Executive Summary

Nigeria’s maternal mortality rate (MMR) is currently among the highest in the world, accounting for over a quarter (28.3%) of global maternal deaths. The country’s MMR rose by approximately 14% between 2017 and 2020, increasing from 917 to 1,047 deaths per 100,000 live births. Between 2005 and 2015 alone, the country recorded an estimated 600,000 maternal deaths and 900,000 near-miss events. Persistent health inequities between wealthy and poor households continue to widen this gap, with women from richer households more than twice as likely to receive care from a skilled birth attendant (SBA) compared to women from poorer households. A major driver of these deaths is the low coverage of SBAs, particularly in rural/low-income communities, where women often rely on Traditional Birth Attendants (TBAs) as opposed to trained midwives, nurses or doctors.

Some international strategies that may be relevant in expanding access to skilled birth attendants and maternal care especially within the Nigeria’s context includes programs from Indonesia, Peru, and Rwanda. This paper compares these programs and evaluates their relevance in addressing Nigeria’s current maternal health needs. Indonesia’s Midwife in the Village (Bidan di Desa) program trained and deployed midwives to rural communities; Peru’s Proyecto 2000 (1996) & Seguro Materno Infantil (SMI) program (1998) increased the quality, awareness and acceptability of Emergency Obstetric Care (EmOC) services and fully covered preventive and maternity care for low-income women; and Rwanda’s Community Health Worker (CHW) Program (1995) provided volunteer community members with a six-week foundational training followed by regular refresher sessions.

Peru’s model emerged as the strongest policy option because it combines quality improvement, accessibility, and financial protection. This models strategy of strengthening EmOC, expanding community awareness, and fully subsidizing maternal services for low-income women has the potential to directly solve Nigeria’s maternal health problems. This approach will subtly address cultural reliance and preference of TBAs, financial barriers to hospital utilization, and gaps in services rendered at public EmOC facilities. In addition to Peru’s model, Rwanda’s community health worker strategy of deploying trusted, locally trained community health workers to support early detection, referral and intervention particularly in rural communities would further expand access.

 

Introduction and Problem Statement

In Nigeria, childbirth remains one of the most dangerous times in a woman’s life. Maternal mortality rate (MMR) in the country is currently among the highest in the world, accounting for over a quarter (28.3%) of global maternal deaths (Dogbanya, 2025). Nigeria’s MMR rose by approximately 14% between 2017 and 2020 with death rates rising from 917 to 1,047 deaths per 100,000 live births (Integrated African Health Observatory, 2023).

Maternal deaths in Nigeria are commonly associated with conditions such as hypertension, sepsis, and hemorrhage, all of which are largely preventable. (Olamijulo et al., 2022). Maternal health outcomes are usually determined or influenced by several factors which usually extend beyond medical factors. These factors may include poverty, low health literacy, culture and beliefs that discourage antenatal care utilization (WHO, 2019). Other contributors include negative perceptions about formal healthcare, low self-perception of risk, transportation issues, absence of skilled birth attendants and delays in referral from lower-level facilities such as primary health centers, Traditional Birth Attendants (TBAs), homes, and mission houses (Sageer et al., 2019)

Specifically on the absence of skilled birth attendants at the time of delivery, research shows that in 2012, more than 32 million of the 40 million births in rural Sub-Saharan Africa and Asia were not attended to by trained personnel, but rather by TBAs (Lane & Garrod, 2016). Many women still deliver with TBAs because they are accessible, culturally acceptable, and affordable (Ntoimo et al., 2022). Skilled Birth Attendants (SBAs) such as midwives, nurses, and obstetricians are often scarce, especially in northern and remote regions where insecurity and poor infrastructure worsen the problem (Chukwuma & Ekhator-Mobayode, 2019). Also, Nigeria’s persistent “brain drain,” where health professionals migrate to other countries in search of better pay and working conditions, has further thinned out the workforce (Umar et al., 2025). Because of this, too many women face childbirth without professional care thus increasing the likelihood that pregnancy complications become fatal.

Some of the policy issues may include lack of trained midwives, nurses and obstetricians, debates on what rights and authorities’ community health workers have to provide certain services and limited training and incentives for community health workers to become skilled attendants. Maternal mortality (MM), which is a key indicator of the health and well-being of a country, should be a rare occurrence. Therefore, research is needed to understand its social and structural determinants, particularly relating to access to SBAs in order to improve outcomes and save the lives of birthing mums across Nigeria.

Evidence

Nigeria’s maternal mortality rate has remained unacceptably high for decades. Between 2005 and 2015 alone, the country recorded an estimated 600,000 maternal deaths and 900,000 near-miss events (WHO, 2019). Persistent health inequities between wealthy and poor households continue to widen this gap, with women from richer households more than twice as likely to receive care from SBAs compared to women from poorer households (WHO, 2019). These socioeconomic disparities and the absence of effective and coordinated, nationwide maternal health interventions, have contributed to both the sustenance and worsening of Nigeria’s maternal mortality burden.

Nigeria accounted for about 13% of all global maternal deaths in 2013 and now, in 2025, the country’s contribution to global maternal deaths has increased to approximately 28%, making Nigerian women nearly 500 times more likely to die from pregnancy-related causes compared to women in developed countries (Olonade et al., 2019; Dogbanya, 2025). Current research links Nigeria’s persistently high maternal and neonatal mortality rate to the “three delays” model. This model includes delays in deciding to seek maternal healthcare, delays in arriving at a health facility, and delays in receiving proper and timely care once at the health facility (Ope, 2020).

A large proportion of pregnant women in Nigeria still do not receive adequate care and this is often caused by the unavailability of maternal health services in their communities or the inability to afford care due to high out-of-pocket costs (WHO, 2019). Even where services are available, women face barriers to accessing needed care due to inadequate infrastructure, limited medical equipment, and critical shortages of skilled healthcare providers (Oladapo et al., 2016).

Focusing on the critical shortages of skilled birth attendants, the Federal Ministry of Health (FMoH) is best positioned to lead a comprehensive national workforce development strategy while receiving support from the state and local governments. Historically, political momentum on this issue once existed specifically with programs like the Midwives Service Scheme (MSS) which previously engaged newly graduated, unemployed, and retired midwives to work in underserved rural areas (Abimbola et al., 2012). Restoring and improving such initiatives is key to strengthening maternal healthcare delivery across the country.

International organizations such as UNICEF, WHO, and USAID continue to invest in and strengthen maternal health systems in Nigeria and in other countries with similar MMRs by providing technical assistance, funding, and strategic partnerships. With maternal mortality increasingly being recognized as both a development and equity issue, there is a huge need for Nigeria to create federal policy priorities which align with the global health agenda of ensuring sustained reductions in maternal deaths.

Key stakeholders include the Nigerian government (federal, state, and local), professional associations (e.g. Nigerian Midwives Association), tertiary and training institutions (e.g. universities), international donors (e.g., WHO, UNICEF, USAID, Gates Foundation), community and religious leaders, and ultimately, the women and families disproportionately affected by adverse maternal health outcomes.

The primary goal of this policy initiative is to reduce maternal mortality in Nigeria by strengthening the health system’s capacity to deliver accessible and high-quality maternal care. This initiative involves increasing access to skilled birth attendants, ensuring availability of emergency obstetric services, improving antenatal and postnatal care utilization, and addressing socioeconomic determinants of health that may limit women’s access to lifesaving interventions. Specifically, these goals include:

1. Expanding training and continuous education for skilled birth attendantsinvolved in maternal care through standardized, competency-based training.
2. Increasing access to and retention of SBAsin rural and underserved areas through the provision of incentives such as financial allowances, career advancement pathways, housing support, and safer working conditions.
3. Strengthening collaborationbetween federal, state, and community-based stakeholders to ensure accessible maternal health services through coordinated planning, resource allocation and distribution across government tiers and health facilities.
4. Integration of community-based structures, particularly effective referral systems between primary health centers and higher-level facilities.

Policy Options

Maternal mortality in Nigeria remains a key public health problem, particularly in rural areas with limited access to SBAs. It will be beneficial to learn effective, evidence-based policy alternatives from a few international programs which successfully led to a reduction in MMR. This section examines three policy responses from other countries and evaluates their relevance and potential utility for Nigeria.

Village Midwife Program – Indonesia (1989)

In the 1980s, Indonesia launched the Midwife in the Village (Bidan di Desa) program in response to high maternal and infant mortality rates (Triyana et al., 2016). Graduates of a three-year nursing program were recruited to participate and undergo an additional year of midwifery training after which they were deployed to rural areas and funded by the government for their first three years of service (Triyanna et al, 2016). In 1989 alone, this program trained 54,000 midwives who were then deployed directly to villages or to health centers but with primary responsibility for their surrounding village (Vieira et al., 2012).

These midwives provided prenatal, birthing, and postnatal care, collaborated with TBAs, referred complicated cases to hospitals, dispensed supplements, conducted health examinations, and delivered community health education. The program significantly reduced reliance on TBAs while increasing births attended to by SBAs (Vieira et al., 2012). Specifically, between 1993 and 2000, villages with midwives increased from 15.26% to 50.32%, and low birth weight incidence decreased from 16% to 13% (Triyana et al., 2016). There were also observed differences in healthcare utilization during pregnancy and childbirth between areas these midwives were deployed and areas where they were not (Frankenberg et al., 2009).

A key benefit of this program is that it substantially improved access to SBAs and midwives in rural areas who also double as community health educators, ultimately extending the program’s impact beyond childbirth.

Some key disadvantages are that the program success was highly dependent on unstable government funding. For example, during the 1997 Asian financial crisis, the number of midwives trained yearly dropped from 164,000 in 1996 to 97,000 in 1999 because of a decline in funding. Also, scaling the program requires substantial, sustained financial and logistical commitment due to the government being responsible for the additional 1-year training and 3 years post training renumeration.

Relevance to Nigeria

Indonesia’s past context of high maternal and infant mortality rate closely mirrors Nigeria’s. Expanding access to trained midwives in rural Nigerian communities could produce similar reductions in mortality rates particularly through improved access to care. Success would depend on sustained government funding, appropriate deployment strategies, and integration with existing healthcare infrastructure.

 

Proyecto 2000 (1996) & Seguro Materno Infantil (SMI) program (1998) – Peru

Between 1992 and 1997, Peru had a health sector decentralization which led to widened disparities in healthcare utilization especially among women living in rural areas and less educated women (McQuestion & Velasquez et al., 2006). In response to this, the government launched Proyecto 2000, a maternal health initiative aimed at improving the quality and use of Emergency Obstetric Care (EmOC) facilities. This program targeted districts with highest rates of maternal mortality, using mass media campaigns, health education, and social mobilization to increase awareness and acceptability of the EmOC services offered (McQuestion, 2006). Proyecto 2000 was a USAID funded project that began in 12 of Peru’s 25 departmentos (states) reporting the highest rates of maternal mortality (McQuestion, 2006)

In 1998, the government introduced the Seguro Materno Infantil (SMI) program, which fully covered preventive and maternity care, including childbirth in public EmOC facilities for low-income women (Vieira, 2012). This program was initially piloted in two regions and later expanded nationwide, serving households in the poorest wealth quintile (McQuestion, 2006). During the 1990s (1990 to 2000), neonatal mortality fell from 27 to 18 deaths per 1,000 live births, maternal mortality declined from 265 to 185 per 100,000 live births, home deliveries decreased from 55% to 38%, and facility-based births increased from 38% to 48%.

Some advantages of this policy are that it improved both quality and acceptability of EMOC facilities through culturally sensitive campaigns and addressed financial barriers to accessing care through free maternal healthcare. A disadvantage is that reliance on donor funding raises significant sustainability concerns. Long-term government support is preferred, necessary and optimal. Also, scaling to nationwide coverage requires significant coordination with local health authorities and this may affect the effectiveness of this intervention.

Relevance to Nigeria

Maternal mortality in Nigeria is concentrated in rural, low-income populations. Programs that combine quality improvement with culturally tailored awareness campaigns and financial support can increase facility-based deliveries with SBAs and reduce maternal deaths (WHO, 2019).

 

Community Health Worker (CHW) Program – Rwanda (1995)

Following the 1994 genocide, Rwanda established a CHW program to improve access to essential maternal and child health services, including vaccination, antenatal care, and postnatal care (Farmer et al., 2013). Villages select people who meet age and literacy requirements for the CHW program, after which they undergo six weeks of training and subsequent, regular refresher sessions (Exemplar, n.d.). CHWs are primarily volunteers, however, the government is currently exploring performance-based incentives to encourage them with.

The CHW workforce expanded from 12,000 in 1995 to 45,000 in 2005, and over 58,000 in 2018 (Community Health Worker Central, n.d.; MOH-Rwanda, n.d.). Each village now has at least three CHWs who contribute daily to reducing maternal and child mortality through malaria, pneumonia, and diarrhea management, as well as routine follow-up for pregnant women (RGB, 2017). Rwanda invests approximately $170 million to sustain this program for 10 years and this cost is significantly less than the cost that would have been with a fully paid workforce. Maternal mortality in Rwanda fell from 1,300 per 100,000 live births in 2002 to 290 in 2015, and neonatal mortality decreased from 41 to 17 per 1,000 live births (Gurusamy & Janagaraj, 2018).

Advantages include expanded access to maternal health services in rural communities and increased trust in healthcare systems due to the use of culturally aligned and community-selected CHWs. Disadvantages include the reliance on volunteers which may threaten sustainability of the program unless they are being compensated appropriately. Also, adequate training and continued supervision will require ongoing government investment.

 

Relevance to Nigeria

Rwanda’s use of community-based human resources demonstrates that even low-income countries can expand maternal health coverage. Nigeria, with its large rural population could replicate this model and potentially combine CHWs with midwives to enhance coverage in rural and hard to reach areas while providing culturally appropriate care.

 

Specific Criteria Used in Making Evaluation

Evaluation Criteria and Scoring Methodology

To evaluate these policy alternatives, five criteria were applied:

• Effectiveness / Population Impact– This is measured by reductions in maternal and neonatal mortality and an increase in SBA coverage.
• Feasibility– This is assessed by training requirements, workforce availability, and logistical challenges.
• Cost / Budget Impact– This is estimated based on program funding, sustainability, and financial barriers to program expansion.
• Equity– This is evaluated by program reach among rural, low-income, or marginalized populations.
• Political / Community Acceptability– This is based on government support, alignment with cultural norms, and community engagement.

Table 1

Policy Analysis

Criteria	Village Midwife Program: Indonesia (1989)	Proyecto 2000: Peru (1996)	Community Health Worker (CHW) Program: Rwanda (1995)
Effectiveness / Population Impact	3	5	5
Feasibility	3	5	3
Cost / Budget Impact	3	5	5
Equity	5	5	5
Political / Community Acceptability	4	5	5
Total	18	24	23

 

Scoring Methodology

Each alternative was scored on a scale of 1–5 (1 = low/poor, 5 = high/strong) using evidence from program outcomes, population impact, feasibility, cost, and acceptability. Scores reflect documented results and expert assessment from peer-reviewed sources.

Justification of Scores

• Indonesia: Moderate effectiveness, feasibility and budget impact due to dependency on government funding and training requirements; strong equity and community acceptability in rural areas.
• Peru: High scores for all criteria due to successful pilot, donor support, financial accessibility, and culturally tailored campaigns.
• Rwanda: High effectiveness as demonstrated by the consistent decrease in country’s health indicators (Maternal mortality and Infant mortality), High cost-effectiveness, budget impact due to volunteer CHWs, strong equity and community acceptability due to utilization of trusted community members and deployment of workers to rural areas; lower feasibility due to reliance on volunteer labor.

 

Recommendation

All three policy alternatives demonstrate evidence-based potential to reduce maternal mortality in Nigeria. However, Peru’s model scored highest overall and is the preferred option due to its integrated focus on quality improvement, accessibility, and financial protection. The core components of the Proyecto and SMI programs include strengthening Emergency Obstetric Care (EmOC) facilities, using mass media campaigns, health education, and community mobilization to increase awareness and acceptability of EmOC services, and fully covering preventive and maternity care for low-income women (McQuestion, 2006).

One major reason for the continued reliance on Traditional Birth Attendants (TBAs) is their cultural acceptability, which often surpasses that of Skilled Birth Attendants. Nigeria stands to benefit significantly from Peru’s approach by addressing the preference of TBAs using culturally appropriate strategies such as community outreach and acceptable communication methods. Also, since low socioeconomic status remains a major cause of maternal mortality in Nigeria, the SMI model that removes financial barriers for low-income women is both relevant and transferable. Finally, strengthening EmOC services, particularly in public facilities, is essential and directly responds to current system weaknesses that contribute to preventable maternal deaths.

Although Peru’s model will generally serve as the foundation for my initiative, selected elements from Rwanda and Indonesia can enhance its impact. Rwanda’s community health worker (CHW) strategy of recruiting trusted community members and providing a short yet effective training program (6-weeks) offers an adaptable solution to Nigeria’s shrinking healthcare workforce. Training and integrating CHWs into the health system would improve early detection and management of complications, improve referral rates and improve access to care in rural and underserved areas.

In summary, a hybrid approach that combines strengthened EmOC services, culturally sensitive community engagement, financial support for low-income women, and a robust CHW workforce is likely to yield the greatest impact in reducing maternal mortality in Nigeria.

References

Abimbola, S., Okoli, U., Olubajo, O., Abdullahi, M. J., & Pate, M. A. (2012). The midwives service scheme in Nigeria. PLoS Medicine, 9(5), e1001211. https://doi.org/10.1371/journal.pmed.1001211

Aregbeshola, B. S., & Khan, S. M. (2017). Primary Health Care in Nigeria: 24 Years after Olikoye Ransome-Kuti’s Leadership. Frontiers in Public Health, 5. https://doi.org/10.3389/fpubh.2017.00048

Chukwuma, A., & Ekhator-Mobayode, U. E. (2019). Armed conflict and maternal health care utilization: Evidence from the Boko Haram Insurgency in Nigeria. Social Science & Medicine, 226, 104–112. https://doi.org/10.1016/j.socscimed.2019.02.055

Community Health Worker Central. (n.d.). Rwanda’s community health worker program. https://chwcentral.org/wp-content/uploads/2018/01/Rwanda-Rwandas-Community-Health-Worker-Program.pdf

Dogbanya, G. (2025). Maternal Mortality in Nigeria: Holding the Line in Uncertain Times. Annals of Global Health, 91(1), 16. https://doi.org/10.5334/aogh.4710

Exemplars. (n.d.) How did Rwanda implement. https://www.exemplars.health/topics/under-five-mortality/rwanda/how-did-rwanda-implement

Farmer, P. E., Nutt, C. T., Wagner, C. M., Sekabaraga, C., Nuthulaganti, T., Weigel, J. L., Farmer, D. B., Habinshuti, A., Mugeni, S. D., Karasi, J.-C., & Drobac, P. C. (2013). Reduced premature mortality in Rwanda: Lessons from success. BMJ, 346(jan18 1), f65–f65. https://doi.org/10.1136/bmj.f65

Frankenberg, E., Buttenheim, A., Sikoki, B., & Suriastini, W. (2009). Do women increase their use of reproductive health care when it becomes more available? Evidence from Indonesia. Studies in Family Planning, 40(1), 27–38. https://doi.org/10.1111/j.1728-4465.2009.00184.x

Gurusamy, P. S. R., & Janagaraj, P. D. (2018). A Success Story: The Burden of Maternal, Neonatal and Childhood Mortality in Rwanda – Critical Appraisal of Interventions and Recommendations for the Future. African Journal of Reproductive Health / La Revue Africaine de La Santé Reproductive, 22(2), 9–16. https://www.jstor.org/stable/26493908

Integrated African Health Observatory. (2023). Maternal mortality: The urgency of a systemic and multisectoral approach in mitigating maternal deaths in Africa. https://files.aho.afro.who.int/afahobckpcontainer/production/files/iAHO_Maternal_Mortality_Regional_Factsheet.pdf

Lane, K., & Garrod, J. (2016). The return of the Traditional Birth Attendant. Journal of Global Health, 6(2), 020302. https://doi.org/10.7189/jogh.06.020302

McQuestion, M.J., Velasquez, A. (2006). Evaluating program effects on institutional delivery in Peru. Health Policy 77: 221–232. https://doi.org/10.1016/j.healthpol.2005.07.007

Ministry of Health–Rwanda. (n.d.). Community health workers policy undergoes reform for better service delivery. https://www.moh.gov.rw/news-detail/community-health-workers-policy-undergoes-reform-for-better-service-delivery

Ntoimo, L. F. C., Okonofua, F. E., Ekwo, C., Solanke, T. O., Igboin, B., Imongan, W., & Yaya, S. (2022). Why women utilize traditional rather than skilled birth attendants for maternity care in rural Nigeria: Implications for policies and programs. Midwifery, 104, 103158. https://doi.org/10.1016/j.midw.2021.103158

Okeke, E., Glick, P., Chari, A., Abubakar, I. S., Pitchforth, E., Exley, J., Bashir, U., Gu, K., & Onwujekwe, O. (2016). The effect of increasing the supply of skilled health providers on pregnancy and birth outcomes: Evidence from the midwives service scheme in Nigeria. BMC Health Services Research, 16(1), 425. https://doi.org/10.1186/s12913-016-1688-8

Okonkwo, P., Olatoregun, O. J., Abolarin, O., & Olajide, O. (2024). Barriers to Accessing Antiretroviral Treatment Among Key Populations in Southwest Nigeria. Cureus, 16(4), e59312. https://doi.org/10.7759/cureus.59312

Oladapo, O. T., Adetoro, O. O., Ekele, B. A., Chama, C., Etuk, S. J., Aboyeji, A. P., … Nigeria Near-Miss and Maternal Death Surveillance Network. (2016). When getting there is not enough: A nationwide cross-sectional study of 998 maternal deaths and 1451 near-misses in public tertiary hospitals in a low-income country. BJOG: An International Journal of Obstetrics & Gynaecology, 123(6), 928–938. https://doi.org/10.1111/1471-0528.13450

Olaitan, T., Okafor, I. P., Onajole, A. T., & Abosede, O. A. (2017). Ending preventable maternal and child deaths in western Nigeria: Do women utilize the life lines?. PloS one, 12(5), e0176195. https://doi.org/10.1371/journal.pone.0176195

Olamijulo, J. A., Olorunfemi, G., & Okunola, H. (2022). Trends and causes of maternal death at the Lagos University teaching hospital, Lagos, Nigeria (2007-2019). BMC Pregnancy and Childbirth, 22(1), 360. https://doi.org/10.1186/s12884-022-04649-4

Ope, B. W. (2020). Reducing maternal mortality in Nigeria: Addressing maternal health services’ perception and experience. Journal of Global Health Reports, 4, e2020028. https://doi.org/10.29392/001c.12733

Rwandan Governance Body. (2017). Rwanda’s Community Health Workers Program: 1995 – 2015. https://www.rgb.rw/fileadmin/user_upload/RGB/Publications/HOME_GROWN_SOLUTIONS/Rwanda_Community_Healt_Workers_Programme_2017.pdf

Sageer, R., Kongnyuy, E., Adebimpe, W. O., Omosehin, O., Ogunsola, E. A., & Sanni, B. (2019). Causes and contributory factors of maternal mortality: Evidence from maternal and perinatal death surveillance and response in Ogun state, Southwest Nigeria. BMC Pregnancy and Childbirth, 19(1), 63. https://doi.org/10.1186/s12884-019-2202-1

Umar, A. A., Salihu, H. M., & Azuine, R. E. (2025). Crisis of Brain Drain in Nigeria’s Health Sector: Challenges, Opportunities, and the Path Forward. International Journal of MCH and AIDS, 14, e011. https://doi.org/10.25259/IJMA_11_2025

UNICEF. (2021). Community Health Program Investment Case in Rwanda.  https://www.unicef.org/rwanda/media/3786/file/2021-CHP-Investment-Case.pdf

Vieira, C., Portela, A., Miller, T., Coast, E., Leone, T., & Marston, C. (2012). Increasing the use of skilled health personnel where traditional birth attendants were providers of childbirth care: a systematic review. PloS one, 7(10), e47946. https://doi.org/10.1371/journal.pone.0047946

World Health Organization. (2019). Maternal health in Nigeria: generating information for action. https://www.who.int/news/item/25-06-2019-maternal-health-in-nigeria-generating-information-for-action