Determinants of Maternal Mortality in Nigeria

Cite this article as: Hashimu R. (2025). Determinants of Maternal Mortality in Nigeria.Zamfara International Journal of Humanities,3(2), 64-72.www.doi.org/10.36349/zamijoh.2025.v03i02.007

DETERMINANTS OF MATERNAL MORTALITY IN NIGERIA

Rabia Hashimu

Department of Sociology

Sokoto State University, Sokoto

Abstract: Maternal mortality continues to pose a critical public health issue in Nigeria, which ranks among the countries with the highest maternal death rates worldwide. The leading causes of maternal mortality in Nigeria are a combination of medical conditions and socio-cultural factors, including obstetric hemorrhage, eclampsia, infections, and unsafe abortions. The general objective of this paper is to examine the social determinant of maternal mortality in Nigeria. These are preventable with timely and quality healthcare intervention. However, Nigeria's socio-economic and cultural context presents considerable challenges. High poverty levels, particularly in northern areas, limited healthcare facilities, widespread illiteracy, and deeply rooted patriarchal norms exacerbate the situation. Cultural practices such as sex preference, harmful practices like female genital mutilation worsen the problem. In many conservative communities, women’s decision-making autonomy is constrained, limiting their ability to pursue necessary healthcare. The paper recommends improvements in healthcare infrastructure, the empowerment of women through education and autonomy, and efforts to eradicate harmful cultural practices.

Keywords: Maternal Mortality, Maternal Health, Pregnant Women

Introduction

One of the main worldwide health related difficulties is maternal mortality. According to United Nations inter-agency projections, there were 287,000 maternal deaths worldwide in (2020), a 34% decrease from 342 deaths to 223 deaths per 100,000 live births. World Health Organization (2020) revealed that the maternal mortality ratio in the African region was estimated at 531 deaths per 100,000 live births, countries such as Nigeria, Chad and South Sudan have had the most extreme mortality rate in the region. Nigeria a nation with vast cultural and religious background, riched with homogeneous tradition social settings where its communities are inclined with their conservative way of life

While Sub Saharan Africa and South Asia accounted for around 87% of all maternal deaths Worldwide. Despite the fact that efforts by the developmental organizations such as WHO, UNICEF etc still maternal mortality has become a global concern that needs to be addressed to ensure it reduces drastically so that no woman will die as a resulted of preventive maternal death complications. This is part of the Sustainable Development Goals SDGs 3 to ensure well being among humanities. According to a report by the United Nations Children’s Fund in (2023), the global maternal mortality ratio decrease to 38% between 2000 and 2017. This was translated by the UN to 2% per year. Maternal mortality is the death of a woman while pregnant or 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 unintentional or incidental causes (WHO, 2019).

According to the United Nations in 2022, approximately 512 women per 100,000 live births die due to complications related to pregnancy and childbirth in Nigeria. This translates to roughly 58,000 maternal deaths annually in the country. The persistent increased of maternal death in the country adversely affect the lifespan of women especially those who live in the rural areas. This is becoming devastated and was as a result of some factors that contributed immensely to this negative outcome in the state. Factors such as limited access to medical healthcare services, shortage of skilled birth attendant, lack of emergency obstetrics care often led to women to found themselves in vulnerable situations.

In the most recent rating, Nigeria is the 6^th   most populous country in the world because it’s a home to more than 228.38 million people and the 6^th most populous country in the world and the most populated country in Africa (UN Turkish Statistical Institute, 2024). According to the global health assessment report on maternal mortality ratio by WHO (2020) shows that Nigeria accounted for 12% of global maternal, still birth, and newborn mortality while India accounted for 17%.

A study by Ezugwu et al (2017) in Transitional hospital Enugu State Nigeria, shows that there were 60 maternal death during the five year period and there was 7, 574 delivery, 810/100 live birth. A national maternal mortality rate was 545 deaths per 100,000 in 2008 and 576 deaths per 100,000 in 2013. Though, studies have revealed that maternal deaths rates differ across the nation. However, when compared to the national average Nigeria’s maternal death rate is higher than the other. For example, in 2008 the rate of maternal mortality in states such as kano was 1,600 deaths per 100,000 live births (Galadanci, et al, 2010).

While in Zamfara, report indicated 1,049 deaths per 100,000 live births (Doctor & Olatunji, 2012). However, health facility at three states eg Katsina, Lagos, and the Federal Capital Territory shows the rate of maternal mortality with 927 deaths per 100,000 live births (Fawolle AO, 2012). Also, Sokoto is among the state in Nigeria with high rate of maternal death over the years. According to Sokoto State Maternal and Perinatal Death Surveillance Annual report in 2021 reveled that, there were 28,813 deliveries out of which 254 maternal mortalities recorded with a ratio of 936/100,000 live births.

Prior to the advent of modern medicine, maternal deaths in Nigeria are associated with supernal powers and other traditional beliefs and practices. Hence, these set of people that hold unto these beliefs years ago still exist predominantly within the rural areas. It is against this that the paper there by aimed at understanding the socio cultural factors that determines maternal mortality in Nigeria.

Determinants of Maternal Mortality in Nigeria

WHO (2020) documented that the leading causal factors of maternal mortality globally was due to medical complications that account for 75% of all maternal mortality. These are severe bleeding, infections, pre-eclampsia and eclampsia, complications from delivery and unsafe abortion. Also this can reflects in inequalities in access to quality health care services resulting from the existing gap between the rich and the poor. All of these medical complications often occurred before or after delivery and can be manageable and preventable. The causes of maternal deaths in most Sub-Saharan African countries such as Nigeria resulted from medical complications that emerged as a result of obstetric hemorrhage, eclampsia, sepsis and complications from unsafe abortions (Akinlo, 2016). Also, researches have shown that many variables, including age, education, prenatal care, domestic abuse, social autonomy, decision making among other cultural beliefs and practices such as prevalence of polygamy have been linked with the cause of maternal mortality in Nigeria (McDermatt, 2015).

 Nigeria is one of the countries with highest illiteracy level and as such these socio-cultural practices led to the rise in maternal death in the area. Health related factors are influenced by all of these. There are differences in maternal mortality rates between the north and the south in Nigeria from the study carried out by Nigeria Demographic Health Survey (2018). In the south west for every 100,000 live births 630 deaths occur, while in the north east 563 mothers died for every 100,000 live births (Sulaiman and Uthman, 2019). As observed by Garba and Umar (2013), there are medical and non medical causes of maternal deaths in Nigeria. The medical determinants include hemorrhage, infection and eclamsia while the non medical factors are social, cultural, economic, beliefs, values attitude that are common in a community and which are still similar to those in other part of Nigeria influencing maternal mortality in the country.

There are other factors influencing maternal mortality in Sokoto and Nigeria in general. These factors include the following:

1. Poverty

Poverty is among the contributing and independent variable that causes social problem in human society. Northern Nigeria is the region with high rate of poverty compare to the Southern part of the country as shown by the National Bureau of Statistics report in 2022. In the North the poverty index was 65% of the poor live in the north (86 million people), 35% live in the South nearly (47 million people) while. For instance, Sokoto state poverty ranking as revealed by NBS (2022) indicated that it is the poorest state in the country with 91% of people who live in poverty. This concluded that the state is one with the highest poor people in the country. This is invariably affecting not only the quality of care people access but undesirable outcome in their social well being. 

Talcott Parsons (1951) conceived that effective medical care is important for society’s ability to function. Effective medical care could only be achieved when the resources are available and accessible for people to utilize. A family’s income level determines the decision to take in seeking medical care from health professionals during illness and childbirth. The under privilleged population is largely concentrated in poor areas with little healthcare facilities, and they also bear the financial burden of transport fare in seeking health care to well-equipped facility, cost of the treatment received, and other expenses related to childbirth all of which may discourage them from using the health system (Zolala, 2012).

According to Garba and Umar (2013) the major causes of maternal mortality in Sokoto are hemorrhage, infection and, eclampsia. This is similar to those identified causes in north central, north east and some southern states in Nigeria. Looking at these causes, it indicates that eclamsia often occurred when mothers refused to attend antenatal care which in the process could be early detected and manageable. Sometimes, coming to health facilities for antenatal care is link to poverty and accessibility of those services at the facility. Some hospitals in Sokoto lacked adequate health facilities unlike private clinics that are well equipped and people in the rural areas have no access to private clinic due to expenses before accessing the services. They preferred to use traditional medicines and other practices to cure themselves than seeking for medical intervention due to the nature of health facilities in their locality.

2. Decision Making Process

Women’s autonomy refers to the ability of women aged from 15-49 years old in making decision to decide on their sexual and reproductive health rights. A woman’s autonomy to choose and recognize what happen in her daily life depends on the decision of her family members to either accept or object it especially mother in law (Sadiq, 2017). It is necessary for the woman and her family to communicate about her decision to seek medical attention. It may be difficult for a woman to have access to proper medical attention if her right is denied by the family members. Allowing women to have access to prenatal care might likely reduce medical complications that may arise during/after delivery. It is proper for women to have autonomous power and say concerning their health condition than deciding by her relative. This is because they are in a position to make appropriate decisions concerning their health. However, SDGs5 underscores the need to address structural barriers affecting appropriate power relations between men and women to have universal access to sexual and reproductive health right by 2020.

Sadiq (2017) revealed that there is a link between the ability to decide and the proper use of prenatal services. The ability of a woman to decide was undermined by the influence of culture, traditions and religion. Furthermore, women’s autonomy during labour and delivery is not within her control, but rather impacted by her spouse and relatives in Sokoto and Nigeria. Her ability to undergo certain medical operations depends on the decision of her relatives. This is because of the values and religious teachings and practices adhere by the community members that restrict her from making independent decision without consulting her husband (Rizkianti et al., 2020).

3. Illiteracy

In Nigeria, there was little enrollment of girls into formal education and some families even went further to withdraw their children which in turn led to the high rate of illiterate women (Amzat, 2015).  In Nigeria a high proportion of people especially those who reside in rural areas have no formal education. A report by the National Commission for Mass Literacy, Ault and Non formal Education data shows that female enrollment in Basic/Adult literacy education was 40.55% in 2020 and later increases to 46.10 % in 2021 and decreases to 28.32% in 2022. Also, in 2020, Lagos state had the highest female enrolments, Sokoto recorded the highest in 2021, Bauchi had the highest in 2022, and Adamawa and Yobe state with the least from 2020 to 2022.

 However, Erinosho (1998) observed that formally educated Nigerians are more likely to utilize cosmopolitan western- style health care services than those who are non literate at the onset of, and during ill-health. Also non literate Nigerian patients prefer to seek treatment from the traditional healers rather than the modern health care facilities simply because of the formalities such a long queue before physical examination etc. this is in contrast with the formally educated patients to find the environment conducive and acceptable (Erinosho 1998: in Dansabo, 2007). The role of women education to safety delivery existed and was encourage in different studies by different scholars. An educated pregnant mother might be aware of the complications that may arise during pregnancy and, as such seek prompt, professional aid unlike the uneducated ones. Low educated women are link with poverty, are more likely to reside in rural areas and are more likely to deliver at home with an in experienced birth attendant (Zolala et al., 2012).

4. Patriarchal System

Patriarchy here signifies a type of society in which men have the power, say and authority over women to determine and make decisions in areas of life such as health, education, politics etc. Nigeria is a patriarchal society where men dominate women and have control over them. The reproductive rights of women indicate that they should be able to regulate fertility and other sexually transmitted disease prevention as well as safe motherhood.  This is just mere dream by reproductive women in Nigeria because men have the rights to determine how many children are to be born. Most these maternal deaths could easily be prevented and averted if women had access and power to make use of family planning services and have a right to make decisions concerning their pregnancy (Makama, 2013). The patriarchal system influences people’s relationships especially when it comes to health care utilization. The determinant of maternal deaths in Nigeria is beyond having access to health care facilities and its utilization.

5. Socio-cultural beliefs and practices

The concept of disease is determined by culture, it incorporate belief systems, which serve as a basis for interpretation and perception of diseases in societies. Erinosho (1998) observed that, the concept of disease or ill-health contradicts with the belief system in non western traditional societies where this originated to magic and religion and attributed to witchcraft, sorcery and mystical forces. Those in traditional societies usually preferred to seek for cure from assorted traditional healers. Cases involving maternal deaths are linked to socio-cultural factors such as culture and religion that affect individual preferences (Nayak et al., 2012).

 Many factors lead to the socio-cultural causes of maternal mortality in Nigeria. However, some of the socio cultural practices include the use of traditional medicine such as herbs, hot water bath, Traditional Birth Attendant/Surgeon among other practices. Female genital mutilation s another socio-cultural belief and practice among Nigerians that has devastating effect on women’s reproductive health. It was assumed to enhance fertility and sexual pleasure among the couples (Ganiyu et al, 2020). It has to do with surgically altering of the female genital for non-medical reason. This is a socio-cultural practice in Sub Saharan Africa especially Nigeria where over 30 countries practice and over three million girls at risk of FGM (UNICEF, 2016).

 Olusegun (2012) concluded that this practice is among the indirect cause of maternal death in Nigeria due to it complication among which include bleeding after delivery and even to the extent of going through caesarean section. The consequences of this practice include urine retention infertility, painful intercourse, psychological and sexual problems. This is a practice done by predominantly rural communities of Nigeria as part of the socio-cultural practices that have negative consequences on both the women and their spouses (Pathfinder, 2013). Similar report was documented by WHO in (2020) which shows that revealed that the practiced of female genital mutilation have been associated with other negative consequences including hemorrhage, infection, obstetric issues and death.

6. Dominance and Fallacy of Sex Preference

Nigeria is a patriarchal country with values that emphasizes sex preference. Women who give birth to female children in the process of having one and satisfy these traditional values tend to bear children even when doing so has detrimental effect on their health. The motive behind why women favored having male child than female child is to inherit their husband’s wealth after his demise and as such end of giving birth rampantly lead to maternal death (Inyang-Etoh et al, 2016).

7. Child/Early Marriage

In Nigeria, child marriage is estimated to 64% which is equivalent to 20 million child marriages that resulted to high increase in maternal death (Yaya, 2019). In northern Nigeria, it is something recommendable by the parent to arrange marriage for their young girls especially to old men in as much as they are capable of taking care of the girl. Similarly, Save the Child International in (2021) reveals that in Nigeria 44% of girls marry before reaching the age of 18. While also, 78% of girls in northern Nigeria marry before the age of 18 which is prevalent in north-west and north east where 48% of girls were married by age 15. Also, in the north the average age is 14.6 years old while in the south it is 20.2 years.

Maternal death could be as a result of severe postpartum  hemorhage and long labour by the pregnant women as indicated by WHO which can lead to still births and Vasico Vaginal Fistula (VVF). This is because their hormones and immune system are yet to experience hormonal changes of pregnancy and child delivery at early years of their life which in end cost they life to death. Most communities in northern Nigeria practice Purdah. Purdah also limited their mobility and other personal affairs. This practice served as a barrier to pregnant women to utilize health care facilities that are available for usage (Bawa, 2017).

8. Lack of Adequate Health Personnel and Maternal Health Services

Punch Newspaper in October 20^th (2022) reported that the Nigeria Medical Association revealed that Nigeria has over 24,000 physicians caring for its population of 228 million people as of 2022. A national average ratio of approximately one doctor per 10,000 patients which beyond in most states. In most southern states, 1 doctor is entitle to 30,000 patients, while states in the north the situation worsen as one doctor to is entitle to 45,000 patients. Based on WHO minimum recommendation, a country requires a mixture of 23 doctors, nurses and midwives per 10,000 people to deliver essential maternal and child health services. As a result of inaccessible to adequate health personnel especially in the rural areas, maternal patients tend to experience high utilization rate of traditional birth attendants and other traditional remedy for themselves. Traditional birth attendants are those unskilled traditional care providers who offered traditional based care to maternal patients and have not undergo any medical training (WHO, 2017).

Maternal health service involves pre-birth care, during labor and postnatal care services. Salomon, et al. (2019) assessed the quality of prebirth care in some health facilities, and how capable they are in discovering and controlling pregnancy complications such as eclampsia. This indicated that expectant mothers first attend basic/primary health centres that are lacking adequate facilities and professionalism to handle disorders. They suggested a holistic improvement to antenatal care. The lack of adequate medical care by the health personnel to maternal patients tend to have effect on their delivery outcome because if they are not adequately offered the maternal services needed for them they might encounter pregnancy related complications which might led to lose of life

Theoretical Review

To integrate this paper, a theoretical perspective called the Three Delays Model was used. Thaddeus and Maine (1994) came up with a framework, the ‘Three Phases of Delay’ in order to identify difficulties in the utilization of quality and timely obstetric care. They introduced the notion of ‘Delays’ between the early detection of a complication and its treatment and the

consequences that may follow. This is a clear framework for the study of maternal mortality in addition to medical causes by combining the social and behavioral causal which are sequential and inter related. The following are the three phases of delays:

1. Delay in deciding to seek care

Sometimes, making decision to go to health facility or seek medical care and even to deliver at home in the presence of unskilled traditional birth attendant is another delay that might cause the live of the pregnant women. This is relatively linked with community and family related factors, the socio-economic level of the pregnant woman could cost delayed, awareness of danger signs, remoteness of the health care center, medical bills/expenses and previous knowledge about the health facility among other grievances are part of the contributing factors to delay and decision concerning seeking for medical intervention especially in a difficult condition. Also, 65.9% of pregnant women faced difficulties in accessing the means for maternal health care utilization. All of these factors could cause delay from the expectant mother that might likely lead to maternal death. Assurance and seeking for medical care by pregnant women is a matter of urgency that requires urgent intervention of medical personnel (TSHIP, 2010).

2. Delay in reaching health care facility

This is concerned with the accessibility challenges faced by pregnant women as a result of farness, adequacy, accessibility and availability of transport vehicles/fares, road condition and other challenges that delay the accessibility and utilization of health care facility at appropriate time (Comb et al 2012). The distance travel and finance affects the use of maternal facilities in Nigeria and 23.7% faced challenges in having access to health care as a result of distance (TSHIP, 2010). Most communities are lacking good road networking system that can link them up with primary health centres where they can receive primary attention by the health personnel. They are not mobile enough to transport themselves to nearby health facility. This could lead to loss of live of either the mother or her child if care is not taken.

 

3. Delay in receiving care at the facility

This has to do with the service provided by the health facility. This can be due to inadequate equipment, unfavourable environment, lack of manpower and poorly trained personnel. This also involved factors affecting effective care provision to pregnant women once they reach health care facility and available personnel as well as quality of care (Yeoh P.L et al 2018). This model adopts to realize diverse duties at home, community level, health facility level so as to reduce the occurrence of maternal mortality.

Limitations of the Model

Fillippi et al (2009) observed that, the model directed its attention to only emergency obstetric care thereby neglecting prevention or danger signs that could timely be identify early during antenatal care. The model has also been criticized for being simplistic and the model is solely on the assumption that expectant mothers will likely encounter delays whenever problem arise; nevertheless, women sometimes encounter delays that could account life-threatening conditions (Comb et al 2012). Also the model failed to explain the link between medical and social factors resulting to maternal deaths thereby giving much emphasis on the delay cause. Also the theory failed to adequately deal with situations where there is no healthcare facility available. Most of the maternal deaths in Nigeria occurred in places such as rural areas where there was no single primary health care for the community members to utilize and deals with emergency situations.

Suggestions for Further Studies

More researches to portray the emerging causes of maternal deaths is of paramount important in understanding the new causal factors. Researches should encourage proper balance diet/healthy food for pregnant women for healthy babies and safe delivery. This will reduce the level of Anemia in pregnancy (low blood condition). Since Northern Nigeria is among the areas with high maternal deaths rate and also one of the region where pregnant women deliver at home by the Traditional Birth Attendant, therefore research efforts should emphasize on finding a regulatory framework to ensure quality and safe delivery especially at rural areas. However, necessary and urgent measures need to be taken to curb this social problem affecting Nigerian societies. 

Conclusion

 This paper indicated that maternal death is still a problem of concern in Nigeria more especially in northern Nigeria and revealed the social determinants influencing the problem. There are other factors associated with maternal deaths beyond those mentioned in this paper. Delay in seeking or reaching health care facility does not always account for the determinant factor that led to maternal death. Therefore the model only captured the emergency factors that if not adequately manage can lead to maternal death thereby neglecting other factors like women’s autonomy to make decision making concerning their reproductive health. The Delays model failed to adequately capture the other causes of maternal death beyond delays in reaching or having access to health facilities. It is of utmost important for pregnant women to have autonomy in making decisions concerning her pregnancy to seek for medical attention (Prenatal, antenatal and postnatal care). Maternal health care services, Health personnel such as midwives, nurses should be adequate, available, access and qualified to understand, detect risk factors affecting expectant mothers in their respective places.

Recommendations

To enhance healthcare accessibility, several steps must be taken to improve the overall healthcare system, especially in underserved regions. Addressing the shortage of skilled health personnel in rural and northern Nigeria is crucial. This can be done by offering higher remuneration, allowances, training programs, and relocation allowances to encourage healthcare workers to serve in these areas. Additionally, upgrading healthcare infrastructure is necessary to ensure that both primary and secondary healthcare facilities are equipped to manage complex maternal care, including essential medical supplies and technology for high-risk pregnancies and complications.

Tackling socio-economic determinants of health is equally important. Alleviating poverty, particularly in northern Nigeria, can be achieved through comprehensive poverty reduction programs that focus on income generation. Economic empowerment of women is also vital, as policies that provide access to microloans, vocational training, and support for women-led businesses can increase their ability to seek healthcare independently, leading to better maternal health outcomes.

Empowering women and strengthening their autonomy are essential components of improving maternal health. This includes prioritizing investments in female education, especially in rural areas, as educated women are more likely to understand the importance of prenatal care. Additionally, promoting legislative and societal changes that give women more control over reproductive health decisions is critical, ensuring they can access health services and family planning methods without fear of social or familial restrictions.

Promoting community awareness about the importance of antenatal care through educational campaigns is another key strategy to improve maternal health outcomes by encouraging early and regular prenatal check-ups. Addressing socio-cultural and religious challenges is also necessary for improving maternal health. Confronting harmful cultural practices like female genital mutilation (FGM) through education about its health risks. Engaging community and religious leaders to challenge entrenched beliefs that discourage women from seeking professional healthcare services can help shift cultural attitudes toward prioritizing maternal health. By implementing these multi-dimensional recommendations, Nigeria can make significant strides in reducing maternal mortality. Top of FormBottom of Form

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