attendants (note: pregnant women are expected to attend at least 3 antenatal sessions before delivery). More women continue to deliver at home – most of which never attend a single antenatal session.  Initially, the general view held was that certain barriers were solely responsible for refusal of communities to patronize orthodox health services; however new evidence seems to be diffusing these initially strong views.  There are cases where women have blatantly called for services of traditional birth attendants in spite of considerable access to skilled orthodox health care. Evidently, there is more to the initially identified 3 delays of accessing obstetric care among women in northern Nigeria.

ANCCD Flagship Project on Maternal and Child Health project.

ANCCD Flagship Project on Maternal and Child Health project provides support to Traditional Birth Attendants (TBAs) and Community Health Extension Workers (CHEWs) in Katsina State, Northern Nigeria.

Underage marriage is a major driver of maternal morbidity and mortality in northern Nigeria which increases the chances of obstructed birth, due to small pelvic size. Also, alternative use of Traditional Birth Attendants (TBAs) and general delays in seeking professional health care assistance when complications occur add to the problem. There are of course other underlying factors such as cultural views about pregnancy. For example, pregnancy is treated as an extremely private condition, with women being secluded, little discussion on the topic even between individuals who know each other well, and birth delivery being performed at home.

Skill gaps with existing professional health staff, and the disconnect between health policymaking at the federal government level and local government decision-making, accountability and implementation of these policies have led to further complications of the problem. It is therefore laughable that people wonder why women in their right senses still patronize TBAs. Why not? What with the increasing lack of access to and use of skilled attendance at birth even for the few who give birth in health facilities; and a weak healthcare delivery system characterized by too few health facilities and even fewer health professionals? Verified cases of hazardous facility practices have also helped to deter women from using skilled health services. Women literally have no choice but seek services where they know they can get them not minding how crude those services may be.