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Policy Strategies to Improve Maternal Health Services Delivery and Outcomes in Anambra State, Nigeria a
Mabel Ezeonwu a
School of Nursing and Health Studies, University of Washington Bothell, Bothell, Washington, USA Accepted author version posted online: 09 Jun 2014.Published online: 12 Aug 2014.
Click for updates To cite this article: Mabel Ezeonwu (2014) Policy Strategies to Improve Maternal Health Services Delivery and Outcomes in Anambra State, Nigeria, Health Care for Women International, 35:7-9, 828-844, DOI: 10.1080/07399332.2014.925454 To link to this article: http://dx.doi.org/10.1080/07399332.2014.925454
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Health Care for Women International, 35:828–844, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2014.925454
Policy Strategies to Improve Maternal Health Services Delivery and Outcomes in Anambra State, Nigeria
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MABEL EZEONWU School of Nursing and Health Studies, University of Washington Bothell, Bothell, Washington, USA
Pregnancy and childbirth present major health risks for Nigerian women. Key maternal mortality measures indicate that the risks are high. Despite improvement efforts, the country has made insufficient progress in reaching the United Nations’ millennium development goal of decreasing maternal mortality by 75% by 2015. The author in this qualitative descriptive study explores the perspectives of experienced nurse leaders on policy strategies to improve maternal health in Nigeria. In this study, the author suggests that removal of financial barriers to access and utilization of health services, spousal and family inclusiveness in plan of care, and health systems-related physical and human infrastructural improvements constitute critical policy approaches. In this qualitative study, the author discusses nurses’ perspectives on pragmatic approaches to improve maternal health outcomes in Anambra State, Nigeria. Although the United Nations’ millennium development goal #5 is to decrease maternal mortality by 75% between 1990 and 2015, Nigeria is moving very slowly toward achieving this goal. The country’s maternal mortality ratio has only decreased by 24% since 1990 (United Nations Population Fund [UNFPA], 2011). With a low contraceptive prevalence (modern type) of 15% (UNFPA, 2011), a total fertility rate of 5.5, and only 39% of live births attended by skilled personnel (World Health Organization [WHO], 2012), the risk of maternal mortality and morbidity remains high. Evidence shows that nurses and midwives are core to maternal health services delivery, and they
Received 31 October 2013; accepted 14 May 2014. Address correspondence to Mabel Ezeonwu, School of Nursing and Health Studies, University of Washington Bothell, 18115 Campus Way NE, Bothell, WA 98011, USA. E-mail: [email protected] 828
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play pivotal roles in preventing maternal mortality in poor countries (Bhutta, Lassi, & Mansoor, 2010; UNFPA, 2006; WHO, 2005; Wirth, 2008). Furthermore, nurses and midwives constitute 45% to 60% of the entire health workforce in sub-Saharan Africa (Dovlo, 2007) and are the professional workforce that is consistently present with women at the critical period preceding birth, during birth, and 24 hours after birth. The views of experienced nurse leaders at the frontlines of maternal health care delivery are therefore critical to any maternal health policy discussions. This study is pertinent to a global interdisciplinary audience since maternal health issues present significant public health and economic burdens to all societies. In addition, it is imperative that policymakers from diverse professional backgrounds in different countries are informed by the experiences of people on the field as they deliberate on policies directed at improving maternal health.
BACKGROUND Nigeria is the most populous country in Africa, with a population of 169 million people (WHO, 2013a). Anambra State is located in the southeast region and is home to 4.2 million people (Anambra State Government, 2013a). It is the second most densely populated state in Nigeria after Lagos State. The state has clusters of numerous rural villages with an estimated 1,500 to 2,000 persons living within every square kilometer (National Bureau of Statistics, 2012). Although state-specific maternal health data are not available, the country-level data are believed to adequately reflect the maternal health status of the state. Nigeria’s maternal mortality ratio (MMR) is one of the highest in the world at 630 deaths per 100,000 live births. The lifetime risk of maternal death is one in 29 considering the high cumulative exposure to pregnancies (WHO, 2012). These are too high, particularly in comparison with developed countries. For the United States and United Kingdom, for example, the MMRs are 21 and 12, respectively with corresponding lifetime risks of maternal death of one in 2,400 and one in 4,600 (WHO, 2013b). Previous reports show that obstetric complications are common in Nigeria and often lead to maternal or fetal death (Ezeonwu, 2011). In most cases, life threatening conditions are not identified, treated, referred, or followed up appropriately by trained providers during the course of the pregnancy, delivery, and postpartum sometimes resulting in disability or death. For example, in most developing countries including Nigeria, hemorrhage accounts for most deaths (WHO, 2012) even though it is mostly preventable. Merson, Black, and Mills (2012) posit that in order to reduce maternal deaths to a significant level in low- and middle-income countries, emphasis on reducing overall fertility levels and the frequency of high-risk pregnancies are unlikely to be sufficient. This is because (a) there are economic and
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social incentives for having more children and (b) there are limitations to trying to reduce high-risk pregnancies. The global consensus on effective intervention aims to ensure, first, that every pregnancy is wanted through universal access to voluntary contraception; and, second, that every childbirth is safe and attended by skilled personnel with midwifery competencies (Gilmore & Gebreyesus, 2012). In other words, reducing the mortality risk for each and every pregnancy must be emphasized (Merson et al., 2012). A critical question for policymakers follows: How could the mortality risk for each and every pregnancy be reduced? According to the United Nations Children’s Fund [UNICEF] (n.d.), the most important interventions for safe motherhood are to make sure that (a) a trained provider with midwifery skills is present at every birth; (b) transport is available to referral services; and (c) quality emergency obstetric care is available. These interventions present significant challenges for Nigeria due to poor physical infrastructures and absence of skilled providers at the majority of deliveries. The most recent Demographic and Health Survey reveals that a significant number of Nigerian women aged 15–49 reported that they received antenatal care from “no one.” These include 71.0% of women who belong to the lowest wealth quintile, 63.7% of women with “no education,” and 46.9% of rural dwellers (National Population Commission [NPC] [Nigeria] and ICF Macro, 2009). The data demonstrate the complexity of maternal health issues and the need for interdisciplinary and multisectorial policy approaches. On a positive note, among the small segments of women who sought some form of obstetric care, Akpabio, Edet, Etifit, and Robinson-Bassey (2014) report that those who preferred and patronized modern health care practitioners (skilled providers) far out-numbered those who preferred and patronized the traditional birth attendants (TBAs) in Cross River State, Nigeria. Evidence also shows that among all skilled providers in Nigeria, nurses and midwives are most preferred (Ezeonwu, 2011; NPC [Nigeria] and ICF Macro, 2009). These data make the case for realistic and effective policies to use the most effective trained providers to target and reach the most vulnerable women irrespective of their abilities to pay, education levels, and where they reside.
METHODS Research Design In this descriptive study, a qualitative approach was used to explore the perspectives of nurse leaders in Nigeria on effective strategies to improve maternal health outcomes. Interview data collected included specific policy recommendations to improve maternal health services delivery and outcome. Content analysis was used to analyze data collected through semistructured
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face-to-face interviews. The study was approved by the Institutional Review Board of the University of Washington.
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Recruitment In order to obtain broad policy recommendations from participants, I recruited and interviewed a convenience sample of nurse experts from diverse backgrounds, including five nurse educators who were directors or principals of their respective nursing and midwifery schools; five health administrators who managed and directed nursing and health services at their respective hospitals; and two top management staff of the Nursing and Midwifery Council of Nigeria (NMCN). Physical access factors in Nigeria, such as road conditions, transportation, and weather influenced participant recruitment because some local roads that lead to potential participant locations were eroded and unsafe to walk or drive on due to heavy rains. In order to be included in the study, participants had to be over 18 years of age and speak and understand English. In addition, they should either be nurse educators who direct their nursing and midwifery schools, hospital administrators who direct the relevant health facility, or members of the management staff of the NMCN who were active representatives of the governing body of the council. All 12 participants were females, with 32 average years of service. They have extensive leadership, educational, and practice experiences acquired through their career locales: government and mission schools; private, mission, and government hospitals and clinics; specialist hospitals; voluntary agencies; government agencies; the Nursing and Midwifery Council; and private practices. Prior arrangements for interviews were not made due to communication difficulties. The interviews were conducted on the spot without prior contact. I walked into the facilities where potential participants worked. After identifying each potential participant, I introduced myself and my study and provided detailed information about the study procedures. Questions regarding the study were answered, and written informed consent was obtained from each participant. The interviews were conducted in participants’ respective offices primarily in Anambra State. Members of the council, however, were interviewed in their offices located outside the state.
Data Collection In addition to completing a basic demographic questionnaire, participants responded to interview questions that centered on practical and effective strategies to improve maternal health in the country. Examples of openended interview questions included the following: (a) What are your views on ways to improve maternal health outcomes in the country? (b) If you had
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all the resources to change and improve things around maternal health, what would be your priorities? The interviews lasted between 45 and 80 minutes. Detailed notes were taken, and all interviews were audiorecorded except for those of two participants who declined voice recordings.
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Data Analysis All identifiers were removed, and data were coded appropriately. All recorded face-to-face interview data and field notes were transcribed verbatim and analyzed using qualitative content analysis procedures and processes outlined by Elo and Kyngas (2007) and Graneheim and Lundman (2004). Interview texts were read multiple times. Units of analysis were extracted from the whole interview texts and condensed into one text. Important sentences, keywords, or phrases that characterize policy strategies were identified and highlighted. Categories and subcategories of data were created by sorting common ideas in the text and carefully coding them based on their differences and similarities. The words and phrases within the categories and subcategories were reduced by crossing out repetitions or similar words or phrases. Policy themes and subthemes emerged, which accounted for all the data in the interview transcript. Three senior researchers from my institution reviewed and agreed with the coding and analysis processes.
FINDINGS Based on the participants’ extensive experiences and years of professional immersion in the Nigerian health care system, several strategies to improve maternal health outcomes in Anambra State Nigeria were suggested and highlighted in Table 1. TABLE 1 Themes and Subthemes Related to Policy Suggestions to Improve Maternal Health Outcomes Main themes Free health care Broad outreach and education Stronger health system to improve access to quality maternal care
Subthemes No charges for provider visits, hospitalizations/birthing, drugs, and other supplies Spousal, family, and community inclusiveness (in reproductive health and maternal plan of care) Physical infrastructural improvement • Physical access to care • Equipment, supplies, and blood products availability Workforce improvement Nursing quality improvement
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Free Health Care: Provider Visits, Hospitalizations/Birthing, Drugs, and Other Supplies All participants in this study concurred that cost is a critical determinant of maternal health services utilization in the country. They reported that poverty affects rural women disproportionately because most of them have minimal or no education and therefore slim opportunities for financial security. In order to improve antenatal clinic turn-out, they asserted that women must have assurance and a good sense of security that they will not be turned away because of their inability to pay for services and that they will not go home with outrageous charges that they will not be able to clear. One participant said that free treatments should be offered to poor rural women. Another said, “Free cost of delivery, free drugs, and free everything, improve attendance.” The most common threaded word related to health care cost among all participants was free. This included free antenatal visits, delivery, and postnatal care; free treatment for all pregnancy-related problems; free tests, immunizations, and drugs particularly antimalarial and antiretroviral therapies; and free contraceptives. In response to how the country could afford free reproductive and maternal health services, respondents stated that the government’s priorities should simply change. Suggestions ranged from stopping all corruption and embezzlement of government money particularly by government officials to increasing the budgetary allocations to the health sector. They pointed out that although Nigeria is one of the world’s largest producers and exporters of crude oil, the oil revenue does not go into meeting public needs. One participant stated, “This is the richest country with the greatest number of poor people.” Another participant summed it up this way: “The government should invest in health care.”
Broad Outreach and Education: Spousal, Family, and Community Inclusiveness Responses from nurse leaders clearly showed that reproductive and pregnancy-related matters are not just a woman’s problem but the collective problem of everyone in the community, particularly spouses and other family members. They noted that in addition to reaching out to women through a one-on-one approach, the extended family members and the larger community (mothers-in-law; sisters-in-law; and young, old, male, and female audiences) should be targeted by delivering health talks at social and religious gatherings. All participants believed that spouses should be included in obstetric plan of care and that they should always accompany their women to antenatal visits particularly for HIV/AIDS education and testing and family planning. A participant described this approach as “public enlightenment” and an important cultural breakthrough because men are not involved in
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childbirth and discussions related to sexuality including contraception in Nigeria. They emphasized the importance of grassroots education and creating awareness of the importance of family planning, sexually transmitted diseases such as HIV/AIDS, and dietary needs during pregnancy. Risks and consequences of not getting antenatal care from trained providers and early recognition of complications were some of the health messages that the communities should receive, according to participants. Another aspect of general community outreach emphasized by participants included supporting and empowering women and wives to go to school and acquire degrees. They noted that women are still living under the shadow of men, and the belief that men should be the main financial provider for their family is hurting women and society. As a paternalistic society, participants emphasized that focusing on and diffusing the pervasive culture of male dominance and superiority will help support the maternal health agenda. It will support each woman’s efforts to pursue education and get good jobs to support themselves and their families. A participant noted that the “re-orientation of the culture so that men will allow their wives to reach their maximum potential” is very important for women, the profession, and the entire population.
Stronger Health System to Improve Access to Quality Maternal Care PHYSICAL INFRASTRUCTURAL IMPROVEMENT Physical access to care. According to participants, in order to utilize available services, mothers should be able to easily access the locations where the services are provided. The nurse experts explained that the distance between rural women and health facilities, often located in the urban areas, negatively affects maternal health outcomes in different ways. For example, some women in the rural areas are often overwhelmed by the challenges of distance and cost of care, and they simply settle with an unlicensed provider or a TBA in their villages. They also stated that most remote villages could only be accessed with okada—a popular commercial motorcycle transportation system in Nigeria. One participant pointed out that “in case of emergency, you cannot carry a pregnant, dying woman on okada,” thus stressing the severity of the problem. They recommended that the government should as a matter of urgency do the following: (a) build and maintain health facilities in every locality, closer to the people to discourage the use of TBAs; (b) provide basic amenities particularly pipe-borne water and electricity to attract trained providers to stay and practice in those rural areas; and (c) improve and maintain the deplorable roads in the rural areas (often washed away during each rainy season) and support appropriate transportation options for easier and quicker access to higher-level facilities in emergency situations.
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Availability of equipment, supplies, and blood products. The majority of health centers and maternity homes in Nigeria lack basic care supplies and drugs, and most hospitals are ill-equipped to deliver high-level care to patients, according to the nurse leaders. They noted the dearth of sophisticated care equipment: scanning and diagnostic imaging machines; basic supplies including gloves, needles, tapes, intravenous fluids, and tubes; and emergency obstetric drugs. A participant said, “Yes, the equipment, the hospital should be well equipped so that when a person comes, we see that we have the things to resuscitate or get the person recovered from the illness. Not when a person comes, we say, ‘Ahh, we are looking for this, we don’t have that.”’ They strongly recommended that health facilities be provided with adequate funding to procure and stock needed items in order to save lives. Participants also pointed out that postpartum hemorrhage remains one of the major causes of maternal death and yet, in most emergency cases, the needed drugs and blood are not available. Family members are sent out to look for blood or blood products for a dying woman even in emergency situations. Participants suggested that blood banks be located and fully stocked in every health facility that delivers high-level obstetric services. WORKFORCE IMPROVEMENT Participants noted that improving maternal health outcomes starts with building a strong health workforce. They believed that nurses and midwives are the most popular and effective workforce in maternal health services delivery in the country, and efforts should be channeled toward improving nursing and midwifery education and workforce development. Although they recognized the efforts of the Nursing and Midwifery Council in reintroducing the basic midwifery program and ensuring regular reviews and reaccreditations of all the schools in the country, they reiterated that a lot more needs to be done to train and retain this critical workforce in order to deliver appropriate and adequate maternal health care to the growing population. A participated stated, “We need enough strength of staff in the hospitals. When people go to the hospitals, they would like to see the doctor and the nurse as quickly as possible. And the nurses should know what they’re doing. We need welltrained nurses and midwives.” All the experts were regretful and emphatic in their views about the total neglect that the nursing and midwifery profession receives. They recommended adequate funding of nursing and midwifery education as a fundamental step, with funds directed to improving physical infrastructures in schools, recruitment, training, and retention. Participants pointed out that professional training of nurses and midwives would be effective with good investment in the following: • Adequate accommodation (classroom, laboratory, and office spaces) to promote teaching and learning;
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• Properly equipped buildings with appropriate lighting, chairs, and tables to support student comfort; • Adequate and appropriate teaching aids such as projectors, computers, and laptops; • Books and periodicals (hard copies and electronic copies); • Properly equipped demonstration laboratories for skills training; • Adequately equipped training facilities (hospitals, health centers, and maternity homes) to enhance practical experiences for students; and • Functional communication mechanisms (stable Internet and phone networks). In addition to the physical infrastructures within and around academic institutions, the experts also stated that efforts directed at recruitment, training, and retention of nurse and midwife educators are crucial in order to strengthen the profession and keep experienced nurses from migrating overseas. Participants’ recommendations follow: • Training and employing more professorial staff to offset teaching staff shortages; • Increasing the salaries, wages, and working conditions of nurse educators to (a) retain academic staff in order to maintain a steady supply of the nursing workforce and (b) entice and convince young nurses to pursue a nursing and midwifery education pathway as a financially and professionally rewarding career option; • Providing professional development and continuing education opportunities for academic staff, clinical staff, and nursing students in the form of workshops, seminars, and conferences both within and outside the country; • Creating opportunities for international collaborations. In addition to improving the schools and the working conditions of academic staff, nurse and midwife clinicians who provide direct care should be supported and compensated well, according to the nurse leaders. They pointed out that rural dwellers are disproportionately affected by health problems and yet there are not enough providers to address those issues due to the unattractiveness of the wages and the working conditions in rural areas. A participant stated that those problems will be minimized if the government saturates the communities and villages with highly skilled nurses and midwives. Another participant said, “Improving the remuneration for nurses and midwives will make them work in the rural areas where the majority of the masses are.” All of the experts’ comments show that paying nurses and midwives higher salaries and providing them with professional development opportunities will improve their morale since they outnumber the physicians and do more in terms of maternal care. They are confident
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that the goal of improved maternal health outcomes would be achieved if a critical mass of trained and well-compensated nurse providers stay in the country and make their ways to the hinterlands.
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NURSING QUALITY IMPROVEMENT Participants noted that due to the weak health system, the professional regulatory mechanism designed to oversee the qualification standards and licenses of health practitioners and health facilities is also weak. For nursing, poor quality assurance tarnishes the image of the profession and also affects the health of patients. They expressed with certainty that nursing would reclaim its respectful position as soon as unqualified personnel are barred from practicing. One expert stated, “Reducing the number of frustrated quacks who are in practice is critical in order to reduce the risks of maternal deaths and to maintain practice standards for the profession.” The quacks in this context refer to individuals who work as nurses in the health care system despite the fact that they were unable to pass the qualifying examinations in order to meet the licensing standards of the NMCN. The participant believes that the “three strikes, you are out” assessment system of the Nursing and Midwifery Council, in which those who fail the qualifying examination three times must start all over, is not only bad for individuals but is bad policy for the profession and the country in general, pointing out that the complex system forces the individuals to drop out. She explained that such individuals still end up practicing on their own in the villages, delivering babies without license, and possibly get recruited by private hospitals and clinics. A major suggested change to the council’s examination practice is to retain all academically at-risk students within the system and professionally support them to practice at a lower level, while they work their way up through the examination retake processes to fully qualify.
DISCUSSION The persistent unimpressive maternal health indicators in Nigeria and the country’s lethargic progress toward achieving Millennium Development Goal #5 show that policymakers must pay attention to fundamental issues that hinder maternal health improvement efforts. As this study suggests, strategic policies should focus on providing free maternal and reproductive health services particularly in the rural areas—the hub of poverty. Previous studies show relationships among poverty, rural residence, and maternal health. For example, Bhutta, Cabral, Chan, and Keenan (2012) reported that much of the global burden of maternal mortality is among women who are poor, uneducated, of indigenous origin, and from marginalized or rural populations. Ezeonwu (2011) also found that poverty has a significant negative effect on
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maternal health because poor women are deterred from accessing and utilizing professional skilled services. Among adolescents who constitute a key segment of Nigerian population, Rai, Singh, and Singh (2012) reported that even when appropriate services are in place, poverty was a key determinant in the way they utilized maternity services. Gilmore and Gebreyesus (2012) recommended that financial restrictions to contraceptive access, especially for the poorest women and those who are pregnant during adolescence, should be addressed by offering free or nearly free services at the point of care. The recommendation for free maternal health care is justified because Nigeria is one of the world’s largest producers of crude oil. Despite the huge revenue from petroleum export, expenditure on health remains low. For example, in 2010 the general government expenditure on health as a percentage of the total government expenditure was only 4% and the per capita total expenditure on health was $59.00 (WHO, 2012). This leaves the citizens with high out-of-pocket costs for health care. Since families and individuals make tough choices between investing their very meager income on basic human needs (food, shelter, and clothing) and health care, a health care option that employs the services of skilled attendants, though desirable, however, will rank lower for mothers particularly when there are cheaper alternatives such as the TBAs. A simple but logical policy approach to increase demand for skilled services among poor women is for the government to subsidize the cost of skilled services and, in this context, make such services free or offered at lower prices than the TBAs. For the poor, increasing access to care depends on reducing financial barriers to receiving care, particularly out-of-pocket costs (WHO, 2012). Evidence shows that the delivery exemption policy in Ghana resulted in increased use of antenatal care in the country (Aboagye & Agyemang, 2013). In South Africa, eliminating user fees for maternal and child health care also led to increased use of antenatal and child health services (WHO, 2005). Broader exemption policies that include reproductive and maternal health services should be fully considered for Nigerian women. Efforts to increase the demand for and utilization of skilled services by eliminating cost must be augmented by targeted education and outreach to women and their support system to ensure that they understand the importance of antenatal care, skilled attendance at delivery, and postnatal care. The findings of this study show that spousal, family, and community inclusiveness in the plan of care are fundamental to improving reproductive and maternal health outcomes. In support of this finding, a recent study conducted in Malawi suggests that involving men, as well as the extension of antenatal care services to men, can help overcome obstacles to improving maternal health at the community level (Aarnio, Chipeta, & Kulmala, 2013).
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In their report on maternal and newborn health roadmaps, Ekechi, Wolman, and De Bernis (2012) pointed out that working with individuals, families, and communities, and ramping up human resources are the top two strategies for reducing maternal mortality. Furthermore, the WHO (2010) Making Pregnancy Safer Initiative emphasized the importance of the collective roles of women, their partners, families, and the larger community in improving health. It recommended that both improvement of maternal and newborn health services and actions at the community level are required to ensure that women and their newborns have access to skilled care when they need it. Intense outreach, education, and engagement of the whole community will help improve outcomes for mothers. Nigeria experiences several health systems-related physical and human infrastructural deficits that directly and indirectly diminish maternal health improvement efforts. The findings of this study consistently suggest that the Nigerian government should prioritize and invest in health care. According to a WHO (2012) report, supportive legislation is a key first step in improving access to quality care, and it must be followed by sustained political commitment and strong support from stakeholders so that policies are translated into actions on the ground. A clear maternal policy agenda that includes support for nursing and midwifery must be articulated in all the 36 states in Nigeria including Anambra State in order to meet the overwhelming health needs. Such a policy agenda must address the country’s weak health system particularly in (a) maintaining a robust financing mechanism and (b) ensuring access to quality maternal care provided by well-trained and adequately paid workforce at well-maintained health facilities. Although Nigeria has made some efforts in fixing the health system, they are not enough to make a significant impact on maternal health. For example, the Federal Executive Council developed and approved the National Strategic Health Development Plan that outlines a broad framework to strengthen the national health system and improve the health status of Nigerians (Nigerian Federal Ministry of Health, 2010). Concrete actions, however, are needed to implement appropriate policies and programs that are associated with the plan including those that relate to maternal health access and associated point of care and workforce supply chain infrastructure. Also, in December 2009, the government launched the Midwives Service Scheme in which new, unemployed, and retired midwives were recruited and deployed to primary health care facilities in rural areas (Abimbola, Okoli, Olubajo, Abdullahi, & Pate, 2012). This program encountered challenges including funding, unavailability of qualified midwives, and retention. There was attrition related to inadequate social amenities, language barriers between the midwives and the local community, and working in hard-to-reach rural areas. Improving maternal health requires a comprehensive package that includes physical infrastructure and workforce development.
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Adequate health workforce is a critical part of health systems since all other programs depend on it. In resource-poor settings such as in Nigeria, nurses and midwives, who are the most patronized and versatile health workforce, can provide skilled and effective maternal health services. Ezeonwu (2013) outlined challenges to nursing and midwifery training and retention including health systems issues that negatively impact the students’ ability to learn and the educators’ ability to teach such as poorly equipped schools, poor remunerations, high unemployment, and transnational migration. With nurse density-to-population ratios of 1.6 per 1,000 for Nigeria (WHO, 2013c) and one per 1,843 for Anambra State (Anambra State Government, 2013b), it is difficult to adequately cover the health needs of the population, particularly those in rural areas. This study found that for the country’s tide to turn in the direction of positive maternal outcomes, nursing and midwifery schools must be supported in order to produce enough highly skilled and qualified personnel. Historical evidence aligns with this study’s findings that nursing training and retention policies should be emphasized in maternal health improvement strategies. For example, increased midwife registrations and retention, followed by strengthening and equipping district hospitals in Thailand since the 1960s, reduced maternal mortality (WHO, 2005). Harrison (2003) reported that in the early 1940s, the state of maternal health was unsatisfactory in the Niger Diocese (within the Niger Delta in Nigeria), and the British colonial government through the Church Missionary Society decided to address the problem. The plan was to “raise the standard of midwifery work and to try to bring it nearer to that of similar work in England and other countries” (Harrison, 2003, p. 582). Policy changes included overhauling the maternity homes by providing adequate infrastructure, upgrading the midwifery training, and approving decent salaries and wages for midwives “to reflect their importance and to allow them to concentrate on their jobs rather than worry about money” (p. 582). According to the report, in 1950, more midwives were trained, antenatal attendance was high, and the maternal mortality rate was low. These important pieces of history clearly show that building a strong nursing and midwifery workforce is central to any maternal health policy in developing countries. It is evident that nursing has not received the adequate political and financial support it needs in order to make a greater impact on maternal health outcomes. For example, instead of directing resources to nursing and midwifery training and retention, the Nigerian government had focused on training community health extension workers and deploying them to the rural areas even though they will not replace the irreplaceable skilled services of nurses and midwives during the perinatal period (Ezeonwu, 2011). Also, Nigeria is among the top three recipients of official development assistance (ODA) and private foundations’ funds in sub-Saharan Africa between 2005
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and 2007 (Esser & Bench, 2011). Kaiser Family Foundation’s breakdown of the ODA’s access to care funding category (as cited in Esser & Bench, 2011) shows that the funding went to medical education/training, medical research, basic health care (nonimmunizations), and health education. It is unclear how much of the funding, if any, went to nursing and midwifery education since the profession was never mentioned in the report. This underscores the findings of this study that nursing is neglected despite the central role it plays in maternal health services delivery. Nursing education often falls through the cracks because it has historically been overshadowed by medical education. Evidence also shows that HIV/AIDS, malaria, tuberculosis, and hunger and malnutrition are funding priorities for major donor agencies and foundations (Esser & Bench, 2011; Kaiser Family Foundation, 2007; Shiffman, 2007). Such prioritization of disease-based medical interventions and medical education, though critical, has not turned the page for the overall health of women in developing countries including those in rural Anambra State, Nigeria. Without enough well-trained nurses to care for and administer new and improved drugs or vaccines to patients with HIV/AIDS, malaria, and tuberculosis, for example, those priority projects and programs will be stalled. Maternal health problems also contribute to global health burdens. A broader health policy approach that also prioritizes women’s health is therefore essential. Such a policy must include the expansion and strengthening of the health workforce, particularly nursing, in order to provide adequate skilled maternal care to all women, even in the most remote areas of the world.
CONCLUSION For Nigeria to make faster progress in improving maternal health outcomes, strategic policies should focus on reducing and removing all financial restrictions to maternal health services access and utilization. The emphasis on cost is essential due to the persistent poverty among women particularly in the rural villages. Policymakers must embrace the principle that a woman’s financial and educational status and where she lives should have no bearing on maternal and reproductive health services that are available to her. Furthermore, nurses and midwives are at the center of maternal health care delivery. They however operate under the shadow of physicians as reflected in the overall differential benefits and professional support and recognition through various major funding mechanisms. Adequate funding of nursing education would be a big step forward. Integrating nurses’ expert knowledge and views—as core maternal health providers in health policies—will help improve health outcome for mothers not only in Nigeria but also in other developing countries.
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ACKNOWLEDGMENTS The author is most grateful to Drs. Debbie Ward, Bobbie Berkowitz, and Catherine Carr for their support during this research.
FUNDING
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This study was supported by the Women’s Health Nursing Research Training Grant, NINR T32NR07039, and the Hester Mclaws Scholarship, University of Washington School of Nursing.
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Wirth, M. (2008). Professionals with delivery skills: Backbone of the health system and key to reaching the maternal health millennium development goal. Croatian Medical Journal, 49(3), 318–333. doi:10.3325/cmj.2008.3.318 World Health Organization (WHO). (2005). The world health report 2005: Make every mother and child count. Retrieved from http://www.who.int/whr/2005/ whr2005_en.pdf World Health Organization (WHO). (2010). Working with individuals, families and communities to improve maternal and newborn health. Retrieved from http://whqlibdoc.who.int/hq/2010/WHO_MPS_09.04_eng.pdf World Health Organization (WHO). (2012). Building a future for women and children: The 2012 report on the countdown to 2015. Retrieved from http://www. countdown2015mnch.org/documents/2012Report/2012-Complete.pdf World Health Organization (WHO). (2013a). WHO African region: Nigeria. Retrieved from http://www.who.int/countries/nga/en/ World Health Organization (WHO). (2013b). Maternal mortality country profiles. Retrieved from http://www.who.int/gho/maternal_health/countries/en/index. html World Health Organization (WHO). (2013c). Health workforce: Aggregated data. Retrieved from http://apps.who.int/gho/data/node.main.A1442?lang=en
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Policy Strategies to Improve Maternal Health Services Delivery and Outcomes in Anambra State, Nigeria a
Mabel Ezeonwu a
School of Nursing and Health Studies, University of Washington Bothell, Bothell, Washington, USA Accepted author version posted online: 09 Jun 2014.Published online: 12 Aug 2014.
Click for updates To cite this article: Mabel Ezeonwu (2014) Policy Strategies to Improve Maternal Health Services Delivery and Outcomes in Anambra State, Nigeria, Health Care for Women International, 35:7-9, 828-844, DOI: 10.1080/07399332.2014.925454 To link to this article: http://dx.doi.org/10.1080/07399332.2014.925454
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Health Care for Women International, 35:828–844, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2014.925454
Policy Strategies to Improve Maternal Health Services Delivery and Outcomes in Anambra State, Nigeria
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MABEL EZEONWU School of Nursing and Health Studies, University of Washington Bothell, Bothell, Washington, USA
Pregnancy and childbirth present major health risks for Nigerian women. Key maternal mortality measures indicate that the risks are high. Despite improvement efforts, the country has made insufficient progress in reaching the United Nations’ millennium development goal of decreasing maternal mortality by 75% by 2015. The author in this qualitative descriptive study explores the perspectives of experienced nurse leaders on policy strategies to improve maternal health in Nigeria. In this study, the author suggests that removal of financial barriers to access and utilization of health services, spousal and family inclusiveness in plan of care, and health systems-related physical and human infrastructural improvements constitute critical policy approaches. In this qualitative study, the author discusses nurses’ perspectives on pragmatic approaches to improve maternal health outcomes in Anambra State, Nigeria. Although the United Nations’ millennium development goal #5 is to decrease maternal mortality by 75% between 1990 and 2015, Nigeria is moving very slowly toward achieving this goal. The country’s maternal mortality ratio has only decreased by 24% since 1990 (United Nations Population Fund [UNFPA], 2011). With a low contraceptive prevalence (modern type) of 15% (UNFPA, 2011), a total fertility rate of 5.5, and only 39% of live births attended by skilled personnel (World Health Organization [WHO], 2012), the risk of maternal mortality and morbidity remains high. Evidence shows that nurses and midwives are core to maternal health services delivery, and they
Received 31 October 2013; accepted 14 May 2014. Address correspondence to Mabel Ezeonwu, School of Nursing and Health Studies, University of Washington Bothell, 18115 Campus Way NE, Bothell, WA 98011, USA. E-mail: [email protected] 828
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play pivotal roles in preventing maternal mortality in poor countries (Bhutta, Lassi, & Mansoor, 2010; UNFPA, 2006; WHO, 2005; Wirth, 2008). Furthermore, nurses and midwives constitute 45% to 60% of the entire health workforce in sub-Saharan Africa (Dovlo, 2007) and are the professional workforce that is consistently present with women at the critical period preceding birth, during birth, and 24 hours after birth. The views of experienced nurse leaders at the frontlines of maternal health care delivery are therefore critical to any maternal health policy discussions. This study is pertinent to a global interdisciplinary audience since maternal health issues present significant public health and economic burdens to all societies. In addition, it is imperative that policymakers from diverse professional backgrounds in different countries are informed by the experiences of people on the field as they deliberate on policies directed at improving maternal health.
BACKGROUND Nigeria is the most populous country in Africa, with a population of 169 million people (WHO, 2013a). Anambra State is located in the southeast region and is home to 4.2 million people (Anambra State Government, 2013a). It is the second most densely populated state in Nigeria after Lagos State. The state has clusters of numerous rural villages with an estimated 1,500 to 2,000 persons living within every square kilometer (National Bureau of Statistics, 2012). Although state-specific maternal health data are not available, the country-level data are believed to adequately reflect the maternal health status of the state. Nigeria’s maternal mortality ratio (MMR) is one of the highest in the world at 630 deaths per 100,000 live births. The lifetime risk of maternal death is one in 29 considering the high cumulative exposure to pregnancies (WHO, 2012). These are too high, particularly in comparison with developed countries. For the United States and United Kingdom, for example, the MMRs are 21 and 12, respectively with corresponding lifetime risks of maternal death of one in 2,400 and one in 4,600 (WHO, 2013b). Previous reports show that obstetric complications are common in Nigeria and often lead to maternal or fetal death (Ezeonwu, 2011). In most cases, life threatening conditions are not identified, treated, referred, or followed up appropriately by trained providers during the course of the pregnancy, delivery, and postpartum sometimes resulting in disability or death. For example, in most developing countries including Nigeria, hemorrhage accounts for most deaths (WHO, 2012) even though it is mostly preventable. Merson, Black, and Mills (2012) posit that in order to reduce maternal deaths to a significant level in low- and middle-income countries, emphasis on reducing overall fertility levels and the frequency of high-risk pregnancies are unlikely to be sufficient. This is because (a) there are economic and
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social incentives for having more children and (b) there are limitations to trying to reduce high-risk pregnancies. The global consensus on effective intervention aims to ensure, first, that every pregnancy is wanted through universal access to voluntary contraception; and, second, that every childbirth is safe and attended by skilled personnel with midwifery competencies (Gilmore & Gebreyesus, 2012). In other words, reducing the mortality risk for each and every pregnancy must be emphasized (Merson et al., 2012). A critical question for policymakers follows: How could the mortality risk for each and every pregnancy be reduced? According to the United Nations Children’s Fund [UNICEF] (n.d.), the most important interventions for safe motherhood are to make sure that (a) a trained provider with midwifery skills is present at every birth; (b) transport is available to referral services; and (c) quality emergency obstetric care is available. These interventions present significant challenges for Nigeria due to poor physical infrastructures and absence of skilled providers at the majority of deliveries. The most recent Demographic and Health Survey reveals that a significant number of Nigerian women aged 15–49 reported that they received antenatal care from “no one.” These include 71.0% of women who belong to the lowest wealth quintile, 63.7% of women with “no education,” and 46.9% of rural dwellers (National Population Commission [NPC] [Nigeria] and ICF Macro, 2009). The data demonstrate the complexity of maternal health issues and the need for interdisciplinary and multisectorial policy approaches. On a positive note, among the small segments of women who sought some form of obstetric care, Akpabio, Edet, Etifit, and Robinson-Bassey (2014) report that those who preferred and patronized modern health care practitioners (skilled providers) far out-numbered those who preferred and patronized the traditional birth attendants (TBAs) in Cross River State, Nigeria. Evidence also shows that among all skilled providers in Nigeria, nurses and midwives are most preferred (Ezeonwu, 2011; NPC [Nigeria] and ICF Macro, 2009). These data make the case for realistic and effective policies to use the most effective trained providers to target and reach the most vulnerable women irrespective of their abilities to pay, education levels, and where they reside.
METHODS Research Design In this descriptive study, a qualitative approach was used to explore the perspectives of nurse leaders in Nigeria on effective strategies to improve maternal health outcomes. Interview data collected included specific policy recommendations to improve maternal health services delivery and outcome. Content analysis was used to analyze data collected through semistructured
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face-to-face interviews. The study was approved by the Institutional Review Board of the University of Washington.
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Recruitment In order to obtain broad policy recommendations from participants, I recruited and interviewed a convenience sample of nurse experts from diverse backgrounds, including five nurse educators who were directors or principals of their respective nursing and midwifery schools; five health administrators who managed and directed nursing and health services at their respective hospitals; and two top management staff of the Nursing and Midwifery Council of Nigeria (NMCN). Physical access factors in Nigeria, such as road conditions, transportation, and weather influenced participant recruitment because some local roads that lead to potential participant locations were eroded and unsafe to walk or drive on due to heavy rains. In order to be included in the study, participants had to be over 18 years of age and speak and understand English. In addition, they should either be nurse educators who direct their nursing and midwifery schools, hospital administrators who direct the relevant health facility, or members of the management staff of the NMCN who were active representatives of the governing body of the council. All 12 participants were females, with 32 average years of service. They have extensive leadership, educational, and practice experiences acquired through their career locales: government and mission schools; private, mission, and government hospitals and clinics; specialist hospitals; voluntary agencies; government agencies; the Nursing and Midwifery Council; and private practices. Prior arrangements for interviews were not made due to communication difficulties. The interviews were conducted on the spot without prior contact. I walked into the facilities where potential participants worked. After identifying each potential participant, I introduced myself and my study and provided detailed information about the study procedures. Questions regarding the study were answered, and written informed consent was obtained from each participant. The interviews were conducted in participants’ respective offices primarily in Anambra State. Members of the council, however, were interviewed in their offices located outside the state.
Data Collection In addition to completing a basic demographic questionnaire, participants responded to interview questions that centered on practical and effective strategies to improve maternal health in the country. Examples of openended interview questions included the following: (a) What are your views on ways to improve maternal health outcomes in the country? (b) If you had
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all the resources to change and improve things around maternal health, what would be your priorities? The interviews lasted between 45 and 80 minutes. Detailed notes were taken, and all interviews were audiorecorded except for those of two participants who declined voice recordings.
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Data Analysis All identifiers were removed, and data were coded appropriately. All recorded face-to-face interview data and field notes were transcribed verbatim and analyzed using qualitative content analysis procedures and processes outlined by Elo and Kyngas (2007) and Graneheim and Lundman (2004). Interview texts were read multiple times. Units of analysis were extracted from the whole interview texts and condensed into one text. Important sentences, keywords, or phrases that characterize policy strategies were identified and highlighted. Categories and subcategories of data were created by sorting common ideas in the text and carefully coding them based on their differences and similarities. The words and phrases within the categories and subcategories were reduced by crossing out repetitions or similar words or phrases. Policy themes and subthemes emerged, which accounted for all the data in the interview transcript. Three senior researchers from my institution reviewed and agreed with the coding and analysis processes.
FINDINGS Based on the participants’ extensive experiences and years of professional immersion in the Nigerian health care system, several strategies to improve maternal health outcomes in Anambra State Nigeria were suggested and highlighted in Table 1. TABLE 1 Themes and Subthemes Related to Policy Suggestions to Improve Maternal Health Outcomes Main themes Free health care Broad outreach and education Stronger health system to improve access to quality maternal care
Subthemes No charges for provider visits, hospitalizations/birthing, drugs, and other supplies Spousal, family, and community inclusiveness (in reproductive health and maternal plan of care) Physical infrastructural improvement • Physical access to care • Equipment, supplies, and blood products availability Workforce improvement Nursing quality improvement
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Free Health Care: Provider Visits, Hospitalizations/Birthing, Drugs, and Other Supplies All participants in this study concurred that cost is a critical determinant of maternal health services utilization in the country. They reported that poverty affects rural women disproportionately because most of them have minimal or no education and therefore slim opportunities for financial security. In order to improve antenatal clinic turn-out, they asserted that women must have assurance and a good sense of security that they will not be turned away because of their inability to pay for services and that they will not go home with outrageous charges that they will not be able to clear. One participant said that free treatments should be offered to poor rural women. Another said, “Free cost of delivery, free drugs, and free everything, improve attendance.” The most common threaded word related to health care cost among all participants was free. This included free antenatal visits, delivery, and postnatal care; free treatment for all pregnancy-related problems; free tests, immunizations, and drugs particularly antimalarial and antiretroviral therapies; and free contraceptives. In response to how the country could afford free reproductive and maternal health services, respondents stated that the government’s priorities should simply change. Suggestions ranged from stopping all corruption and embezzlement of government money particularly by government officials to increasing the budgetary allocations to the health sector. They pointed out that although Nigeria is one of the world’s largest producers and exporters of crude oil, the oil revenue does not go into meeting public needs. One participant stated, “This is the richest country with the greatest number of poor people.” Another participant summed it up this way: “The government should invest in health care.”
Broad Outreach and Education: Spousal, Family, and Community Inclusiveness Responses from nurse leaders clearly showed that reproductive and pregnancy-related matters are not just a woman’s problem but the collective problem of everyone in the community, particularly spouses and other family members. They noted that in addition to reaching out to women through a one-on-one approach, the extended family members and the larger community (mothers-in-law; sisters-in-law; and young, old, male, and female audiences) should be targeted by delivering health talks at social and religious gatherings. All participants believed that spouses should be included in obstetric plan of care and that they should always accompany their women to antenatal visits particularly for HIV/AIDS education and testing and family planning. A participant described this approach as “public enlightenment” and an important cultural breakthrough because men are not involved in
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childbirth and discussions related to sexuality including contraception in Nigeria. They emphasized the importance of grassroots education and creating awareness of the importance of family planning, sexually transmitted diseases such as HIV/AIDS, and dietary needs during pregnancy. Risks and consequences of not getting antenatal care from trained providers and early recognition of complications were some of the health messages that the communities should receive, according to participants. Another aspect of general community outreach emphasized by participants included supporting and empowering women and wives to go to school and acquire degrees. They noted that women are still living under the shadow of men, and the belief that men should be the main financial provider for their family is hurting women and society. As a paternalistic society, participants emphasized that focusing on and diffusing the pervasive culture of male dominance and superiority will help support the maternal health agenda. It will support each woman’s efforts to pursue education and get good jobs to support themselves and their families. A participant noted that the “re-orientation of the culture so that men will allow their wives to reach their maximum potential” is very important for women, the profession, and the entire population.
Stronger Health System to Improve Access to Quality Maternal Care PHYSICAL INFRASTRUCTURAL IMPROVEMENT Physical access to care. According to participants, in order to utilize available services, mothers should be able to easily access the locations where the services are provided. The nurse experts explained that the distance between rural women and health facilities, often located in the urban areas, negatively affects maternal health outcomes in different ways. For example, some women in the rural areas are often overwhelmed by the challenges of distance and cost of care, and they simply settle with an unlicensed provider or a TBA in their villages. They also stated that most remote villages could only be accessed with okada—a popular commercial motorcycle transportation system in Nigeria. One participant pointed out that “in case of emergency, you cannot carry a pregnant, dying woman on okada,” thus stressing the severity of the problem. They recommended that the government should as a matter of urgency do the following: (a) build and maintain health facilities in every locality, closer to the people to discourage the use of TBAs; (b) provide basic amenities particularly pipe-borne water and electricity to attract trained providers to stay and practice in those rural areas; and (c) improve and maintain the deplorable roads in the rural areas (often washed away during each rainy season) and support appropriate transportation options for easier and quicker access to higher-level facilities in emergency situations.
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Availability of equipment, supplies, and blood products. The majority of health centers and maternity homes in Nigeria lack basic care supplies and drugs, and most hospitals are ill-equipped to deliver high-level care to patients, according to the nurse leaders. They noted the dearth of sophisticated care equipment: scanning and diagnostic imaging machines; basic supplies including gloves, needles, tapes, intravenous fluids, and tubes; and emergency obstetric drugs. A participant said, “Yes, the equipment, the hospital should be well equipped so that when a person comes, we see that we have the things to resuscitate or get the person recovered from the illness. Not when a person comes, we say, ‘Ahh, we are looking for this, we don’t have that.”’ They strongly recommended that health facilities be provided with adequate funding to procure and stock needed items in order to save lives. Participants also pointed out that postpartum hemorrhage remains one of the major causes of maternal death and yet, in most emergency cases, the needed drugs and blood are not available. Family members are sent out to look for blood or blood products for a dying woman even in emergency situations. Participants suggested that blood banks be located and fully stocked in every health facility that delivers high-level obstetric services. WORKFORCE IMPROVEMENT Participants noted that improving maternal health outcomes starts with building a strong health workforce. They believed that nurses and midwives are the most popular and effective workforce in maternal health services delivery in the country, and efforts should be channeled toward improving nursing and midwifery education and workforce development. Although they recognized the efforts of the Nursing and Midwifery Council in reintroducing the basic midwifery program and ensuring regular reviews and reaccreditations of all the schools in the country, they reiterated that a lot more needs to be done to train and retain this critical workforce in order to deliver appropriate and adequate maternal health care to the growing population. A participated stated, “We need enough strength of staff in the hospitals. When people go to the hospitals, they would like to see the doctor and the nurse as quickly as possible. And the nurses should know what they’re doing. We need welltrained nurses and midwives.” All the experts were regretful and emphatic in their views about the total neglect that the nursing and midwifery profession receives. They recommended adequate funding of nursing and midwifery education as a fundamental step, with funds directed to improving physical infrastructures in schools, recruitment, training, and retention. Participants pointed out that professional training of nurses and midwives would be effective with good investment in the following: • Adequate accommodation (classroom, laboratory, and office spaces) to promote teaching and learning;
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• Properly equipped buildings with appropriate lighting, chairs, and tables to support student comfort; • Adequate and appropriate teaching aids such as projectors, computers, and laptops; • Books and periodicals (hard copies and electronic copies); • Properly equipped demonstration laboratories for skills training; • Adequately equipped training facilities (hospitals, health centers, and maternity homes) to enhance practical experiences for students; and • Functional communication mechanisms (stable Internet and phone networks). In addition to the physical infrastructures within and around academic institutions, the experts also stated that efforts directed at recruitment, training, and retention of nurse and midwife educators are crucial in order to strengthen the profession and keep experienced nurses from migrating overseas. Participants’ recommendations follow: • Training and employing more professorial staff to offset teaching staff shortages; • Increasing the salaries, wages, and working conditions of nurse educators to (a) retain academic staff in order to maintain a steady supply of the nursing workforce and (b) entice and convince young nurses to pursue a nursing and midwifery education pathway as a financially and professionally rewarding career option; • Providing professional development and continuing education opportunities for academic staff, clinical staff, and nursing students in the form of workshops, seminars, and conferences both within and outside the country; • Creating opportunities for international collaborations. In addition to improving the schools and the working conditions of academic staff, nurse and midwife clinicians who provide direct care should be supported and compensated well, according to the nurse leaders. They pointed out that rural dwellers are disproportionately affected by health problems and yet there are not enough providers to address those issues due to the unattractiveness of the wages and the working conditions in rural areas. A participant stated that those problems will be minimized if the government saturates the communities and villages with highly skilled nurses and midwives. Another participant said, “Improving the remuneration for nurses and midwives will make them work in the rural areas where the majority of the masses are.” All of the experts’ comments show that paying nurses and midwives higher salaries and providing them with professional development opportunities will improve their morale since they outnumber the physicians and do more in terms of maternal care. They are confident
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that the goal of improved maternal health outcomes would be achieved if a critical mass of trained and well-compensated nurse providers stay in the country and make their ways to the hinterlands.
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NURSING QUALITY IMPROVEMENT Participants noted that due to the weak health system, the professional regulatory mechanism designed to oversee the qualification standards and licenses of health practitioners and health facilities is also weak. For nursing, poor quality assurance tarnishes the image of the profession and also affects the health of patients. They expressed with certainty that nursing would reclaim its respectful position as soon as unqualified personnel are barred from practicing. One expert stated, “Reducing the number of frustrated quacks who are in practice is critical in order to reduce the risks of maternal deaths and to maintain practice standards for the profession.” The quacks in this context refer to individuals who work as nurses in the health care system despite the fact that they were unable to pass the qualifying examinations in order to meet the licensing standards of the NMCN. The participant believes that the “three strikes, you are out” assessment system of the Nursing and Midwifery Council, in which those who fail the qualifying examination three times must start all over, is not only bad for individuals but is bad policy for the profession and the country in general, pointing out that the complex system forces the individuals to drop out. She explained that such individuals still end up practicing on their own in the villages, delivering babies without license, and possibly get recruited by private hospitals and clinics. A major suggested change to the council’s examination practice is to retain all academically at-risk students within the system and professionally support them to practice at a lower level, while they work their way up through the examination retake processes to fully qualify.
DISCUSSION The persistent unimpressive maternal health indicators in Nigeria and the country’s lethargic progress toward achieving Millennium Development Goal #5 show that policymakers must pay attention to fundamental issues that hinder maternal health improvement efforts. As this study suggests, strategic policies should focus on providing free maternal and reproductive health services particularly in the rural areas—the hub of poverty. Previous studies show relationships among poverty, rural residence, and maternal health. For example, Bhutta, Cabral, Chan, and Keenan (2012) reported that much of the global burden of maternal mortality is among women who are poor, uneducated, of indigenous origin, and from marginalized or rural populations. Ezeonwu (2011) also found that poverty has a significant negative effect on
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maternal health because poor women are deterred from accessing and utilizing professional skilled services. Among adolescents who constitute a key segment of Nigerian population, Rai, Singh, and Singh (2012) reported that even when appropriate services are in place, poverty was a key determinant in the way they utilized maternity services. Gilmore and Gebreyesus (2012) recommended that financial restrictions to contraceptive access, especially for the poorest women and those who are pregnant during adolescence, should be addressed by offering free or nearly free services at the point of care. The recommendation for free maternal health care is justified because Nigeria is one of the world’s largest producers of crude oil. Despite the huge revenue from petroleum export, expenditure on health remains low. For example, in 2010 the general government expenditure on health as a percentage of the total government expenditure was only 4% and the per capita total expenditure on health was $59.00 (WHO, 2012). This leaves the citizens with high out-of-pocket costs for health care. Since families and individuals make tough choices between investing their very meager income on basic human needs (food, shelter, and clothing) and health care, a health care option that employs the services of skilled attendants, though desirable, however, will rank lower for mothers particularly when there are cheaper alternatives such as the TBAs. A simple but logical policy approach to increase demand for skilled services among poor women is for the government to subsidize the cost of skilled services and, in this context, make such services free or offered at lower prices than the TBAs. For the poor, increasing access to care depends on reducing financial barriers to receiving care, particularly out-of-pocket costs (WHO, 2012). Evidence shows that the delivery exemption policy in Ghana resulted in increased use of antenatal care in the country (Aboagye & Agyemang, 2013). In South Africa, eliminating user fees for maternal and child health care also led to increased use of antenatal and child health services (WHO, 2005). Broader exemption policies that include reproductive and maternal health services should be fully considered for Nigerian women. Efforts to increase the demand for and utilization of skilled services by eliminating cost must be augmented by targeted education and outreach to women and their support system to ensure that they understand the importance of antenatal care, skilled attendance at delivery, and postnatal care. The findings of this study show that spousal, family, and community inclusiveness in the plan of care are fundamental to improving reproductive and maternal health outcomes. In support of this finding, a recent study conducted in Malawi suggests that involving men, as well as the extension of antenatal care services to men, can help overcome obstacles to improving maternal health at the community level (Aarnio, Chipeta, & Kulmala, 2013).
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In their report on maternal and newborn health roadmaps, Ekechi, Wolman, and De Bernis (2012) pointed out that working with individuals, families, and communities, and ramping up human resources are the top two strategies for reducing maternal mortality. Furthermore, the WHO (2010) Making Pregnancy Safer Initiative emphasized the importance of the collective roles of women, their partners, families, and the larger community in improving health. It recommended that both improvement of maternal and newborn health services and actions at the community level are required to ensure that women and their newborns have access to skilled care when they need it. Intense outreach, education, and engagement of the whole community will help improve outcomes for mothers. Nigeria experiences several health systems-related physical and human infrastructural deficits that directly and indirectly diminish maternal health improvement efforts. The findings of this study consistently suggest that the Nigerian government should prioritize and invest in health care. According to a WHO (2012) report, supportive legislation is a key first step in improving access to quality care, and it must be followed by sustained political commitment and strong support from stakeholders so that policies are translated into actions on the ground. A clear maternal policy agenda that includes support for nursing and midwifery must be articulated in all the 36 states in Nigeria including Anambra State in order to meet the overwhelming health needs. Such a policy agenda must address the country’s weak health system particularly in (a) maintaining a robust financing mechanism and (b) ensuring access to quality maternal care provided by well-trained and adequately paid workforce at well-maintained health facilities. Although Nigeria has made some efforts in fixing the health system, they are not enough to make a significant impact on maternal health. For example, the Federal Executive Council developed and approved the National Strategic Health Development Plan that outlines a broad framework to strengthen the national health system and improve the health status of Nigerians (Nigerian Federal Ministry of Health, 2010). Concrete actions, however, are needed to implement appropriate policies and programs that are associated with the plan including those that relate to maternal health access and associated point of care and workforce supply chain infrastructure. Also, in December 2009, the government launched the Midwives Service Scheme in which new, unemployed, and retired midwives were recruited and deployed to primary health care facilities in rural areas (Abimbola, Okoli, Olubajo, Abdullahi, & Pate, 2012). This program encountered challenges including funding, unavailability of qualified midwives, and retention. There was attrition related to inadequate social amenities, language barriers between the midwives and the local community, and working in hard-to-reach rural areas. Improving maternal health requires a comprehensive package that includes physical infrastructure and workforce development.
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Adequate health workforce is a critical part of health systems since all other programs depend on it. In resource-poor settings such as in Nigeria, nurses and midwives, who are the most patronized and versatile health workforce, can provide skilled and effective maternal health services. Ezeonwu (2013) outlined challenges to nursing and midwifery training and retention including health systems issues that negatively impact the students’ ability to learn and the educators’ ability to teach such as poorly equipped schools, poor remunerations, high unemployment, and transnational migration. With nurse density-to-population ratios of 1.6 per 1,000 for Nigeria (WHO, 2013c) and one per 1,843 for Anambra State (Anambra State Government, 2013b), it is difficult to adequately cover the health needs of the population, particularly those in rural areas. This study found that for the country’s tide to turn in the direction of positive maternal outcomes, nursing and midwifery schools must be supported in order to produce enough highly skilled and qualified personnel. Historical evidence aligns with this study’s findings that nursing training and retention policies should be emphasized in maternal health improvement strategies. For example, increased midwife registrations and retention, followed by strengthening and equipping district hospitals in Thailand since the 1960s, reduced maternal mortality (WHO, 2005). Harrison (2003) reported that in the early 1940s, the state of maternal health was unsatisfactory in the Niger Diocese (within the Niger Delta in Nigeria), and the British colonial government through the Church Missionary Society decided to address the problem. The plan was to “raise the standard of midwifery work and to try to bring it nearer to that of similar work in England and other countries” (Harrison, 2003, p. 582). Policy changes included overhauling the maternity homes by providing adequate infrastructure, upgrading the midwifery training, and approving decent salaries and wages for midwives “to reflect their importance and to allow them to concentrate on their jobs rather than worry about money” (p. 582). According to the report, in 1950, more midwives were trained, antenatal attendance was high, and the maternal mortality rate was low. These important pieces of history clearly show that building a strong nursing and midwifery workforce is central to any maternal health policy in developing countries. It is evident that nursing has not received the adequate political and financial support it needs in order to make a greater impact on maternal health outcomes. For example, instead of directing resources to nursing and midwifery training and retention, the Nigerian government had focused on training community health extension workers and deploying them to the rural areas even though they will not replace the irreplaceable skilled services of nurses and midwives during the perinatal period (Ezeonwu, 2011). Also, Nigeria is among the top three recipients of official development assistance (ODA) and private foundations’ funds in sub-Saharan Africa between 2005
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and 2007 (Esser & Bench, 2011). Kaiser Family Foundation’s breakdown of the ODA’s access to care funding category (as cited in Esser & Bench, 2011) shows that the funding went to medical education/training, medical research, basic health care (nonimmunizations), and health education. It is unclear how much of the funding, if any, went to nursing and midwifery education since the profession was never mentioned in the report. This underscores the findings of this study that nursing is neglected despite the central role it plays in maternal health services delivery. Nursing education often falls through the cracks because it has historically been overshadowed by medical education. Evidence also shows that HIV/AIDS, malaria, tuberculosis, and hunger and malnutrition are funding priorities for major donor agencies and foundations (Esser & Bench, 2011; Kaiser Family Foundation, 2007; Shiffman, 2007). Such prioritization of disease-based medical interventions and medical education, though critical, has not turned the page for the overall health of women in developing countries including those in rural Anambra State, Nigeria. Without enough well-trained nurses to care for and administer new and improved drugs or vaccines to patients with HIV/AIDS, malaria, and tuberculosis, for example, those priority projects and programs will be stalled. Maternal health problems also contribute to global health burdens. A broader health policy approach that also prioritizes women’s health is therefore essential. Such a policy must include the expansion and strengthening of the health workforce, particularly nursing, in order to provide adequate skilled maternal care to all women, even in the most remote areas of the world.
CONCLUSION For Nigeria to make faster progress in improving maternal health outcomes, strategic policies should focus on reducing and removing all financial restrictions to maternal health services access and utilization. The emphasis on cost is essential due to the persistent poverty among women particularly in the rural villages. Policymakers must embrace the principle that a woman’s financial and educational status and where she lives should have no bearing on maternal and reproductive health services that are available to her. Furthermore, nurses and midwives are at the center of maternal health care delivery. They however operate under the shadow of physicians as reflected in the overall differential benefits and professional support and recognition through various major funding mechanisms. Adequate funding of nursing education would be a big step forward. Integrating nurses’ expert knowledge and views—as core maternal health providers in health policies—will help improve health outcome for mothers not only in Nigeria but also in other developing countries.
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ACKNOWLEDGMENTS The author is most grateful to Drs. Debbie Ward, Bobbie Berkowitz, and Catherine Carr for their support during this research.
FUNDING
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This study was supported by the Women’s Health Nursing Research Training Grant, NINR T32NR07039, and the Hester Mclaws Scholarship, University of Washington School of Nursing.
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