High maternal mortality in Jigawa State, Northern Nigeria estimated using the sisterhood method

Role of men in women's health service utilisation in northern Nigeria: a qualitative study of women, men and provider perspectives

BACKGROUND

The 2018 Nigeria Demographic and Health Survey shows poor maternal health in northern Nigeria. Contraceptive use remains low and maternal mortality high. Studies show that cultural norms related to men's decision-making role in the family significantly contribute to this phenomenon.

OBJECTIVES

The assessment was designed to identify barriers to service delivery and utilisation of maternal-health and family-planning services in three northern Nigerian states, focusing on aspects of service delivery affected by husband involvement.

DESIGN

Qualitative design included 16 focus group discussions and 12 in-depth interviews with facility clients, and 16 in-depth interviews with healthcare providers, in each of the three states.

SETTING

Primary healthcare facilities in three northern Nigeria states: Bauchi, Kebbi and Sokoto.

PARTICIPANTS

Women who came to the facility for family-planning services (n=233 in 24 focus groups); women who came for antenatal care (n=97 in 12 focus groups); men married to women who either received antenatal care or delivered in a facility (n=96 in 12 focus groups); mothers of newborns who delivered in a facility (n=36) and healthcare providers (n=48).

RESULTS

We found gender barriers to contraceptive use and to obtaining maternal healthcare, with some women requiring their husband's permission to use services, even in emergencies. Several supply-side barriers exacerbate the situation. Many healthcare providers would not provide women with a family-planning method without their husbands' presence or approval; some male providers would not admit a woman to deliver in a facility if her husband objected to her being treated by a man and there was no female provider present and some facilities do not have the infrastructure to accommodate men.

CONCLUSION

Despite years of programming, barriers to women's family-planning and maternal-health service utilisation persist. State governments in northern Nigeria should invest in additional provider training, improving infrastructure and hiring more female healthcare providers.

Approaches to improve and adapt maternal mortality estimations in low- and middle-income countries: A scoping review

BACKGROUND

In the absence of robust vital registration systems, many low- and middle-income countries (LMICs) rely on national surveys or routine surveillance systems to estimate the maternal mortality ratio (MMR). Although the importance of MMR estimates in ending preventable maternal deaths is acknowledged, there is limited research on how different approaches are used and adapted, and how these adaptations function.

OBJECTIVES

To assess methods for estimating maternal mortality in LMICs and the rationale for these modifications.

SEARCH STRATEGY

A literature search with the terms "maternal death", "surveys" and "low- and middle-income countries" was performed in Medline, Embase, Web of Science, Scopus, CINAHL, APA PsycINFO, ERIC, and IBSS from January 2013 to March 17, 2023.

SELECTION CRITERIA

Studies were eligible if their main focus was to compare, adapt, or assess methods to estimate maternal mortality in LMICs.

DATA COLLECTION AND ANALYSIS

Titles and abstracts were screened using Rayyan. Relevant articles were independently reviewed by two reviewers against inclusion criteria. Data were extracted on mortality measurement methods, their context, and results.

MAIN RESULTS

Nineteen studies were included, focusing on data completeness, subnational estimates, and community involvement. Routinely generated MMR estimates are more complete when multiple data sources are triangulated, including data from public and private health facilities, the community, and local authorities (e.g. vital registration, police reports). For subnational estimates, existing (e.g. the sisterhood method and reproductive-age mortality surveys [RAMOS]) and adapted methods (e.g. RAMOS 4 + 2 and Pictorial Sisterhood Method) provided reliable confidence intervals. Community engagement in data collection increased community awareness of maternal deaths, provided local ownership, and was expected to reduce implementation costs. However, most studies did not include a cost-effectiveness analysis.

CONCLUSION

Household surveys with community involvement and RAMOS can be used to increase data validity, improve local awareness of maternal mortality estimates, and reduce costs in LMICs.

Healthcare Financing in Nigeria: A Policy Review

A good health financing system is crucial for the effective performance of a country's health system. Many health systems around the world, especially in lower- and middle-income countries such as Nigeria, grapple with perennial challenges such as chronic underfunding, wastefulness, and lack of accountability rendering these systems inefficient. Nigeria's health system faces additional extraneous challenges such as a huge and rapidly growing population, a stagnant economy, and worsening insecurity of lives and property. Furthermore, recent disease outbreaks such as the Ebola epidemic and the COVID-19 pandemic and an evolving disease demography evidenced by an increasing prevalence of chronic, noncommunicable diseases asphyxiate an already floundering health system. To address these challenges and to bolster its efforts in attaining universal health coverage (UHC) and meeting the targets of the Sustainable Development Goals, the Nigerian government launched a new health policy in 2017. A review of the health financing section of this policy shows a focus on improving funding for health care by all levels of government and guaranteeing affordable and equitable access to health services by all Nigerians, albeit with insufficient clarity on how these will be achieved. A more critical review of the country's health financing system also reveals deep-seated systemic issues. Its out-of-pocket payments for funding health care are among the highest in the world, with abysmally low government contributions to health. Successive governments seem to lack the political will to address these shortfalls. Critical gaps exist in the country's health laws, making it difficult to implement the strategies proposed in the new policy. Nigeria must strengthen its health laws to, among other things, mandate health insurance and provide adequate funding for the health system by the government. It should also formulate a dedicated, more precise health financing policy with specific, measurable aims targeting identified problems to enable it to attain universal health coverage.

High severity of abortion complications in fragile and conflict-affected settings: a cross-sectional study in two referral hospitals in sub-Saharan Africa (AMoCo study)

BACKGROUND

Abortion-related complications are one of the five main causes of maternal mortality. However, research about abortion is very limited in fragile and conflict-affected settings. Our study aims to describe the magnitude and severity of abortion-related complications in two referral hospitals supported by Médecins Sans Frontières and located in such settings in northern Nigeria and Central African Republic (CAR).

METHODS

We used a methodology similar to the World Health Organization (WHO) near-miss approach adapted in the WHO multi-country study on abortion (WHO-MCS-A). We conducted a cross-sectional study in the two hospitals providing comprehensive emergency obstetric care. We used prospective medical records' reviews of women presenting with abortion-related complications between November 2019 and July 2021. We used descriptive analysis and categorized complications into four mutually exclusive categories of increasing severity.

RESULTS

We analyzed data from 520 and 548 women respectively in Nigerian and CAR hospitals. Abortion complications represented 4.2% (Nigerian hospital) and 19.9% (CAR hospital) of all pregnancy-related admissions. The severity of abortion complications was high: 103 (19.8%) and 34 (6.2%) women were classified as having severe maternal outcomes (near-miss cases and deaths), 245 (47.1%) and 244 (44.5%) potentially life-threatening, 39 (7.5%) and 93 (17.0%) moderate, and 133 (25.6%) and 177 (32.3%) mild complications, respectively in Nigerian and CAR hospitals. Severe bleeding/hemorrhage was the main type of complication in both settings (71.9% in the Nigerian hospital, 57.8% in the CAR hospital), followed by infection (18.7% in the Nigerian hospital, 27.0% in the CAR hospital). Among the 146 women (Nigerian hospital) and 231 women (CAR hospital) who did not report severe bleeding or hemorrhage before or during admission, anemia was more frequent in the Nigerian hospital (66.7%) compared to the CAR hospital (37.6%).

CONCLUSION

Our data suggests high severity of abortion-related complications in these two referral facilities of fragile and conflict-affected settings. Factors that could contribute to this high severity in these contexts include greater delays in accessing post-abortion care, decreased access to contraceptive and safe abortion care that result in increased unsafe abortions; as well as increased food insecurity leading to iron-deficiencies and chronic anaemia. The results highlight the need for better access to safe abortion care, contraception, and high quality postabortion care to prevent and manage complications of abortion in fragile and conflict-affected settings.

Pregnancy-related acute kidney injury in the African continent: where do we stand? A systematic review

BACKGROUND

Pregnancy-Related Acute kidney injury (PR-AKI) is a global health problem with substantial maternal and fetal morbidity and mortality. However, little is known about the current situation in the developing world including African countries. Africa is the poorest continent per capita, and women from Sub-Saharan Africa alone account for 66% of the estimated global maternal deaths from preventable obstetric causes.

METHODS

OBJECTIVE: To review the literature on the clinical profile, maternal and renal outcomes of women with PR-AKI in the African continent.

SEARCH STRATEGY

Medline, ISI Web of Science, Scopus, and Cochrane library were searched in February 2022, using the MeSH terms and text key words: "pregnancy", "pregnant", "acute kidney injury", "acute renal insufficiency", "acute renal injury", "acute renal failure", and "Africa".

SELECTION CRITERIA AND DATA COLLECTION

Studies from African countries which reported maternal and renal outcomes in women with PR-AKI during pregnancy or postpartum were included. Editorials, short communications, and case reports were excluded. The study quality was assessed using the NHLBI tool. Data extraction was done using predefined data fields.

RESULTS

A total of 167 studies were evaluated, of which 14 studies from seven African countries met the inclusion criteria. Preeclampsia, obstetric hemorrhage, and sepsis represented the main causes of PR-AKI. Maternal mortality ranged between 0 and 34.4%. Although the majority of women needed ICU admission and hemodialysis, renal recovery occurred in 53.1-90% of patients. Perinatal mortality has been reported to be 1.5-60.5% in the included studies.

AUTHORS' CONCLUSIONS

PR-AKI in Africa represents the second leading cause of AKI. Limited access to obstetric care, late referral, and late diagnosis of women with risks for PR-AKI hinder the curtailment of the problem. Provision of health care facilities with adequately trained personnel and implementation of preventive strategies will be of great value in decreasing the magnitude of the problem.

Trends in and predictors of pregnancy termination among 15-24 year-old women in Nigeria: a multi-level analysis of demographic and health surveys 2003-2018

BACKGROUND

Three-quarters of pregnancy terminations in Africa are carried out in unsafe conditions. Unsafe abortion is the leading cause of maternal mortality among 15-24 year-old women in Sub-Saharan Africa. Greater understanding of the wider determinants of pregnancy termination in 15-24 year-olds could inform the design and development of interventions to mitigate the harm. Previous research has described the trends in and factors associated with termination of pregnancy for women of reproductive age in Nigeria. However, the wider determinants of pregnancy termination have not been ascertained, and data for all women have been aggregated which may obscure differences by age groups. Therefore, we examined the trends in and individual and contextual-level predictors of pregnancy termination among 15-24 year-old women in Nigeria.

METHODS

We analysed data from the 2003, 2008, 2013 and 2018 Nigerian Demographic and Health Surveys (NDHS) comprising 45,793 women aged 15-24 years. Trends in pregnancy termination across the four survey datasets were examined using bivariate analysis. Individual and contextual predictors of pregnancy termination were analysed using a three-level binary logistic regression analysis and are reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

Trends in pregnancy termination declined from 5.8% in 2003 to 4.2% in 2013 then reversed to 4.9% in 2018. The declining trend was greater for 15-24 year-old women with higher socioeconomic status. Around 17% of the total variation in pregnancy termination was attributable to community factors, and 7% to state-level factors. Of all contextual variables considered, only contraceptive prevalence (proxy for reproductive health service access by young women) at community level was significant. Living in communities with higher contraceptive prevalence increased odds of termination compared with communities with lower contraceptive prevalence (aOR = 4.2; 95% CI 2.7-6.6). At the individual-level, sexual activity before age 15 increased odds of termination (aOR = 2.3; 95% CI 1.9-2.8) compared with women who initiated sexual activity at age 18 years or older, and married women had increased odds compared with never married women (aOR = 3.0; 95% CI 2.5-3.7).

CONCLUSION

Our findings highlight the importance of disaggregating data for women across the reproductive lifecourse, and indicates where tailored interventions could be targeted to address factors associated with pregnancy termination among young women in Nigeria.

"That's a woman's problem": a qualitative analysis to understand male involvement in maternal and newborn health in Jigawa state, northern Nigeria

Background

Maternal and newborn mortality continue to be major challenges in Nigeria. While greater participation of men in maternal and newborn health has been associated with positive outcomes in many settings, male involvement remains low. The objective of this analysis was to investigate male involvement in maternal and newborn health in Jigawa state, northern Nigeria.

Methods

This qualitative study included 40 event narratives conducted with families who had experienced a maternal or newborn complication or death, in-depth interviews with 10 husbands and four community leaders, and four focus group discussions with community health workers. The interviews focused on understanding illness recognition and care seeking as well as the role of husbands at each stage on the continuum of maternal and newborn health. Data were transcribed, translated to English, and coded and analyzed using Dedoose software and a codebook developed a priori.

Results

This paper reports low levels of knowledge of obstetric and newborn complications among men and limited male involvement during pregnancy, childbirth and the post-partum period in Jigawa state. Men are key decision-makers around the location of the delivery and other decisions linked to maternal and newborn health, and they provide crucial resources including nutritious foods and transportation. However, they generally do not accompany their wives to antenatal visits, are rarely present for deliveries, and do not make decisions about complications arising during delivery and the immediate post-partum period. These gendered roles are deeply ingrained, and men are often ridiculed for stepping outside of them. Additional barriers for male involvement include minimal engagement with health programs and challenges at health facilities including a poor attitude of health providers towards men and accompanying family members.

Conclusion

These findings suggest that male involvement is limited by low knowledge and barriers related to social norms and within health systems. Interventions engaging men in maternal and newborn health must take into account these obstacles while protecting women’s autonomy and avoiding reinforcement of gender inequitable roles and behaviors.

Mitigating Gender and Maternal and Child Health Injustices through Faith Community-Led Initiatives

BACKGROUND AND OBJECTIVE

Congregational Health Empowerment and Social Safety Advocates (CHESS-Advocates) initiative, a project aimed at mitigating maternal and child health (MCH) and gender injustices in religiously pluralistic societies, was implemented in two Northern Nigerian states of Benue and Kaduna between September 2018 and July 2019. The objective of this study was to assess the effectiveness, sustainability and factors of success in the CHESS-Advocates model as a faith community approach to mitigating gender and MCH injustices in Northern Nigeria.

METHODS

Data were from desk review of monthly project reports which were documented monthly all through the 10-month project life, and qualitative assessment conducted in July 2019 at the end of project. The assessments involved focus group discussions, key informant interviews, and in-depth interviews conducted in four randomly selected communities in each of the project states. The variables of interest were sustainability, effectiveness of initiative, and the factors that contributed to the success of the program.

RESULTS

The CHESS-Advocate model was effective in the mobilization of community response that improved uptake and acceptance of antenatal care (ANC), immunization, and uptake of human immunodeficiency virus (HIV) testing services. The model was cost-effective and able to instigate change in harmful practices, particularly in highly religious communities. The model showed promise of sustainability and identified some factors that led to its success in the different communities.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

The CHESS advocates model showed promises of efficacy in engaging faith communities as important actors in promoting MCH practices and mitigating gender injustices particularly in rural and underserved communities. Like other faith based models, the CHESS-Advocates model provided opportunities in faith congregations for building sustainable development in health and social justice. The model helped to improve MCH seeking behavior, influenced change in harmful gender norms and in community response against gender based violence in rural communities.

Associations between birth kit use and maternal and neonatal health outcomes in rural Jigawa state, Nigeria: A secondary analysis of data from a cluster randomized controlled trial

BACKGROUND

The burden of maternal and neonatal mortality remains persistently high in Nigeria. Sepsis contributes significantly to both maternal and newborn mortality, and safe delivery kits have long been promoted as a cost-effective intervention to ensure hygienic delivery practices and reduce sepsis. However, there is limited evidence on the effectiveness of home birth kit distribution by community health workers, and particularly the impact of this intervention on health outcomes. This paper reports a secondary analysis of data from a cluster randomized trial in rural northern Nigeria in which birth kits were distributed by community health workers to pregnant women in their homes, analyzing non-experimental variation in receipt and use of birth kits. More specifically, associations between pregnant women's baseline characteristics and receipt and use of birth kits, and associations between birth kit use, care utilization and maternal and newborn outcomes were assessed.

METHODS AND FINDINGS

Baseline, post-birth and endline data related to 3,317 births observed over a period of three years in 72 intervention communities in Jigawa state, Nigeria, were analyzed using hierarchical, logistic regression models. In total, 140 women received birth kits, and 72 women used the kits. There were no associations between baseline demographic characteristics, health history, and knowledge and attitudes and receipt of a kit, suggesting that community health workers did not systematically target the distribution of birth kits. However, women who used the kit reported reduced odds of past pregnancy complications (OR = 0.44, 95% CI: 0.19-1.00) as well as significantly higher odds of feeling generally healthy at baseline (OR = 2.00, 95% CI: 1.06-3.76), of exposure to radio media (OR = 1.97, 95% CI: 1.21-3.22), and of perceiving themselves as having a low-risk pregnancy (OR = 3.05, 95% CI:1.39-6.68). While there were no significant associations between birth kit use and facility based delivery, skilled birth attendance or post-natal care, women who used a kit exhibited significantly lower odds of completing four or more ANC visits (adjusted OR = 0.39, 95% CI: 0.18-0.85) and significantly higher odds of reporting prolonged labor (adjusted OR = 4.75, 95% CI: 1.36-16.59), and post-partum bleeding (adjusted OR = 3.25, 95% CI: 1.11-9.52).

CONCLUSIONS

This evidence suggests that use of birth kits is low in a rural population characterized by minimal baseline utilization of maternal and neonatal health services, and the use of birth kits was not associated with reductions in maternal or neonatal morbidity. While further research is required to understand how the effectiveness of birth kits may be shaped by the mechanism through which women access and utilize the kits, our findings suggest that the provision of kits to women outside of the formal health system may be associated with increased risk of adverse outcomes.

Maternal mortality ratio in selected rural communities in Kebbi State, Northwest Nigeria

Background

Maternal mortality remains a topical issue in Nigeria. Dearth of data on vital events posed a huge challenge to policy formulation and design of interventions to address the scourge. This study estimated the lifetime risk (LTR) of maternal death and maternal mortality ratio (MMR) in rural areas of Kebbi State, northwest Nigeria, using the sisterhood method.

Methods

Using the sisterhood method, data was collected from 2917 women aged 15–49 years from randomly selected rural communities in 6 randomly selected local government area of Kebbi State. Retrospective cohort of their female siblings who had reached the childbearing age of 15 years was constructed. Using the most recent total fertility rate for Kebbi State, the lifetime risk and associated MMR were estimated.

Result

A total of 2917 women reported 8233 female siblings of whom 409 had died and of whom 204 (49.8%) were maternal deaths. This corresponds to an LTR of 6% (referring to 11 years before the study) and an estimated MMR of 890 deaths/100,000 live births (95% CI, 504–1281).

Conclusion

The findings provide baseline information on the MMR in rural areas of the State. It underscores the need to urgently address the bane of high maternity mortality, if Kebbi State and Nigeria in general, will achieve the health for all by year 2030 as stated in the Sustainable Development Goals (SDGs).

Electronic supplementary material

The online version of this article (10.1186/s12884-018-2125-2) contains supplementary material, which is available to authorized users.

The influence of the social and cultural environment on maternal mortality in Nigeria: Evidence from the 2013 demographic and health survey

Introduction

Reducing maternal mortality remains a priority for global health. One in five maternal deaths, globally, are from Nigeria.

Objective

This study aimed to assess the sociocultural correlates of maternal mortality in Nigeria.

Methods

We conducted a retrospective analysis of nationally representative data from the 2013 Nigeria Demographic and Health Survey. The analysis was based on responses from the core women’s questionnaire. Maternal mortality was categorized as ‘yes’ for any death while pregnant, during delivery or two months after delivery (as reported by the sibling), and ‘no’ for deaths of other or unknown causes. Multilevel logistic regression analysis was conducted to test for association between maternal mortality and predictor variables of sociocultural status (educational attainment, community women’s education, region, type of residence, religion, and women’s empowerment).

Results

Region, Religion, and the level of community women’s education were independently associated with maternal mortality. Women in the North West were more than twice as likely to report maternal mortality (OR: 2.14; 95% CI: 1.42–3.23) compared to those in the North Central region. Muslim women were 52% more likely to report maternal deaths (OR: 1.52; 95% CI: 1.10–2.11) compared to Christian women. Respondents living in communities where a significant proportion of women have at least secondary schooling were 33% less likely to report that their sisters died of pregnancy-related causes (OR: 0.67; 95% CI: 0.48–0.95).

Conclusion

Efforts to reduce maternal mortality should implement tailored programs that address barriers to health-seeking behavior influenced by cultural beliefs and attitudes, and low educational attainment. Strategies to improve women’s agency should be at the core of these programs; they are essential for reducing maternal mortality and achieving sustainable development goals towards gender equality. Future studies should develop empirically evaluated measures which assess, and further investigate the association between women’s empowerment and maternal health status and outcomes.