Attaining MDG 5 in northern Nigeria: Need to focus on skilled birth attendance

Abstract

Nigeria‟s maternal mortality ratio remains at an unacceptably high level and is considered to be one of the highest in the developing world¹. The most recent Nigerian National Demographic and Health survey (NDHS)² reported maternal mortality ratio to be 545 / 100,000 live births. The data showed wide regional disparity in maternal mortality ratios between the different geopolitical zones of the country². The report showed that average maternal mortality ratio in northern Nigeria was 2420 (range:1060 - 4477) per 100,000 live births^4,5,6,7, while similar data in the southern parts of the country were considerably lower - between 454 and 772/100,000 live births^8,9. There is increasing evidence that this difference in maternal mortality between the northern and southern parts of the country may be due to disparity in the accessibility and utilisation of health services, especially differences in the availability of skilled birth attendants between the regions.

The WHO defines a skilled birth attendant (SBA) ‟‟as an accredited health professsional- such as a midwife, doctor or nurse- who has been educated and trained to proficiency in the skills needed to manage uncomplicated pregnancies, childbirth and the immediate post natal period and in the identification, management and referral of complications in women or newborns‟‟¹⁰. The availability of SBAs at delivery was one of the key indicators identified for monitoring progress towards attainment of MDG 5. To ensure skilled attendants at birth for all women, the international community set a target of 80% by 2005, 85% by 2010 and 90% coverage by 2015. To date, whilst developed countries have attained near universal coverage (>99%) of SBAs, just slightly over 50% of all births in developing countries take place under the supervision of a SBA¹¹. In Nigeria, the 2008 NDHS reports an overall coverage of 39% for SBAs at delivery. Again, the data showed remarkable regional differences in this indicator within the country. While 81.8% and 76.5% of births were attended by SBAs in the southeast and southwest regions respectively, only15.5% in the northeast and 9.8% in the northwest regions of the country were attended by skilled providers².

Available data indicate that the regions of the world with dramatic gains in the proportion of deliveries attended by SBAs since the millennium declaration recorded more reductions in maternal mortality ratios^12,13. Specifically, a 50% reduction in the maternal mortality ratio was observed in Egypt following the doubling of the proportion of deliveries attended by skilled attendants¹². In comparison, Nigeria with no substantial increase in the number of deliveries attended by SBAs over the same period, did not record any remarkable change in the high maternal mortality ratio. This lack of access to SBAs, especially in northern Nigeria are due to various socioeconomic and cultural factors, including low educational level, young maternal age, igno-rance, rural residence and high rate of poverty. These reasons are further buttressed by data from the NDHS which reports that the proportion of women with no formal education in the southeast and southwest geopolitical zones were 6.3% and 6.0% respectively, compared to 68.1% and 74.3% of women in the northeast and northwest regions². The data also showed that only 8% of women from the poorest 20% of families deliver in a healthcare facility compared to 86% of women from the richest 20% of families. This is the largest equity gap on the continent, and possibly in the world, and provides further evidence that inadequate means of livelihood and poverty are critical factors associated with poor utilization of evidence-based maternal and child health services in Nigeria. Consequently any program designed to improve women‟s access to skilled attendants at birth must address these barriers if such programs are to achieve their intended objectives.

This edition of the African Journal of Reproductive Health (AJRH) features three original articles that report the low utilisation of SBAs in Northern Nigeria and the challenges this poses for progress in achieving MDG 5 in the region. The first article was a population-based study random survey of 6,809 women in northern Nigeria, which showed a high rate of utilisation of unskilled birth attendants¹⁴. In particular, the data showed that unskilled birth attendants were more likely to deliver low quality maternity care as compared to skilled health workers. This corroborates the findings from the 2008 NDHS, and suggests that if the trend continues attaining the MDG 5 in northern Nigeria would be a nightmare. The second paper by Dalyop et al¹⁵ also demonstrates similar results of high use of unskilled birth attendants in north-central Nigeria, and its negative effects on maternal health. The third paper reports the results of a study that identify poor referral practices by traditional birth attendants in north-central Nigeria, and its negative consequences for maternal health indicators¹⁶.

Clearly, there is a need to focus on promoting increased access to skilled birth attendance as a principal strategy for achieving a reduction in maternal mortality in northern Nigeria. Hopefully, the „Midwives Service Scheme‟ (MSS) recently launched by the Federal Ministry of Health to increase skilled attendance at birth, will likely achieve some beneficial effects in reducing maternal mortality in states with low percentage of skilled birth attendance¹³. The scheme seeks to mobilise midwives, especially newly qualified midwives, to health facilities in rural communities to undertake a one year community service. The MSS is therefore set to address the human resource need for skilled attendance at the primary level of care as the majority of Nigeria‟s obstetric population reside in the rural area¹⁷. 

While the presence of a health worker with midwifery skills at every birth is one of the most important interventions for attaining safe motherhood, there is the additional need to address major operational challenges in the delivery of maternal health care. These include the recruitment, mobilisation and distribution of adequate numbers of midwives to all parts of the country, ensuring equitable distribution to communities where they are most needed, addressing the issues of morale and motivation while providing an enabling environment with availability of essential supplies and equipment. Also, there is the need to back up the program with expanded emergency obstetric care facilities, including the provision of effective transportation, an organized referral system, and link up of the participating health centres to secondary health care centres that have facilities for operative delivery. Additionally, community involvement and participation as key stakeholders is essential to the initiation and sustenance of an effective partnership needed for the attainment of the specific objectives of the policy. For example, in Thailand, some of these barriers were circumvented through the use of home town deployments of midwives, general development of rural areas and career development incentives^18,19.

In conclusion, a substantial number of women in northern Nigeria still patronise unskilled birth attendants. Ensuring large scale access to SBAs during pregnancy and delivery is crucial in accelerating progress towards the attainment of MDG 5, as available evidence has shown that when the number of midwives increases, the number of women who die decreases. While MSS is a step in the right direction, what is required to achieve the program objectives is to ensure adequate coverage, provision of an enabling environment with proper supervision and appropriate motivation, community participation and above all the political will to ensure sustainability and continuity of the program. 

rance, rural residence and high rate of poverty. These reasons are further buttressed by data from the NDHS which reports that the proportion of women with no formal education in the southeast and southwest geopolitical zones were 6.3% and 6.0% respectively, compared to 68.1% and 74.3% of women in the northeast and northwest regions². The data also showed that only 8% of women from the poorest 20% of families deliver in a healthcare facility compared to 86% of women from the richest 20% of families. This is the largest equity gap on the continent, and possibly in the world, and provides further evidence that inadequate means of livelihood and poverty are critical factors associated with poor utilization of evidence-based maternal and child health services in Nigeria. Consequently any program designed to improve women‟s access to skilled attendants at birth must address these barriers if such programs are to achieve their intended objectives.

This edition of the African Journal of Reproductive Health (AJRH) features three original articles that report the low utilisation of SBAs in Northern Nigeria and the challenges this poses for progress in achieving MDG 5 in the region. The first article was a population-based study random survey of 6,809 women in northern Nigeria, which showed a high rate of utilisation of unskilled birth attendants¹⁴. In particular, the data showed that unskilled birth attendants were more likely to deliver low quality maternity care as compared to skilled health workers. This corroborates the findings from the 2008 NDHS, and suggests that if the trend continues attaining the MDG 5 in northern Nigeria would be a nightmare. The second paper by Dalyop et al¹⁵ also demonstrates similar results of high use of unskilled birth attendants in north-central Nigeria, and its negative effects on maternal health. The third paper reports the results of a study that identify poor referral practices by traditional birth attendants in north-central Nigeria, and its negative consequences for maternal health indicators¹⁶.

Clearly, there is a need to focus on promoting increased access to skilled birth attendance as a principal strategy for achieving a reduction in maternal mortality in northern Nigeria. Hopefully, the „Midwives Service Scheme‟ (MSS) recently launched by the Federal Ministry of Health to increase skilled attendance at birth, will likely achieve some beneficial effects in reducing maternal mortality in states with low percentage of skilled birth attendance¹³. The scheme seeks to mobilise midwives, especially newly qualified midwives, to health facilities in rural communities to undertake a one year community service. The MSS is therefore set to address the human resource need for skilled attendance at the primary level of care as the majority of Nigeria‟s obstetric population reside in the rural area¹⁷. 

African Journal of Reproductive Health Jun 2010; 14(2): 10

While the presence of a health worker with midwifery skills at every birth is one of the most important interventions for attaining safe motherhood, there is the additional need to address major operational challenges in the delivery of maternal health care. These include the recruitment, mobilisation and distribution of adequate numbers of midwives to all parts of the country, ensuring equitable distribution to communities where they are most needed, addressing the issues of morale and motivation while providing an enabling environment with availability of essential supplies and equipment. Also, there is the need to back up the program with expanded emergency obstetric care facilities, including the provision of effective transportation, an organized referral system, and link up of the participating health centres to secondary