In 2017, there were 67,000 maternal deaths in Nigeria, more than any other country on earth, and 23% of the global total. Nigeria has a maternal health crisis so severe as to prompt federal authorities to declare a state of emergency. I am a mother myself. I was fortunate to have received quality care when I gave birth to my own daughters. But too many women in Nigeria are not getting the care they need and deserve during pregnancy and childbirth.
Most of these maternal deaths in Nigeria are preventable. Change is possible, as highlighted within this report in the significant reductions catalyzed through focused, collective action.
This is why Merck created Merck for Mothers. As a global pharmaceutical company, Merck has a nearly 130-year-old legacy of solving global health challenges. Founded in 2011, Merck for Mothers is our company’s US$500 million initiative to help create a world where no woman has to die giving life. We work in 48 countries around the world to improve the health and well-being of women during pregnancy, childbirth and the postpartum period. Our mission is to help push forward innovative and sustainable solutions that reduce maternal mortality.
Merck for Mothers does not accept business as usual. We challenge assumptions. We ask the tough questions. We push ourselves and our collaborators to invest in creative and sustainable ideas that are women-centered and disrupt the status quo.
We’ve committed to ending preventable maternal deaths in Nigeria, not only because of the country’s high burden of maternal mortality, but also because we are optimistic about the tremendous potential of Nigeria’s local private health sector, which serves more than 60% of the population, to help solve the problem and sustain gains in women’s health for years to come.
Since 2015, working with the government and through Nigerian-led collaboration, we are pursuing new approaches to strengthen the health system and support national health priorities so that no woman has to die while giving life.
There’s a favorite Nigerian expression: "Naija no dey carry last" — we must persevere, together, to reach our goals. Let’s heed that call in maternal health, so that all mothers, their children, families, communities and the nation may prosper.
Nigeria Director, Merck for Mothers
Jummai Amos has a story to tell. It’s about how her sister Martha, a mother of four, died during childbirth as a result of obstructed labor, a treatable complication. Martha had stayed home in her rural village in Abuja to deliver, as she had with her first four children, but this fifth time her labor did not progress. The baby’s head was stuck. Martha needed a C-section, but she died before she could reach a hospital where there was a doctor who could perform the procedure.
Martha’s death highlights many of the barriers to quality maternity care in Nigeria — an avoidable tragedy caused by delays in seeking care, reaching care, and receiving care.
In telling Martha’s story, Jummai joins a growing chorus of voices that are being amplified online and on social media as part of Giving Birth in Nigeria, a public awareness and advocacy campaign led by a team of Nigerian organizations — Africare, Nigeria Health Watch, and EpiAfric — supported by Merck for Mothers.
Launched in March 2019, the campaign is sparking impassioned conversations around critical issues — how high out-of-pocket health costs are keeping women from seeking the care they need; how the tradition of delivering at home puts them at risk. In providing new insights into the many factors, both clinical and non-clinical, that contribute to maternal deaths, this campaign is beginning to drive informed public discussions on how to address them.
Dr. Ifeanyi Nsofor, a physician and EpiAFRIC’s CEO, met Jummai and heard her story while visiting her Sauka community in a rural part of Abuja. He shared it on Twitter and posted a video on YouTube. "This is an important part of the process — elevating women’s voices, making sure their stories are heard," Dr. Nsofor says — a task made easier thanks to an increasingly digitally-engaged public.
"Our teams are going into communities — poor and rural — as well as middle and upper middle class urban ones, across six states and the Federal Capital Territory — interviewing women, men, youth, traditional leaders, cultural and religious leaders. We’re asking everyone why women are dying, and what they think can be done about it. Everyone has a role to play in helping to mitigate the risks. Some solutions need to be built from the ground up."
In its 2018 recommendations, The Lancet’s commission on high quality health systems, co-chaired by Dr. Muhammad Pate, Nigeria’s former Minister of State for Health, recommended leveraging patients’ voices to inform quality. By amplifying people’s stories and sparking these conversations, Giving Birth in Nigeria also aims to catalyze accountability among other stakeholders and accelerate action at the state level to effect broader system change.
Important steps forward include strengthening reporting mechanisms so that every maternal death is counted, and investigated. This is why Merck for Mothers is working with the African Union, the World Health Organization and other collaborators to require all African countries to report on maternal deaths, so that the data can inform improvements across the continent.
While the Giving Birth in Nigeria teams continue with the community visits, campaign collaborators are also hosting workshops in the different states, where health officials, other leaders from state government, primary health care workers, maternal health advocates and others can share insights, discuss the campaign’s findings, and coordinate efforts to learn from every maternal death.
In Konduga town, on the north bank of the Ngadda River southeast of Maiduguri, Borno State, the local primary health center closes at 3pm. The community, just beginning to recover after years of violence and destruction at the hands of Boko Haram, keeps a 7pm curfew.
Zainab Makinta, 20, is one of 250 volunteer Village Health Workers (VHWs) who have been trained and deployed by Girl Child Concerns, a Nigerian NGO and a Merck for Mothers collaborator. Like other VHWs, Zainab Makinta supports local clinic staff during the early part of the day, and then makes house calls in the afternoons and evenings. She checks in on pregnant women and women who have recently given birth to see how they are faring; to provide guidance on breastfeeding and other ways to improve overall health in the household. She has the skills to treat minor ailments and refers more serious cases to the primary health center nearby.
Yagana Modu, an expecting mother in Zainab’s village, had a case that couldn’t wait. One early morning, at 1:30am, she delivered her baby at home, and Zainab was there. Then the excessive bleeding started and wouldn’t stop — a case of postpartum hemorrhage, a leading cause of preventable maternal mortality in Nigeria and globally.
Zainab did what she could to staunch the flow, applying gentle pressure on the womb and stimulating uterine contractions, techniques she had learned during her training. By the time the health clinic opened the next morning and Yagana could be transferred, she was out of danger.
“This is how we are reducing maternal mortality in these vulnerable communities in Nigeria — by empowering women like Zainab with life-saving skills, and putting them on the front lines where they can make a real difference,” says GCC’s Board Chairperson Dr. Mairo Mandara. “This is how we are addressing the health worker shortage in these communities that are being resettled, but where there is still so much fear and uncertainty.”
Through their personal, day-to-day interactions, VHWs are changing attitudes and behaviors in positive ways — encouraging pregnant women to seek prenatal care, and, when possible, to go to a facility to deliver. Soon after the first group of VHWs had been deployed, the primary health care center in Konduga noted a surge in prenatal care visits and an uptick in facility-based births — tracing both back to the VHWs’ referral efforts.
The message was not lost on the Borno State Government, who is now working with GCC to expand the program — the kind of community-based solution that empowers individuals and leverages local resources to help more mothers survive and thrive.
There are many points at which something can go wrong during pregnancy and childbirth — so many factors that can determine whether a mother lives or dies while giving life. Tackling maternal mortality requires a holistic approach — solutions that address delays in seeking, reaching and receiving the quality care a mother needs by working together with key collaborators at the community, facility — both public and private — and state levels.
This is what the Saving Mothers, Giving Life (SMGL) initiative — a public-private partnership that was already making steady progress for mothers in Uganda and Zambia —brought to Nigeria’s Cross River State in 2016, ultimately reducing maternal deaths across 108 supported facilities by 66% in just three years..
Action at the community level meant engaging local leaders to help spread the word about the importance of seeking antenatal care (ANC) during pregnancy, and delivering at a facility with a skilled birth attendant. SMGL collaborators also recruited volunteer drivers to provide round-the-clock emergency transport services for women who need urgent care.
Action at the facility level included ensuring public and private providers were well educated to deliver quality maternity care, and that the facility had adequate infrastructure to support quality service delivery. As a key collaborator of SMGL, Merck for Mothers recognized that private maternity care — a primary source of care for many Nigerians — was inconsistent and poorly regulated, and would need to be improved. Stronger linkages between public and private health facilities would need to be established to improve care coverage and to enable seamless and timely referrals.
Today, with public and private facilities working in tandem, more than 90% of women in Cross River State have access to quality emergency obstetric care within the recommended 2-hr time frame. Mary Ekpo Eyo, the officer-in-charge at Atani Eki primary health center, reports that as a result of all collaborators working together toward a common goal, ANC visits had tripled in just a few months. She noted that listening to women’s complaints and needs, engaging with community leaders and traditional birth attendants, and improving provider education around quality maternity care are “driving women to our facility.” Comfort Okoli, a mother of four, decided to go to her local hospital in Calabar to give birth after learning about the SMGL-supported improvements happening there: “When I got to the hospital (for my ANC visit) I decided to pass through the labor and delivery unit to confirm for myself, and behold — I was already falling in love with the look of the room and the way the nurses treated the women in labor.”
By making private health providers true partners in improving maternal health, there was positive change at the state level too. "Stronger ties between private providers and the state health ministry improves monitoring and oversight and transparency across the health system," project lead Dr. Farouk M. Jega, Nigeria Country Director for Pathfinder International, SMGL’s implementing collaborator in Nigeria, points out. "Before SMGL, only 20% of private facilities were reporting their health data to the state, and now they all do," Dr. Jega says.
Working with local private providers as a strategy for overall health system improvement is gaining traction within the global health community as well — including the WHO’s Quality, Equity, Dignity initiative, of which Nigeria is a key focus country.
"If we can do all this in Cross River, we can do it in other parts of Nigeria, and beyond," Dr. Jega says. "But we will need all hands on deck. We need more government officials, business leaders and innovative thinkers to join us in partnership to make that happen."
The gains from the model can be further sustained by every state setting up insurance coverage for its citizens to make maternity care affordable for all, and ensuring that maternal health is prioritized as part of the nation’s Universal Health Coverage strategy.
In Nigeria, many mothers are at risk of getting pregnant before they are ready. Only 12% of married women in the country use a modern method of contraception — one of the lowest prevalence rates in the world.
Family planning is widely considered a highly cost-effective way to reduce the risk of pregnancy and childbirth-related complications, potentially averting one-third of all maternal deaths by empowering women to plan and space their pregnancies.
In Nigeria, 60% of users seek modern contraceptive methods from the local private sector such as drug shops and community pharmacies. In many rural and semi-urban areas, these private vendors are the primary if not only source of health care for women; they play a pivotal role at a critical moment in a women’s health journey. Yet many of these outlets are unregulated.
A project called IntegratE seeks to address this issue in Lagos and Kaduna states: improving access to quality family planning services by educating and supporting local community pharmacies and local private drug shops to provide a full range of modern contraceptive methods, while also improving their practices to meet quality standards.
"This is an opportunity to reach women who are already going to these stores, to reach them with these other critical health services — and a very promising test case for how to tap into the local private sector as part of the solution," says Rodio Diallo, Senior Program Offi cer for The Bill & Melinda Gates Foundation, Merck for Mothers’ cofunder on the IntergratE.
Daramola Oluwaseun, who owns and operates a local private drug shop in Alimosho, was one of the first to sign up. "The training has been an eye opener," she says. When customers come into her store, she can now counsel them on their options. Ojeleke Foashade Damilola, owner of Damilat PMS,—another drug shop—has also embraced her new role. “Young ladies are opening up to me and I am able to counsel them,” she says. "They relate to me like an older sister. They are not able to talk to their mothers about these things."
Given low modern contraceptive use in Nigeria, Merck for Mothers and the Bill & Melinda Gates Foundation saw another opportunity to leverage private facilities – by integrating post pregnancy family planning (PPFP) services. Our collaborators are working with private health facilities to deliver information to women while they are still pregnant, when they come in for antenatal checkups, and during other routine health visits. Like IntegratE, the PPFP project "is about meeting women where they are," Diallo says
According to our implementing collaborator, a year after the project launched, 22% more women were opting for family planning across 40 facilities in Lagos.
Mobolaji Temitope, 38, recalls how she first learned about the different modern methods of contraception during a routine health check while in the second trimester of her third pregnancy — an unplanned one — and was glad to receive her method of choice within 48 hours after delivery. "This change is very important to me, because it gives me peace of mind," Mobolaji says. "Now I can plan well for my life."
Merck for Mothers Nigeria Director:
I understand that NAFDAC’s role is huge within the Nigerian health system. What is your mandate?
PROFESSOR MOJISOLA ADEYEYE
Nigeria imports about 70% of our medicines. Our mandate is to control the quality and distribution of those medicines, among other things (food, beverages, chemicals, detergents and water). For medicines, we make sure they get to where they need to go, and we work to prevent misuse and misdirection and to keep counterfeit medicines out of circulation in Nigeria.
At Merck for Mothers, we are working with collaborators in Nigeria to help improve access to quality medicines as part of an overall strategy for improving maternal health. As you know, maternal mortality is still very high in Nigeria. Has this issue touched you personally?
Yes. My own sister died after giving birth. She bled to death from postpartum hemorrhage (PPH). That should not have happened and it breaks my heart.
I myself went through a difficult childbirth. It’s very likely that my own difficulties were the result of poor quality medicine. I was in labor for 27 hours before my doctors performed an emergency C-section.
Women are still dying from postpartum bleeding. So we have some work to do. We need to educate the patent medicine vendors and pharmacists about quality medicines. The government has a role to play in this, and non-governmental organizations and international partners are also part of this story. We need a multi-sectoral approach and joint actions.
Agreed. Merck for Mothers and our collaborators are taking that multi-stakeholder approach you are talking about with all our maternal health programs. What else have you been focusing on lately?
My top priorities have been to establish a sound quality management system — making sure the internal workings of the agency are aligned and that every department is working together holistically. We’ve reduced our debt, we’ve improved internal communications and we’ve made our registration system more efficient. Our mantra is to be customer-focused, and agency minded.
I’ve also been focusing on motivating our staff, because staff development is also important to me. I want them to be motivated to move themselves up the career ladder.
We are also working with local manufacturers, to make sure they are doing their part to ensure quality. Last year we started working with USAID and U.S. Pharmacopeia to create a Good Manufacturing Practices (GMP) road map for our local manufacturers, to ensure compliance with global quality standards, and to create incentives for them to strive for quality. When we have quality medicines for maternal and child health our country will be better for it.
What kinds of partnerships and collaborations would help Nigeria make further progress on this issue?
We must collaborate with our sister regulatory agencies such as the U.S. Food and Drug Administration and the European Medicines Agency and with the WHO. We are already doing that. We need to work to harmonize medicine regulation across West Africa and across the African continent. And we have to keep partnering with others –international partners like the Gates Foundation, the World Bank. We cannot do this alone.
This is inspiring. With you at the helm of NAFDAC, I am sure we can convince more of our colleagues to come to Nigeria and be part of the positive changes that are happening.
Yes, things are changing. We have a great culture. We have great people. We just need more good and strong leaders to follow.