In Nigeria, over 80,000 women die each year from pregnancy and childbirth complications. Recently, Nigeria's coordinating minister of health and social welfare, Muhammad Pate, announced the Maternal Mortality Reduction Initiative. It aims to provide free cesarean section (CS) and essential maternal care to poor women nationwide, ensuring safer childbirth and improved maternal health outcomes. Free CS is a life-saving solution. But while the idea is great, let's take a closer look to unpack how it can really help Nigerian women.
To access the free CS, pregnant women must be enrolled in the country's National Health Insurance Scheme, which covers pregnancy-related emergencies. Social welfare units in public hospitals will check if women qualify and can't afford the procedure. But is this enough?
For a policy like this to work, it must be well-planned, involve many stakeholders, and take into account the rising cost of living, widespread poverty, and the large number of women in informal jobs who are not routinely covered by health insurance
The survival of women at childbirth hinges on availability of expertise to provide cesarean section when needed. A study found a national cesarean section prevalence of 17.6%, with a significantly higher prevalence in facilities in the south (25.5%) compared to the north (10.6%). The authors also identified higher prevalence of emergency cesarean section (75.9%) compared to elective CS (24.3%).
The Reality of Maternal Deaths in Nigeria
An unacceptable number of women in Nigeria die before, during, and after childbirth. Those 80,000 annual deaths are equivalent to 80% of the population of Seychelles.
This reaffirms Nigeria as a large country with an estimated population of more than 200 million; covering 36 states, the federal capital territory, and 774 local government areas.
For a policy like this to work, it must be well-planned, involve many stakeholders, and take into account the rising cost of living, widespread poverty, and the large number of women in informal jobs who are not routinely covered by health insurance.
Poverty is a big issue. Many women cannot afford hospital births and instead deliver in places like faith homes (run by churches) or with traditional birth attendants. If this policy is to work, women's preference for health facility-based deliveries must improve significantly.
These are five ways to make the free CS policy truly equitable.
Does Nigeria Have Enough Obstetricians?
A CS is a life-saving surgery for high-risk pregnancies, like those with large babies, breech positions, or obstructed labor. But Nigeria faces a shortage of healthcare workers. Many doctors are leaving the country for better opportunities abroad.
As of 2021, Nigeria had only 84,277 doctors--about 3.95 per 10,000 people, far below the global recommendation. Who will perform these surgeries if our skilled workers are gone? The government needs to retain healthcare workers by offering better pay, housing, and improved working conditions. Training and career development programs are also crucial to ensure enough professionals are available for this initiative.
Bridging the Health Insurance Gap
Healthcare costs continue to hinder timely access to essential services, especially for marginalized and low-income populations, including women. To improve women's health outcomes and realize the right to health, it's imperative to address these inequities in healthcare delivery.
One effective strategy is to adopt the Health Equity Funds (HEF) model, a proven approach used in various countries. HEFs are third-party mechanisms that cover user fees at public health facilities for eligible low-income individuals.
By establishing and operationalizing a functional equity account, governments can facilitate the enrollment of more women from the informal sector into health insurance schemes, enhancing access and inclusivity.
Fighting Stigma and Myths About Cesarean Sections
Another challenge is the negative perception of CS. In some instances, women who undergo CS are stigmatized and labeled as "weak". A study reveals that factors such as fear, lack of spousal consent, and poor education contribute to its underutilization.
Addressing these gaps requires intensified public education campaigns to inform women and dispel myths about CS, leveraging platforms like radio, TV, and social media to reach a wider audience. Additionally, integrating accurate information about CS as a normal and safe form of childbirth into school health education curricula is essential for long-term impact.
Federal, State, and Local Governments Cooperation
Healthcare in Nigeria is on the concurrent list, which means that federal, state and local councils have core responsibilities for healthcare delivery. How is this policy going to work within states and local government areas? Who is going to cover the costs for women in these sub-national areas?
For this policy to work, all three levels must collaborate. It is not enough for the federal government to announce the policy. State and local governments must also step up to implement it properly. The Federal Ministry of Health and Social Welfare through the National Health Insurance Scheme must collaborate with states through existing State Health insurance Schemes.
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Will This Policy Truly Save Lives?
Women enrolled in the National Health Insurance Scheme might benefit immediately, but the majority--those poor, uninsured, and vulnerable--are left out. These are the women who need this policy the most. To deliver real change, the government must address these gaps.
Conclusion
In the end, every pregnant woman in Nigeria wants the same thing: to deliver safely and not die at childbirth. Will this free cesarean section policy truly deliver for them? Only time will tell, but much more needs to be done to make it work for all women in Nigeria.
About the Authors
Dr. Ifeanyi M. Nsofor, a public-health physician, global health equity advocate and behavioral-science researcher, serves on the Global Fellows Advisory Board at the Atlantic Institute, Oxford, United Kingdom. You can follow him @Ifeanyi Nsofor, MD on LinkedIn. Thelma Chioma Thomas-Abeku is a seasoned communications specialist with a decade-long experience in public health advocacy and communications. She is a graduate of Liverpool John Moores University and University of Abuja. You can follow her @Thelma Thomas-Abeku on LinkedIn.
