Ending Maternal Deaths in Nigeria: A Multifaceted and All-Encompassing Approach

Author: Dr Azuka Ezeike MBBS, FWACS, FMCOG, MSc(PH)

Highlights

• Maternal mortality remains a critical issue in Nigeria, accounting for more than 20% of global maternal deaths.
• The 3-delay model highlights key delays that contribute to maternal deaths: delays in seeking care, reaching healthcare facilities, and receiving quality care.
• Primary prevention focuses on reducing maternal risks before pregnancy through improved nutrition, girl-child education, financial empowerment, access to family planning services, and a supportive legal framework for policy implementation.
• Secondary prevention ensures early detection and management of pregnancy-related risks, emphasizing quality antenatal care, delivery care, and postnatal care.
• Tertiary prevention involves emergency interventions to prevent maternal deaths, including improved critical care facilities, functional emergency services, and efficient referral and ambulance systems.
• Addressing maternal mortality requires synergy among individuals, community and religious stakeholders, healthcare workers, policymakers, and the government.

Prologue

The sad end of Mrs M

Mrs. M married her longtime friend and became pregnant within a few months. She had a smooth pregnancy; however, towards the end, she developed high blood pressure, which led to a Caesarean section (C-section). The same complication occurred in her second pregnancy, requiring another C-section.

During her third pregnancy, she felt distressed about having another C-section and was determined to have a vaginal delivery. As a result, she refused to book antenatal care, intending to wait until labour had advanced at home before going to the hospital.

When labour started, the contractions became intense while she was still at home. Unfortunately, her husband was at work. When she called, he rushed home but was delayed by heavy traffic. With no available vehicle to take her to the hospital, she remained at home in distress.

By the time her husband arrived, she was already bleeding. He rushed her to the nearest hospital, but they refused to admit her due to a power outage and a faulty generator. At the second hospital, they were told that no doctor was available that night. By the time they reached the third hospital, she had already passed away.

This story highlights the grim reality of maternal deaths in Nigeria. The challenges range from poor health-seeking behaviour and inadequate transportation systems to a dysfunctional healthcare system.

Introduction

Maternal mortality is the death of a woman during pregnancy or within 42 days of the end of the pregnancy. Over time, various efforts have been made to combat maternal mortality. These initiatives date back to the 1987 Safe Motherhood Conference in Nairobi, the 1994 International Conference on Population and Development in Cairo, Egypt, and the 1995 Fourth World Conference on Women in Beijing. Despite these efforts, maternal deaths remain alarmingly high.

As of 2020, Nigeria accounted for 28.5% of global maternal deaths, a statistic that underscores the urgent need for effective preventive measures. According to the World Health Organization (WHO) 2023 report, Nigeria had the second-highest maternal mortality ratio globally, with 1,047 deaths per 100,000 live births, surpassed only by South Sudan with 1,223 deaths per 100,000 live births and Chad with 1,063 deaths per 100,000. This figure is more than double the maternal mortality ratio cited in the Nigerian Demographic and Health Survey (NDHS) 2018. Moreover, it is a stark contrast to the 2030 Sustainable Development Goal (SDG) target of reducing maternal mortality to 70 deaths per 100,000 live births.

Causes, levels of delay, and levels of prevention of maternal mortality

Causes of maternal mortality

Pregnant women in Nigeria die from various causes, notably :

• High blood pressure
• Bleeding
• Sepsis (infection)
• Unsafe abortion
• Obstructed labour

Levels of delay leading to maternal mortality

The 3-delay model was described in 1994 by Thaddeus and MaineThese three key delays contribute to maternal deaths:

1. Delay in seeking care – Often due to a lack of awareness, cultural beliefs, or financial constraints.
2. Delay in reaching a healthcare facility – Caused by poor transportation systems or geographic barriers.
3. Delay in receiving care at a health facility – Due to inadequate staffing, lack of medical supplies, or inefficient hospital protocols.

The case scenario presented earlier illustrates the interplay of these delays in maternal mortality.

Levels of prevention

Maternal mortality can be prevented through three levels of intervention:

• Primary prevention – Actions taken before pregnancy.
• Secondary prevention – Care provided during pregnancy.
• Tertiary prevention – Emergency and specialized care for complications during pregnancy

This article will discuss the prevention of maternal deaths in relation to its causes and these levels of delay.

Preventive measures for maternal deaths in Nigeria

Primary prevention

These measures are put in place before a woman gets pregnant. They include:

• Improving nutrition for the girl child
• Enforcing girl child education
• Women’s financial empowerment
• Prevention of unsafe abortion
• Health literacy campaigns
• Challenging and changing negative cultural norms
• Improving the experience of care
• Provision of family planning services
• Strengthening the health system
• Preconception Care
• Functional maternal death response systems
• Strengthening data collection systems
• Creating the enabling legal climate for policy implementation
• Combating corruption

Improving nutrition for the girl child

Improving nutrition plays a crucial role in supporting women of childbearing age, helping to prevent conditions like bony deformities such as rickets, which can lead to obstructed labour. It also helps reduce the risk of anaemia and infections, which can complicate pregnancy. [1]Malnutrition is often linked to poverty, with many families struggling to access enough food. Improving employment opportunities, creating an enabling environment for entrepreneurship, providing microcredit to traders, and enhancing food security by supporting farmers to boost food production can all help combat malnutrition. Additionally, school feeding programs are an effective strategy for preventing childhood malnutrition.

Enforcing girl child education

Evidence shows that education is a key social determinant of health. Girls' education influences health-seeking behaviours and empowers them to make informed choices.Although Nigeria's Child Rights Act provides for girls' education, its implementation remains limited due to weak enforcement, poverty, insecurity, and other barriers. To reduce maternal mortality, ensuring that girls receive at least a secondary school education should not only be mandated but also strictly enforced.

Women’s financial empowerment

The financial empowerment of women enhances their ability to make life choices and control resources. There have been cases where women bled to death at home due to a lack of money for transportation to a health facility. Financial empowerment improves a woman's purchasing power, including access to healthcare services and commodities.

Providing women with access to microcredit and savings schemes can strengthen their financial stability, equipping them to better care for themselves. Additionally, educating girls increases their chances of gaining meaningful employment. Women's empowerment leads to increased access to skilled birth attendants during delivery, improved antenatal care attendance, and greater utilization of family planning services.

The Maternal and Neonatal Mortality Reduction Innovation and Initiative (MAMII) project, recently launched by the Nigerian government, has the potential to significantly reduce maternal mortality if properly implemented and monitored.

Enhancing health insurance coverage and either subsidizing or making maternal care services free can reduce the financial barriers that limit access to care. On May 19, 2022, the National Health Insurance Act  was signed into law, making health insurance mandatory. However, this mandate is yet to be fully realized, as many women in rural areas remain unaware of the policy. Ensuring the effective implementation of this law will improve women's access to healthcare services.

Prevention of unsafe abortion

Unsafe abortion is one of the five most common causes of death in Nigeria. Deaths due to unsafe abortion account for 13% of all maternal deaths, and Africa contributes to nearly two-thirds of all abortion-related deaths. Unsafe abortion refers to the termination of a pregnancy performed by individuals lacking the necessary skills, in an environment that does not meet minimal medical standards, or both.Abortion is illegal in Nigeria except when the mother's life is threatened. As a result, many unwanted pregnancies end in unsafe abortions. Prevention measures include sex education, the provision of contraceptives, and access to post-abortion care facilities. Additionally, providing safe homes for unmarried girls with unwanted pregnancies can help prevent them from resorting to unsafe abortion by protecting them from public condemnation and stigma.

Health literacy campaigns

There is a significant association between maternal health literacy levels and health service utilization. Even when women are educated, they still need specific education on health issues. Education on the labour process is needed to encourage appropriate health-seeking behaviour. Due to the influence of family, culture, religion, and community structures on health-seeking behaviours, health literacy campaigns should also target men, other family members, and community stakeholders.

Challenging and changing negative cultural norms

Culture and religion influence women's health and their utilization of healthcare services. Cultural practices such as female genital mutilation can damage the female genital tract and increase childbirth complications. The patriarchal societal structure and female disinheritance patterns also undermine women's rights, limiting their decision-making power and access to healthcare services. Additionally, religious beliefs about orthodox medical care can impact health service utilization. Deliberate efforts through education, advocacy, and legislation are needed to challenge these harmful norms.

Improving the experience of care

Evidence has shown that the challenge is not just the availability of health services but also the reluctance to use them, even when they are accessible. This is largely due to the community's poor perception of healthcare service delivery. Some women may choose to give birth at home or in traditional birth centres, even when healthcare facilities are available.A positive childbirth experience encourages better utilization of maternal health care services. More research on the perception of care is needed to generate evidence that can drive interventions aimed at improving the healthcare experience. [2] 

Provision of family planning services

Unregulated fertility is a major risk factor for maternal deaths. In Nigeria, some women give birth too frequently and too much, which reduces their ability to cope with pregnancy and significantly increases health risks. According to the 2023/2024 National Demographic and Health Survey, 21% of currently married women and 36% of sexually active unmarried women have an unmet need for family planning.

In a statement at the 8th Nigeria Family Planning Conference in 2024, the Honourable Minister of Health, Muhammad Ali Pate, stated that Nigeria hopes to improve contraceptive usage by integrating family planning into antenatal care, immunization programs, HIV treatment programs, and the health insurance scheme. This initiative if well implemented aims to reduce the health burden caused by unplanned pregnancies.

Strengthening the health system 

Nigeria has a weak health system characterized by poor infrastructure, an inadequate distribution of health facilities, a shortage of healthcare workers, and under-equipped hospitals.To improve the quality of care, it is essential to increase the number of health facilities, particularly primary healthcare centres, and ensure the adequate distribution of healthcare workers, including in rural areas. Enhancing access roads to health facilities and ensuring a sufficient supply of medical equipment and essential medicines are also crucial steps.Additionally, training and retraining healthcare workers in best practices will enhance service delivery. Providing opportunities for facility users to give feedback and share their experiences can help identify gaps and drive improvements in healthcare processes. 

Preconception Care

Some women enter women with preexisting diseases and conditions like hypertension, diabetes and obesity. These conditions increase the risk of pregnancy. Preconception care is a set of interventions that are to be provided before pregnancy, to promote the health and well-being of women and couples, as well as to improve the pregnancy and child health outcomes.In Nigeria, preconception care is not yet widely implemented due to a lack of awareness, unplanned pregnancies, poor health-seeking behaviour, and suboptimal healthcare practices [3].To improve maternal and child health, preconception care should be institutionalized in health facilities across the country.

Functional maternal death response systems 

No woman should die in vain; therefore, every maternal death must be investigated. A Maternal Death Surveillance and Response (MDSR) system aims to prevent future maternal deaths by analyzing previous cases. Data on each death, along with studies and recommendations, should be used to guide preventive measures. These reviews should be conducted with confidentiality and a blame-free approach.

The WHO recommends that countries establish a Maternal and Perinatal Death Surveillance and Response (MPDSR) system to reduce maternal and perinatal deaths (death of a baby before or soon after birth) through continuous monitoring and action. While significant policy changes have been made in response to this, implementation remains poor.

In Nigeria, every hospital should have an MPDSR unit dedicated to this role, ensuring that all maternal deaths are properly investigated. This unit should report its findings to a central authority responsible for analyzing data and coordinating intervention efforts.

Strengthening data collection systems

A well-functioning healthcare system relies on accurate, high-quality data to guide decision-making and policy implementation. Collecting sex-disaggregated population data is essential for designing effective programs that address the unique challenges faced by women.

The Nigeria Demographic and Health Survey (NDHS) plays a crucial role in tracking key health statistics, but there is an urgent need to improve its quality. The maternal mortality ratio (MMR), a critical measure of maternal health, should be consistently included in all editions of the survey. Additionally, robust monitoring mechanisms must be established to ensure data integrity, prevent underreporting, and enhance the reliability of maternal health statistics.

Strengthening data collection and utilization will enable evidence-based interventions and targeted resource allocation, ultimately contributing to the reduction of maternal mortality in Nigeria.

Creating the enabling legal climate for policy implementation

Despite the existence of numerous international treaties, agreements, and national policies aimed at improving maternal health, implementation remains a major challenge in Nigeria. Key frameworks such as the Abuja Declaration (2001) and the Maputo Protocol (2003) were established to protect women's health rights and ensure adequate healthcare funding. However, years after their adoption, these commitments remain largely unfulfilled.

Similarly, several domestic policies and initiatives have fallen short of their intended impact due to weak enforcement mechanisms and a lack of sustained political will. Strengthening the legal framework and ensuring strict oversight of these policies are crucial for driving meaningful implementation. With the right legal supervision and accountability structures in place, Nigeria would significantly reduce maternal mortality and improve healthcare outcomes for women nationwide.

Combating corruption

In 2024, Nigeria ranked 140th out of 180 countries on the Corruption Perceptions Index  by Transparency International. While this may not directly impact maternal deaths, corruption indirectly affects maternal health.When funds allocated for maternal care services are either diverted or underutilized, essential healthcare services are not delivered. Despite government and donor agency investments, some healthcare centres remain non-functional. Ensuring transparency in service provision is crucial to preventing the inefficiencies and resource wastage caused by corruption.

Secondary Prevention

Secondary prevention are measure to ensure a safe pregnancy. They include: 

• Ensuring antenatal care coverage 
• Skilled attendance at childbirth
• Adequate post-delivery care

 Ensuring Antenatal Care Coverage

Evidence shows that antenatal care reduces maternal deaths. Unfortunately, some women become pregnant but receive no medical supervision throughout their pregnancy.

Data from the 2023/2024 National Demographic Health Survey indicate that only about 63% of the sampled women received antenatal care. Antenatal care helps prevent pregnancy complications through early detection, preventive measures, and timely interventions. Interventions such as tetanus vaccination, iron and vitamin supplementation, malaria preventive therapy, and the use of insecticide-treated nets play a crucial role in reducing risks.

Factors such as illiteracy, lack of funds, and the unavailability of healthcare facilities and resources hinder access to antenatal care services in Nig. Addressing these barriers is essential to improving maternal health. The involvement of men during the antenatal period also helps to improve maternal care. The incorporation of telemedicine into antenatal care into antenatal care will also help to bridge care gaps.

Skilled attendance at childbirth

Most maternal deaths are linked to complications that arise around the time of birth. Figures from the 2023/2024 National Demographic Health Survey (NDHS) show that 43% of live births and 51% of stillbirths in the two years preceding the survey occurred in health facilities.

One major advantage of delivering in a health facility is the presence of skilled birth attendants (SBAs) and trained healthcare professionals such as doctors, nurses, or midwives who provide maternal health services during pregnancy, childbirth, and the postpartum period. When a skilled birth attendant oversees delivery, the risk of complications like obstructed labour, infections, and excessive bleeding is significantly reduced.

However, there is a shortage of functional healthcare facilities and skilled healthcare workers, especially in rural areas. Strategies must be implemented to ensure the availability of both. These include improving working conditions, such as better remuneration and incentives for healthcare workers willing to serve in villages, enhancing security, and increasing the training of health professionals.

Additionally, community education and advocacy should involve local stakeholders to discourage harmful practices that lead women to deliver at home, with untrained traditional birth attendants, or in worship centres.

Adequate post-delivery care

Maternal mortality includes deaths that occur within 42 days of delivery, so care should not end once a woman has given birth. Most maternal deaths happen within the first month after childbirth, with nearly half occurring within the first 24 hours. Some complications may arise after delivery, particularly within this critical period. Adequate postnatal care helps prevent, detect early, and treat complications, ultimately reducing maternal deaths.

In some health facilities in Nigeria, women are discharged just a few hours after giving birth. Data from the 2023 National Demographic Health Survey showed that only 43% of women received postnatal care. This is despite the World Health Organization (WHO) recommendation that a newly delivered mother should be monitored at the facility for at least 24 hours and receive additional check-ups until the sixth week after birth.

 Caregivers, women and healthcare workers should be educated on the need to ensure compliance with postnatal appointments.

Tertiary prevention

Even when the necessary measures are put in place, some pregnancies may still complicated and thus there is a need for tertiary preventive measures when such arise

These include

• Optimal referral system 
• Functional ambulance services
• Availability of critical care facilities
• Blood transfusion services
• Emergency Obstetric services

Optimal referral system

When the referral system is poor, the risk of maternal death increases. In Nigeria, it is not uncommon for a pregnant woman with complications to be referred to another facility without prior notice to the receiving facility. In some cases, the patient may not be accepted at multiple facilities due to a lack of bed space or capacity to manage such complications. Some women even die along the way as they are transported from one facility to another.

Optimal referral should involve proper documentation, communication with the receiving facility, and feedback to the referring facility. There should also be a central database with contact details of all health facilities within a locality, which should be circulated among all facilities in the area.

The use of ICT services to facilitate communication between health facilities is recommended. For example, a central WhatsApp group that includes all health facilities in a locality can help ensure proper communication. Additionally, the development of country-specific referral guidelines can make referrals more efficient and help prevent maternal deaths.[4]

Functional ambulance systems

Patients usually bear the burden of transportation from their homes to healthcare facilities and, in some cases, even between facilities. This is due to the lack of emergency ambulance services, unlike in developed countries.

Type 2 delay refers to a delay in reaching the place of care, often caused by transportation challenges such as unavailability or high costs of transport. To address this issue, the Nigerian Federal Government, in February 2025, established the Rural Emergency Services and Maternal Transport Program under the National Emergency Services and Ambulance System (NEMSAS). This program aims to ease transportation difficulties in rural areas.

To ensure that the program meets its objectives, proper mapping of high-need areas is essential to deploy resources effectively. Additionally, the program must be adequately funded and monitored. The use of GPS-enabled ambulances can also improve navigation and transport efficiency during emergencies.

Availability of critical care facilities

The COVID-19 pandemic highlighted the urgent need for critical care facilities in the country. When pregnancy becomes complicated, admission to an intensive care unit (ICU) and other critical care interventions may be required. Sometimes, patients are referred from one facility to another due to the lack of critical care services.

Evidence from a WHO multicountry survey on maternal and newborn health shows that the availability of ICU services is associated with a lower maternal mortality rate. Making these services readily accessible, especially to rural populations in Nigeria, will help reduce maternal deaths.[5]

Making blood transfusion services available

Bleeding before and after delivery is the most common cause of maternal deaths in Nigeria. There is a direct link between the lack of blood transfusion services and maternal mortality. Some women require multiple blood transfusions to survive a bleeding episode, and if these services are unavailable, the risk of death increases.

In some localities, safe blood transfusion services are lacking due to inadequate infrastructure and a shortage of voluntary blood donors. Encouraging voluntary blood donation, providing blood transfusion infrastructure, decentralizing these services, and integrating them into maternal health care can help prevent maternal deaths due to anaemia.

Emergency Obstetric Services 

Emergency obstetric care refers to a range of services used in managing complications during pregnancy. These services are divided into basic and comprehensive care.Basic emergency obstetric care includes the following:

• Administration of parenteral (intravenous or intramuscular) antibiotics, uterotonics (drugs that help the womb to contract), and anticonvulsants (drugs used to treat convulsion)
• Manual removal of the placenta
• Removal of retained products of pregnancy(after a miscarriage)
• Assisted vaginal delivery, and neonatal resuscitation.

Comprehensive emergency obstetric care includes

•  Blood transfusion
•  Surgery (Caesarean section). 

The World Health Organization recommends that there should be at least five emergency obstetric care facilities (including at least one comprehensive facility) for every 500,000 people.However, remote and hard-to-reach areas in Nigeria still lack functional emergency obstetric care facilities, contributing to maternal deaths. Ensuring an adequate distribution of these facilities, particularly in rural areas, would help reduce maternal mortality.

Conclusion

Maternal mortality in Nigeria remains high, but it is preventable with strategic multifaceted interventions. Addressing socioeconomic barriers, improving maternal health literacy, and strengthening healthcare infrastructure are essential. Policymakers, medical experts, and communities working together can save countless lives and drastically lower maternal mortality.

References

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2. Ope BW. Reducing maternal mortality in Nigeria: addressing maternal health services’ perception and experience. Journal of Global Health Reports [Internet]. 2020 May 18 [cited 2025 Mar 19];4:e2020028. Available from: https://www.joghr.org/article/12733-reducing-maternal-mortality-in-nigeria-addressing-
3. Opayele BF, Ohaeri BM, Ojo IO, Babarimisa O. Preconception care: an untapped route towards reducing infant and maternal mortality in Nigeria. European Journal of Medical and Health Sciences [Internet]. 2022 Dec 29 [cited 2025 Mar 23];4(6):38–41. Available from: https://ej-med.org/index.php/ejmed/article/view/154 
4. Ameyaw EK, Njue C, Tran NT, Dawson A. Quality and women’s satisfaction with maternal referral practices in sub-Saharan African low and lower-middle income countries: a systematic review. BMC Pregnancy and Childbirth [Internet]. 2020 Nov 11 [cited 2025 Mar 21];20(1):682. Available from: https://doi.org/10.1186/s12884-020-03339-3
5. Soares FM, Pacagnella RC, Tunçalp Ö, Cecatti JG, Vogel JP, Togoobaatar G, et al. Provision of intensive care to severely ill pregnant women is associated with reduced mortality: Results from the WHO Multicountry Survey on Maternal and Newborn Health. Int J Gynaecol Obstet [Internet]. 2020 Sep [cited 2025 Mar 21];150(3):346–53. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7496974/

Published March 25, 2025