Abuja — Nigeria's health services halved the maternal mortality rate between 1990 and 2010, but in parts of the predominantly Muslim north, which is less socio-economically advanced, women are 10 times more likely to die in childbirth than in the oil-rich, predominantly Christian south. Maternal health personnel are calling for more appropriate interventions to bridge the gap.

Reasons for the divide mirror those in many West African states: too few referral facilities and health practitioners - especially midwives - and inadequate antenatal equipment; too few clinics and poor roads that make accessing clinics difficult and expensive; poverty and cultural barriers to visiting hospitals.

The Partnership for Reviving Routine Immunization in Northern Nigeria; Maternal Newborn and Child Health Initiative (PRRINN-MNCH), is a landmark project to track the under-documented maternal population in the four northern Nigerian states of Yobe, Jigawa, Katsina, and Zamfara.

"Insufficient health services, issues surrounding northern culture, and the region's social development challenges all merge into a perfect storm for maternal mortality," is how Rodion Kraus, deputy programme manager for PRINN-MNCH, summed up the situation.

Nigeria's 40,000 pregnancy-related deaths a year account for approximately 14 percent of the world's total, according to a 2012 report by the UN Population Fund (UNFPA), and despite good progress it is unlikely to meet the 2015 Millennium Development Goal (MDG) of reducing its maternal mortality by three-quarters.

Efforts are being stepped up: in 2007 the government launched a nine-year strategy to bring down maternal, neo-natal and infant mortality, including better immunizations for mothers and babies, nutritional supplements, bed nets, and efforts to prevent mother-to-child HIV transmission. The strategy is now in phase II, which focuses on training health workers, and giving them better salaries and incentives to work in rural areas.

The country's primary healthcare agency has been training midwives to work in rural areas for several years. In 2009 it set up the Midwife Service Scheme (MSS), to improve maternal care by sending recently graduated midwives to the north during their mandatory year of national service. By July 2010 more than 2,600 midwives had been sent to serve northern rural health facilities.

"The MSS [graduate scheme] was a very good intervention - it proved very effective," said Hafsat Sugra Mahmood, a midwife and teacher in northern Nigeria, but a lack of regular payment and poor coordination between local, state and federal authorities, among other problems, led to low retention rates.

Staying put

Midwives are highly skilled and trained to provide life-saving services during the birth process, and offer counselling and family planning. Even though Mahmood has spent 20 years teaching midwives, many of whom now work in northern communities, she knows these skills will be redundant in many communities.

"Midwives encourage women to come to the hospital to deliver but... in the north people prefer to deliver at home," Kraus said. "Most Muslim women in northern Nigeria are not comfortable being treated by men - most health workers are men."

Other powerful cultural issues that often prevent northern women from accessing professional health services before and during childbirth include early marriage, which can lead to complications such as fistulas when underdeveloped girls give birth. The quality of education, especially for women and girls, means many don't recognize the danger signs in childbirth. Some communities even see dying in childbirth as immediate access to paradise, community health workers told IRIN.

The Nigerian Union of Road Transport Workers (NURTW) has set up schemes in four northern states to provide better emergency transportation to hospitals, but this does not necessarily persuade women to use them, said Kraus.

Go to them

Clinics In rural areas are often overworked and under-staffed. There are usually one or two midwives per health centre and on average 10 women give birth every day. Midwives are supposed to attend home births in rural areas, but "that leads to burnout", Mahmood remarked, so they often do not make it.

Instead, women turn to traditional birthing attendants (TBAs). There have been calls for TBAs to be given some level of training so they can detect complications early and encourage women to seek antenatal care, refer them to hospitals and give family planning advice.

The danger is that TBAs, if more formally trained, will not recognize their limits and will want to venture into interventions that are really highly technical, so they would need to be closely monitored, say health experts.

Informal studies show TBAs have not had much impact on reducing maternal mortality, but there are a few signs of quality work, Mahmood said, and some have monitored women with pregnancy complications and referred them to health authorities.

"Whether we like it or not," TBAs are respected in rural northern communities and women are using them. "We really need to target TBAS with information and basic skills", so they can help women properly, she said.

Well-trained care at home can be more effective than referral to a hospital - Nigeria's health services are among the 10 worst in the world, said Kraus, noting that maternal mortality has dropped significantly in Bangladesh, where 75 percent of births take place at home. "It flies against current conventional wisdom, but the successful introduction of skilled home-based care is something we might learn from," he commented.

Community responsibility

Dr Fatima Adamu, a lecturer at Usamanu Dan Fodyo University in Sokoto, northwestern Nigeria and community development adviser for maternal health services in the north, said the only approach that will work is to get the community more involved by training village-level health workers to teach women, within their own cultural milieu, to recognize danger signs during pregnancy

"It is important to convey that the responsibility of stopping the death is the community's as a whole, that Islam has given the community that responsibility," she told IRIN.

Adamu is "not optimistic" that Nigeria will be able to meet the MDG by 2015, "but if we continue to push from all angles, maybe we will be able to meet the goal by 2020."

[ This report does not necessarily reflect the views of the United Nations ]