Issues with MCH in Nigeria and Various Strategies for Addressing the Identified Issues

A Critical Evaluation of Maternal and Child Health Issues in Nigeria
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Table of Contents
I.Introduction 
2.Access and Utilization of MCH in Nigeria 
2.1. Factors influencing Access to and Utilization of MCH
2.2.Strategies for Improving Access and Utilization of MCH
3.Maternal and Child Mortality 
3.1.Maternal Mortality 
3.1.1.Factors that Cause/ Contribute to Maternal Deaths 
3.2.Child Mortality 
3.2.1.Factors that Cause/ Contribute to Child Mortality 
3.2.2.Trends in Child Mortality in Nigeria 
3.3.Maternal and Child Survival Strategies 
4.Health Workers’ Attitude 
4.1.Factors Contributing to Health Workers’ Negative Attitudes
4.2.Strategies for Improving Health Workers’ Attitude
5.Data Management Issues 
6.Government’s Role in Improving MCH 
6.1.Surveillance and Response Efforts 
6.2.Funding 
7.Conclusion 
References
* Introduction
Maternal and child health (MCH) remains a global challenge and an important issue in public health. The need to promote effective MCH has gained global prominence over the last few decades. Specifically, promoting effective MCH is one of the priorities of the sustainable development goals (SDGs) (Kalipeni et al., 2017). The goal is to promote well-being and health for all, and this cannot be achieved without effective MCH. Poor MCH contributes to high mortality rates for mothers, infants, and children aged below 5 years. While promoting MCH is a global challenge, the challenge is more significant in African countries, such as Nigeria. According to Okigbo et al. (2017), countries in Africa bear the heaviest burden of maternal mortality. Nigeria, in particular, faces great challenges in promoting effective MCH had the highest number of maternal deaths globally in 2015. In 2010, it had the second-highest number of maternal deaths globally, according to the World Health Organization (WHO) (Sageer et al., 2019). In addition to maternal deaths, child mortality in Nigeria continues to be an alarming public health issue. Adewusi and Nwokocha (2018) indicate that every year, about 20% of Nigerian children die before they reach five years old. This indicates that Nigeria is in a continuous struggle with MCH issues. This is not to say that there has been no progress in addressing MCH. According to Okigbo et al. (2017), there has been a 40% decline in the rate of maternal mortality in Nigeria between 1990 and 2015. However, this progress is slow and insufficient in achieving the SDG priority in ending maternal and child mortality. There are many MCH issues in Nigeria that need to be addressed to reduce maternal and child mortality and improve the overall health of this specific population. This paper critically examines some of the issues with MCH in Nigeria with a special focus on access and utilization, mortality and mortality index, health workers attitude, data management, government and funding efforts, as well as the various strategies for addressing the identified issues.
1 Access and Utilization of MCH in Nigeria
To promote effective MCH, mothers and their children need access to quality healthcare services. They also need to be able to utilize the available health services to enhance their well-being. Yet, access to and utilization of MCH services are hindered by many factors, thus affecting the efforts to improve MCH and decrease maternal and child mortality. Access is defined as the ability to use health services and resources to promote health and well-being, while utilization is defined as the use of health services based on whether an individual knows they need care and want to obtain the care that is already accessible to them (National Academies of Sciences, 2018). Due to several factors, people can have access to health services but fail to utilize those services.
2.1. Factors influencing Access to and Utilization of MCH
Access to MCH is very is instrumental in building healthy communities. According to Alkali and Hussain (2016), access to comprehensive MCH services reduces the risk of maternal death during pregnancy and enhances the likelihood of giving birth and raising healthy children. Yet, access to health is not guaranteed, especially in low and middle-income countries with a limited number of skilled or trained health personnel. Below are some of the issues that affect access to and utilization of MCH in Nigeria:
* Lack of education
Education plays an instrumental role in access to MCH. According to a study by Adeyanju et al. (2017), women with no education were less likely to access health services from skilled health personnel. A lack of education contributes to illiteracy about basic health factors such as the availability and usefulness of being assisted by trained personnel during childbirth. Also, a lack of education contributes to great ignorance around MCH and cements long-held myths about childbirth. For instance, Alkali and Hussain (2016) reveal that many uneducated women in Nigeria believe that only lazy people go to healthcare facilities for childbirth. Others believe that pregnancies come with risks and complications, and there is nothing that can be done to eliminate them. As such, their ability to use MCH services is incapacitated by their illiteracy and ignorance. In addition, uneducated women are less likely to utilize family planning, antenatal care, childbirth, and immunization services (Agunwa et al., 2017). This has been attributed to the women’s lack of knowledge and awareness about the existence and value of such services.
* Poverty
A significant number of people in Nigeria live in poverty, which has influenced women’s ability to use MCH services. Adeyanju et al. (2017) reveal that approximately two-thirds of Nigerians live below the poverty line, which affects the accessibility of healthcare. Poverty affects the affordability of health services which, in turn, affects access to care. Alkali and Hussain (2016) indicate that most Nigerians cannot afford the direct costs associated with MCH. As such, they prefer to give birth at home and not seek assistance from skilled personnel during pregnancy and childbirth to avoid paying for the medical charges. Even when a woman understands the importance of seeking skilled services for MCH, lack of finances and high cost of care hinder the utilization of MCH services (Ishola et al., 2017; Okonofua et al., 2018). Many women start utilizing the services when it is too late, while others never get to utilize them for fear of the financial burden MCH services will place on them. They, instead, seek assistance from traditional birth attendants who provide their services at low or no cost at all (Amutah-Onukagha et al., 2017).
* Distance and Inadequate Transport Infrastructure
Distance and poor roads are some of the barriers that hinder access to MCH. Adeyanju et al. (2017) indicate that most women, especially those from rural areas, travel long distances to gain access to healthcare facilities. This limits their access to MCH since those unwilling to travel find it time-consuming and frustrating and may opt to just stay at home and use traditional resources for pregnancy and childbirth. In addition, poor roads and transportation systems worsen women’s travel experiences seeking access to MCH (Alkali & Hussain, 2016). According to Adeyanju et al. (2017), two-fifths of Nigerian women cannot access MCH at healthcare facilities due to transportation challenges. Thus, distance and the state of the roads are major barriers to access to MCH in Nigeria.
* Lack of Trained Personnel
MCH is usually provided by healthcare workers who have gained some level of training to provide the necessary services effectively. As such, a lack of trained personnel hinders access to MCH services. Nigeria has a limited supply of healthcare personnel, and although there have been efforts to increase the number, the ratio of healthcare professionals to patients is still very insufficient. For instance, the WHO recommends a ratio of 1 doctor to 650 patients, yet Nigeria has a ratio of 1 doctor to 6,000 patients (Alkali & Hussain, 2016). This means that many people have limited access to healthcare services because healthcare professionals are overwhelmed. In their study, Okonofua et al. (2018) reveal that many Nigerians fail to utilize MCH services such as antenatal care and child delivery services because often, there are no healthcare providers in the healthcare facilities. As such, women tend to give up MCH services because they lack providers to offer them the necessary services and seek help from the more accessible traditional birth attendants.
* Abuse and Mistreatment of Patients
Access to and utilization of MCH is also hindered by the poor treatment of women seeking MCH. According to Ishola et al. (2017), women in Nigeria have reported different forms of abuse and mistreatment during labor and childbirth, such as physical abuse, neglect, undignified care, and discrimination. These factors hinder women’s access and utilization of MCH because when seeking help during childbirth, women expect to be treated with compassion, respect, and dignity. Orpin et al. (2019) and Adeyanju et al. (2017) posit that abuse and mistreatment cause women to avoid or delay utilizing MCH services even when they know they need the services and are willing to obtain them. No one wants to pay to go to a healthcare facility only to be physically abused or disrespected in any way. Also, mistreatment and abuse of women seeking MCH influence their decision about the type of attendants to involve during childbirth. According to Ope (2020), many Nigerian women prefer traditional attendants to skilled/trained health personnel because they believe traditional birth attendants show them more compassion and concern. As such, women will be more willing to utilize traditional birth attendants even when they have access to skilled birth attendants in healthcare facilities because they receive better treatment from the former.
* Age
The age of a woman affects the utilization of MCH because it influences decision-making. According to Agunwa et al. (2017), younger women, especially those below 20 years, are less likely to utilize MCH services when compared to women above the age of 20 years. Specifically, younger women are less likely to utilize family planning, antenatal care, childbirth, and immunization services. This has been attributed to the fact that younger women have limited exposure to childbirth and child care. It is more likely that a woman younger than 20 years is experiencing her first pregnancy and lacks the necessary exposure and information about MCH. Older women are more likely to have experienced childbirth before, and as such, they have more knowledge about MCH and its value in promoting the health of the mother and child. In addition, younger women are less financially empowered to make decisions on their own, unlike older women (Agunwa et al., 2017). As such, they are less likely to make decisions about how or when to start utilizing MCH services.
1 Strategies for Improving Access and Utilization of MCH
Given the challenges experienced by women in accessing and utilizing MCH services in Nigeria, it is important to investigate some of the strategies that have been or can be put in place to address the situation. According to Amutah-Onukagha et al. (2017), the use of traditional birth attendants in Nigeria is rampant, especially in rural areas, since traditional birth attendants are considered low-cost, convenient, accessible, and compassionate when compared to skilled health personnel in healthcare facilities. About 63% of all live births in Nigeria are home births. This means that more women and children are at risk of complications because of a lack of access to skilled personnel.
One of the strategies to improve access and utilization of MCH services in Nigeria has been building on these traditional birth attendants. Specifically, there has been a focus on providing formal training to traditional birth attendants to provide them with adequate skills for effective MCH. According to Amutah-Onukagha et al. (2017), training traditional birth attendants increases the utilization of MCH services in rural Nigeria. Traditional birth attendants already have a respectful relationship with women, and as such, women gain access to their services more easily. With adequate formal training, these birth attendants can offer skilled assistance to women, thereby eliminating the risks and complications associated with unskilled home births.
Another strategy has been increasing the number of midwives in healthcare facilities. The Nigerian government has made efforts, through the Nigerian Primary Health Care Development Agency (NPHCDA), a public health agency, to provide adequate skilled professionals in healthcare facilities, especially in rural areas. According to Yaya et al. (2018), the NPHCDA established the Midwives Services Scheme (MSS) to ensure that under-served areas have access to adequate health professionals in maternal health centers. As such, more midwives have been employed in healthcare centers to ensure women have access to skilled birth attendants as well as access to other MCH services.
In addition, the use of digital technology has been considered an effective strategy in enhancing access and utilization of MCH services, especially among low-income communities and rural areas. A study conducted by Ebenso et al. (2021) revealed that the use of digital technology in Nigerian healthcare facilities improved the relationship between healthcare workers and patients and enhanced patient engagement in antenatal care classes. As a result, the utilization of MCH significantly increased since women were encouraged by the positive healthcare worker-patient relationship. In another study, it was revealed that the use of mobile technology in health enhanced the provision of MCH services in low- and middle-income countries (Balakrishnan et al., 2016). Specifically, the study revealed that the implementation of mobile technology (mHealth) programs enhances the equitable reach of MCH services. It improves coverage and access to MCH services regardless of the patients’ socioeconomic status. Thus, the incorporation of digital technology in the provision of MCH services can go a long way in addressing some of the barriers to access and utilization of MCH services in Nigeria.
Finally, the implementation of free MCH programs is considered an effective strategy in removing the costs associated with MCH, thus improving access and utilization of MCH services. According to Onwujekwe et al. (2019), the free MCH program implemented by the National Health Insurance Scheme (NHIS) in Nigeria between 2009 and 2015 improved access and utilization of MCH services. Specifically, the program reduced costs of MCH services, improved availability of services, and enhanced efficiency in the delivery of MCH services. However, the program was deactivated. Reactivating such a program on a national scale can improve access and utilization of services. In a study examining the effectiveness of a free maternal health program in the Cross River State of Nigeria, Edu et al. (2017) found out that the free MCH program increased access and utilization of MCH services. This provides support for the implementation of a nationwide MCH program to enhance access and utilization of MCH services across Nigeria.
1 Maternal and Child Mortality
Assessing maternal and child mortality is important in determining the socioeconomic status of a country. According to Olonade et al. (2019), maternal and child mortality rates are used as social indicators of development for countries across the globe. Moreover, they are an important indication of the overall health of a population in any given country. Thus, reducing maternal and child mortality can promote overall population health.
1 Maternal Mortality
Maternal mortality is defined as all deaths caused by pregnancy- and childbirth-related complications (Olonade et al., 2019). Poor access and utilization of MCH services increase the chances of maternal mortality. Maternal mortality is a leading cause of a high burden of women-specific illnesses. It is measured as maternal mortality rate/ ratio, which is the number of deaths per 100,000 annual live births. According to WHO (2019), Nigeria has a maternal mortality ratio of over 800 deaths per 100,000 annual live births based on the most recent data. In addition, Nigeria accounts for about 20% of the total global maternal deaths. These statistics are quite alarming, and as such, it is important to identify some of the key factors that contribute to maternal deaths in Nigeria.
1 Factors that Cause/ Contribute to Maternal Deaths
One of the main causes of maternal death in Nigeria is obstetric hemorrhage. In their study, Sageer et al. (2019) found that about 43% of maternal deaths in Nigeria resulted from obstetric hemorrhage. Obstetric hemorrhage involves excessive bleeding that occurs during pregnancy, childbirth, or postpartum. The blood loss causes a drop in blood pressure, leading to shock and death. Further, Sageer et al. (2019) found that eclampsia or pre-eclampsia is the second leading cause of maternal death in Nigeria, contributing to 36% of all maternal deaths. This involves a drastic rise in the mother’s blood pressure during pregnancy that is life-threatening not only to the mother but also to the child. Other obstetric causes of maternal death in Nigeria include prolonged obstructed labor and maternal sepsis (Okonofua et al., 2017). Further, many women in Nigeria die as a result of complications from unsafe abortion, as well as ruptured uteruses (Sageer et al., 2019). These are medical issues that can be addressed through adequate MCH services.
In addition to obstetric causes, maternal deaths are also caused by a lack of access to skilled birth attendants. Skilled birth attendants are essential in identifying and promptly responding to pregnancy/childbirth-related complications that can result in maternal death. According to Ope (2020), many women die upon arrival at health care facilities due to delays in receiving skilled care. In addition, there is also a delay in women making decisions about seeking MCH services. This delay can be attributed to many factors such as negative attitudes of healthcare workers towards women seeking MCH services (Ope, 2020), poverty, and illiteracy (Alkali & Hussain, 2016), as well as transportation challenges (Adeyanju et al., 2017), among others. These patient-related factors contribute significantly to maternal deaths because they cause a delay in prompt delivery of MCH services as well as treatment of complications.
2 Child Mortality
Child mortality refers to the death of children under the age of five years. Indicators of measurement of child mortality include child mortality rate. The child mortality rate is defined as the number of deaths per 1,000 annual live births (Adebowale & Udjo, 2016). Nigeria has some of the highest childhood mortality rates in the world. Currently, child mortality rate is 114 deaths per 1,000 live births (United Nation Children’s Fund (UNICEF), 2021). Children are the future, and it is necessary to protect children from premature death first to protect the future. This is why there is so much focus on ending child mortality not only in Nigeria but around the world. According to Morakinyo and Fagbamigbe (2017), child mortality is classified under neonatal, infant, and under-five mortalities. Neonatal mortality occurs within the first 28 days of birth, infant mortality occurs within the first year of birth, and under-five mortality occurs before age five. It is important to understand the underlying medical causes of child mortality as well as the contributing factors to child mortality to understand why child mortality is so high in Nigeria.
2 Factors that Cause/ Contribute to Child Mortality
The main medical causes of childhood mortality in Nigeria include neonatal sepsis, asphyxia, preterm complications, and acute respiratory complications (Smith et al., 2016). Specifically, neonatal sepsis and birth asphyxia are common causes of neonatal deaths in Nigeria. Malaria, diarrhea, and chronic malnutrition are also common causes of child death in Nigeria (Morakinyo & Fagbamigbe, 2017), especially among infants and older under-five children. Other causes include congenital abnormalities, sudden death syndrome, accidental injuries, meningitis, and pneumonia (Smith et al., 2016). Most of these illnesses can be addressed with appropriate interventions, provided the mother presents the child to a healthcare facility on time. However, this is not always the case, especially in Nigeria, where various factors contribute to childhood mortality through late presentation or inadequate attention to childhood illnesses.
Some of the non-medical factors that contribute to childhood mortality include limited maternal health education, illiteracy, incomplete immunization, and inadequate breastfeeding (Smith et al., 2016). Poverty also contributes to child mortality. For instance, poverty contributes to low immunization, poor nutrition, and negatively influences health-seeking behaviors among mothers (Adedokun et al., 2017), and all these factors contribute to childhood illnesses. In addition, Morakinyo and Fagbamigbe (2017) reveal that in low-and middle-income countries such as Nigeria, the use of unclean fuel is common because of high poverty levels. This use of unclean fuel exposes children to fumes that cause acute respiratory infections and ultimately contribute to child mortality. Also, lack of clean water and poor sanitation practices are leading causes of diarrhea among children in Nigeria (Morakinyo & Fagbamigbe, 2017). These are also issues common in poor communities that cannot obtain clean water and sanitary toilets. Further, Smith et al. (2016) indicate that malaria is common in areas with poor or blocked drainages as well as stagnant water. These environmental issues also contribute to high child mortality in Nigeria.
3 Trends in Child Mortality in Nigeria
There has been a decline in the child mortality rate in Nigeria over the last several decades. According to UNICEF (2021) data, the child mortality rate has declined steadily from 210 deaths per 1,000 live births in 1990 to 114 deaths per 1,000 live births in 2020, as shown in Figure 1 below. This means that in the 1990s, one out of five children died before the age of five, while now, one out of ten children died before the age of five. This decline has been attributed to several factors, including collaborative efforts to meet the millennium development goal and, later, the SDG priority on MCH.
Figure 1: Trends in Child Mortality Rate in Nigeria
Source: (UNICEF, 2021)
3 Maternal and Child Survival Strategies
As indicated earlier, reducing maternal and child mortality is a global priority. As Smith and Shiffman (2016) indicate, maternal and child mortality are high-burden issues that impact global health significantly. To reduce the burden of these two issues, strategies have been developed to increase maternal and child survival. Yet, Nigeria has some of the lowest maternal and child survival rates because of its high maternal and child mortality rates, especially compared to other developing countries (Agunwa et al., 2017; Amutah-Onukagha et al., 2017). Below are some of the strategies that can improve maternal and child survival rates in Nigeria:
* Maternal Nutrition
Adequate and appropriate nutrition for both the mother and child is considered effective in enhancing maternal and child survival. Through nutrition, women and their children consume foods that promote the child’s growth and the health of the mother and child. Undernutrition and overnutrition in women affect not only their health but also the health of their children, thereby threatening the survival of mother and child (Adinma et al., 2017). There is an increased demand for nutrients during pregnancy and breastfeeding as the mother shares nutrients with the child. As such, providing adequate nutrients to the mother during pregnancy and breastfeeding is important in ensuring that both the mother and child meet the nutritional demands for better health outcomes. In Nigeria, maternal nutrition is quite poor. According to Adinma et al. (2017), there is high under-nutrition among pregnant women in Nigeria, especially those living in rural areas, because of dietary restrictions resulting from food taboos. In addition, malnutrition is also common among breastfeeding women in Nigeria. This means that more women are exposed to health vulnerabilities arising from poor nutrition. They are also unable to pass on adequate nutrients to their children through breastfeeding, which also exposes the child to health complications. Adinma et al. (2017) reveal that maternal nutrition can be improved by ensuring that pregnant women have access to nutritional supplements such as folic acid and iron. In addition, offering counseling and education on nutrition to pregnant women can improve maternal nutrition during pregnancy and breastfeeding. Also, advising women on family planning and appropriate spacing of children can allow time for the body to replenish the deficient nutrients before the next conception.
* Skilled Attendants
Access to skilled attendants during pregnancy, childbirth, and postpartum is a strategic approach to improving maternal and child survival. Many complications can occur during these periods, but having access to a trained attendant can prevent the risk of death from such complications. As Yaya et al. (2018) indicate, only about a third of Nigerian women receive assistance from skilled birth attendants, and only about two-fifths receive postnatal care. This has been identified as one of the causes of high maternal and child mortality rates in Nigeria. As discussed earlier, a limited supply of skilled healthcare personnel in maternal healthcare facilities hinders access to skilled attendants. In addition, transport challenges, cost, and perceived negative attitudes of healthcare workers towards pregnant women are some of the factors that limit women’s access to skilled attendants in Nigeria (Amutah-Onukagha et al., 2017). However, these challenges can be addressed through increased efforts in employing midwives, such as through the MSS (Yaya et al., 2018). Also, Oguntunde et al. (2018) indicate that providing women, especially those from rural areas, with transport services through emergency transport schemes can ensure women have access to trained/skilled attendants, thus increasing maternal and child chances of survival.
* Immunization
Even though maternal survival gained traction earlier than child survival (Smith & Shiffman, 2016), the need to promote child survival has become quite significant in recent years. One of the strategies that have been recommended for improving survival is immunization. Maternal immunization protects women from potential adverse outcomes before pregnancy. Also, as Adebowale and Udjo (2016) reveal, maternal immunization during pregnancy, such as tetanus toxoid injections, protects the mother and child from specific infections. However, such immunizations can only be given if the mother is seeking MCH services at healthcare facilities. According to Oyo-Ita et al. (2016), immunization is an effective strategy for enhanced child survival because it helps prevent life-threatening diseases, thus ensuring that children do not die from preventable diseases. Yet, according to Adedokun et al. (2017), Nigeria is among the top 10 countries in the world where children are not completely immunized. Some of the factors contributing to low immunization include mother illiteracy, poverty, and a lack of access to antenatal care. However, child immunization can be improved in Nigeria by providing health education to women of child-bearing age. Oyo-Ita et al. (2016) indicate that both facility- and community-based health education programs can enhance awareness about the importance of immunization. In addition, the provision of a monetary incentive to women who immunize their child as well as well-coordinated home visits for immunization coverage can increase immunization.
* Effective Infant Feeding
Another strategy to enhance child survival is effective infant feeding practices such as exclusive breastfeeding for the first six months followed by complementary feeding after the first six months. According to Rollins et al. (201...