MATERNAL MORTALITY: UNRAVELING THE INTERSECTIONAL WEB IN NIGERIA

AN OVERVIEW OF MATERNAL MORTALITY IN NIGERIA

Maternal mortality is a serious global health issue that is more prevalent in sub-Saharan Africa, contributing to about 70% of deaths in 2020, which is indicative of the gaps between the affluent and the non-affluent and unequal access to good health care (World Health Organization, 2023). Many countries have made strides in the fight against maternal mortality; however, with a global burden of over 20% (Ope, 2020), a maternal mortality ratio of 814 for every 100,000 live births and a combined total of about 34% of the world’s maternal mortality rates with India (WHO, 2015), Nigeria lags.

Research in Nigeria has indicated that women living in rural communities are predominately affected by poor maternal health outcomes in contrast to those in urban regions (Azuh et al., 2017) (Ibrahim, 2014), mainly due to a lack of access to professional health services (Okonofua et al., 2018), and therefore, many mothers count on the help of traditional birth attendants who are heavily utilised in rural communities (Esan et al., 2023). Furthermore, other studies suggest that the continual increase in maternal deaths is due to transportation barriers to health facilities, lack of prompt attendance by health professionals and poor decision-making in seeking timely care (Okonofua et al., 2018)(Yaya et al., 2018).

Introspectively, these issues can be linked to medical factors and, most importantly, non-medical factors (social determinants of health) (Figure 1) that play a massive role in determining inequalities in health (Cockerham, 2009, p. 78). Therefore, this article will analyse the intersectional factors contributing to maternal mortality in Nigeria while considering gender dynamics, socioeconomic factors, cultural and religious practices, regional disparities, and government policies. Investigating the gaps contributing to health disparities at all levels is imperative to recommend practical measures for change.

UNDERSTANDING GENDER DYNAMICS IN NIGERIA

Women have been subject to inequities in various societies forever, and this is still a reality for many women in Nigeria today. The societal expectation of women to bear children and take care of the home is overbearing, and it has affected their socioeconomic standing and access to financial resources, which, in turn, has affected their health outcomes (Borrell et al., 2014). Societal and cultural norms have allowed for the continual patriarchy, where some men dominate women, leaving them with no social or even personal autonomy. Over the years, many initiatives to empower the role of women in Nigerian societies have been enacted, including developing a Ministry for the Affairs of Women in 1995 and equity-promoting policies, such as “affirmative action” to improve socioeconomic outcomes and equity for women (Olonade et al., 2021). Nonetheless, all these initiatives and policies have proven fruitless, leaving many women in various societies at a disadvantage and facing multiple gender-discriminating stereotypes, regulating their access to socioeconomic advantages, which has affected their good health and well-being (Lan and Tavrow, 2017).

Most health outcomes are strongly influenced by gender (Krieger, 2003) (Sen and Ostlin, 2008), and women in Nigeria continue to face drastic maternal health outcomes due to imposing gender norms that keep widening the gaps in health inequities and inequalities.

SOCIOECONOMIC CHALLENGES: POVERTY AND EDUCATION

An individual’s socioeconomic standing can be devised as the significant origin of health inequality (Cockerham, 2007). Over 60% of women account for the overall poverty level in Nigeria (Ifeanyi et al., 2019), with women in rural communities accounting for most of the percentage. The high level of maternal deaths in Nigeria can be attributed to poverty and the low status of women across communities who have subpar educational attainment. The northern part of the country is more impoverished, and a correlation between educational attainment and maternal deaths has been seen (Meh et al., 2019).

Education is pivotal in influencing women’s behavioural decisions when seeking prompt health services (Yakubu et al., 2018); however, gaps in educational inequality persist in Nigeria. Lack of access to literacy and health education resources has left women in many communities with poor health outcomes. Cultural practices most prominent in the northern part of the country involve early marriage for girls who end up not attending educational institutions, which can influence maternal mortality (Meh et al., 2019). Many studies have shown an association between women’s educational attainment and maternal mortality ratios. For example, a study in sub-Saharan Africa suggests a strong relationship between education and maternal mortality (Alvarez et al., 2009). Recently, a study in Ethiopia (Borde, 2023) showed that women with poor educational attainment are more prone to socioeconomic inequalities.

CULTURAL AND RELIGIOUS PRACTICES IN NIGERIA

Cultural practices are deeply rooted in many communities of Nigeria, especially in rural communities where women prefer to deliver their babies with the help of a traditional birth attendant who has gained a level of acceptance from living in the same community. Due to transportation and financial barriers, most women cannot access skilled birth attendants. Therefore, they have to rely solely on the expertise of traditional birth attendants who still need formal education training (Garces et al., 2019). Early marriage practices for young girls, especially in the northern culture, leading to painful and complicated pregnancies, are a contributor to maternal deaths. Additionally, religious practices in some areas where married women are prohibited by their husbands from seeing a skilled male professional during or after pregnancy have contributed to their deficient health outcomes. Families in some parts of the country are strictly traditional and do not utilize modern healthcare.

All these practices have proven detrimental to maternal mothers, and existing structural disparities have perpetuated the continual of such practices amongst populations.

REGIONAL DISPARITIES

Nigeria, the most populous country in Africa, has six geopolitical zones, with North and South as its major regions (Adebowale et al., 2012). There’s a distinct difference if we compare the population status of educational accomplishments and the accessibility of health facilities between these regions (Henry V. Doctor et al., 2012). Consequently, maternal mortality rates are disproportionally distributed, with the highest burden seen in the northern states (Meh et al., 2019), which is attributed to illiteracy and underserved and underdeveloped health facilities (Alabi et al., 2014). It has been reported that the rates of maternal deaths seen in northern states are second-rate worldwide (Henry Victor Doctor et al., 2012). Most of these mortality cases go unreported because they happen in homes, and there is poor data reporting practice across healthcare facilities (Sharma et al., 2017). Compared to the South, most women in the North do not utilise health facilities but are put to bed in their homes (Ononokpono and Odimegwu, 2014). A higher burden of maternal deaths is seen in the North due to the common practice of early marriages (Henry Victor Doctor et al., 2012). Conversely, women have been associated with the use of traditional contraception, which is mainly attributed to maternal mortality in the South (Meh et al., 2019). All these factors have contributed to outcome imbalance across regions in Nigeria.

GOVERNMENT POLICIES AND INTERVENTIONS

The Abuja Declaration in 2001 emerged as a beacon of hope through the government’s effort to boost health financing, and as a result, maternal deaths dropped from 856 to 512 per live births between 2015 and 2020 (Adegoke et al., 2022). Several programs, policies and interventions have been implemented ever since. For example, a maternal cash transfer programme, “SURE-P MCH” (Onwujekwe et al., 2020), which ran from 2012 to 2015 to facilitate efficient services for pregnant mothers was plagued with challenges (Oduenyi et al., 2019). As a result, it was not sustained to achieve significant outcomes. Several other government strategies, like the “free maternal and child health program” (Onwujekwe et al., 2019) and health insurance schemes, have shown varying outcomes across different locations in Nigeria (Mao et al., 2023). Consequently, maternal mortality is still on the rise today due to the government’s continual dismissal of addressing health as a fundamental human right through a lack of increased financing for health and strengthening of health systems, leaving thousands of women with poor health outcomes in Nigeria.

CONCLUSION AND RECOMMENDATIONS

Even though maternal deaths are preventable with strategic schemes, we can see the disturbing rate in Nigeria stems from intersectional factors that have been weaved into gender inequalities, socioeconomic factors, cultural and religious practices and ineffective governmental interventions and policies. Policymakers must not only increase accessibility to health and revitalise health systems delivery but also look into the political, social, and environmental factors as core contributors to inequities (Heise et al., 2019). Finally, with the recommendations below, the government must take comprehensive action using an intersectional lens and a multisectoral approach to save women’s lives in Nigeria.

RECOMMENDATIONS

1. Addressing gender inequity in Nigeria: The poor health outcomes of women in Nigeria can be attributed to gender inequity, which is ingrained in societies. It is imperative to prioritise equity to increase the status and freedom of women and break down existing barriers. To achieve this, we must first address the issue of poverty and low levels of education.
2. Improving access to education and empowerment strategies for women: From the above findings, we can deduce the importance of women’s educational attainment, which can influence health decision-making and reduce maternal mortality (Koch et al., 2012). Women’s empowerment through education can positively impact their decision-making capacity (Dimbuene et al., 2018), especially in a patriarchal society like Nigeria, where some women lack autonomy. Reinforcing the legal age for marriage can be a strategy to increase school attendance for girls (Meh et al., 2019). Cash transfer programs can empower women, increasing their decision-making capacity and health outcomes. This can be seen in Brazil’s success (de Brauw et al., 2014) and can be replicated by carefully considering intersecting factors to achieve positive health outcomes for women in Nigeria.
3. Addressing gaps in healthcare accessibility in Nigeria: Deploying skilled professionals, especially in rural areas and strengthening health systems’ service capacities, especially primary healthcare centres, as the first contact for women in communities. Reducing corruption in the healthcare system can improve maternal health outcomes (Lan and Tavrow, 2017). Increasing health coverage can be pivotal in curbing maternal deaths, as evidenced by a recent study in Nigeria (Mao et al., 2023). Furthermore, research has shown that many interventions primarily aim to address the proximal determinants of health without giving much attention to addressing distal factors contributing to maternal health outcomes in Nigeria (Nasir et al., 2022). Therefore, we must consider the structural conditions of living and work for people and social categorisation (Dahlgren and Whitehead, 1991). Lastly, regional disparities must be addressed to achieve proportional maternal health outcomes and universal coverage across various regions.   
4. Cultural and religious sensitive healthcare interventions: Nigeria is a multi-ethnic country with many women in communities and regions engrossed in cultural, traditional and religious practices. With that in mind, policymakers need to Initiate healthcare interventions through community involvement and empowerment strategies to assess populations’ specific needs, which can be vital in understanding cultural and religious nuances to develop effective Interventions that improve women’s health and quality of life.
5. Upscaling health data collection and research in Nigeria: Accurate monitoring and data collection practices at facility levels to track maternal mortality rates to improve outcomes (Henry Victor Doctor et al., 2012). Research around maternal health outcomes is necessary because several studies show that utilising research evidence can go a long way in boosting health policy development and implementation (Campbell et al., 2009) (Innvær et al., 2002). It has been found that foreign researchers accrue over a third of maternal and neonatal health research in Nigeria (Nasir et al., 2022); therefore, local research must be upscaled to achieve context-specific goals.

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Munira Musa Ladan
Executive Director
Elkheir Healthcare Foundation