A public health physician and Lead, Service Delivery and Innovation at the Health Strategy and Delivery Foundation (HSDF), Olasunmbo Makinde, has said the continued loss of women during pregnancy and childbirth reflects a complex set of challenges that extend beyond clinical care.

Makinde said Nigeria’s maternal mortality crisis cannot be solved through a single intervention because the factors driving maternal deaths cut across community behaviour, health facility capacity and broader health system governance.

“There isn’t a magic bullet that can significantly reduce maternal mortality in Nigeria because the problem is multi-layered,” she said, noting that the challenges range from the community level to health facilities and the overall enabling environment for healthcare delivery.

While several programmes and reforms have been introduced to improve maternal health outcomes, she stressed that inadequate funding remains one of the most significant barriers to progress.

According to her, government spending on health remains far below international commitments, limiting the country’s ability to strengthen infrastructure, recruit skilled personnel and ensure the availability of essential medical commodities. “If we do not increase funding in health, then we cannot address maternal mortality,” she said, adding that current allocations fall well short of global recommendations.

Makinde told The Guardian that funding gaps have far-reaching consequences for the entire healthcare system. “Limited resources affect the availability of skilled healthcare workers, the condition of health facilities and the supply of essential drugs and equipment needed to manage pregnancy complications,” she said.

For instance, she noted that some facilities still lack basic diagnostic equipment required for routine antenatal care, including blood pressure monitors used to detect hypertensive disorders in pregnancy.

“You can imagine a woman going for antenatal care and nobody checks her blood pressure because the facility does not have the equipment,” she said, explaining how seemingly minor gaps in medical supplies can escalate into life-threatening complications.

Supply chain weaknesses also affect access to newer and more effective medicines used to treat complications such as Postpartum Haemorrhage, one of the leading causes of maternal deaths in Nigeria.

Although research has produced more stable drugs and improved tools for measuring blood loss after childbirth, Makinde said these innovations have not been widely distributed within the country’s health system due to persistent logistical and procurement challenges.

Beyond funding constraints, shortages of skilled health workers continue to undermine maternal health services across the country.

Makinde said the number of doctors and trained healthcare professionals available in many states is far below what is required to provide quality care for pregnant women. Even in Lagos, where the concentration of medical personnel is relatively higher, she noted that the workforce remains insufficient when compared with population needs.

The shortage of skilled personnel is particularly critical in emergencies where timely surgical intervention can determine whether a woman survives complications during childbirth.

However, Makinde said the problem is not only about manpower but also the environment in which health workers operate.

“You have the human resources, but you don’t have the commodities to perform the surgery,” she said, explaining that healthcare workers are often unable to provide life-saving care because essential surgical supplies are unavailable.

She added that healthcare strikes in the country are frequently linked to these systemic challenges rather than an unwillingness to work. “These are the things healthcare workers are fighting for. They want an enabling environment to do the kind of work they are trained to do,” she said.

Makinde also noted that transportation barriers contribute significantly to delays in accessing emergency obstetric care. She explained that ambulance services remain limited in many communities, while alternative transport systems capable of moving pregnant women quickly to appropriate facilities are poorly developed.

“In rural areas especially, the absence of reliable emergency transport can mean the difference between life and death for women experiencing complications,” she said.

According to her, addressing maternal mortality requires improvements not only within hospitals but also stronger engagement with communities where many of the delays begin.

Many women still rely on traditional birth attendants (TBAs) for childbirth services, often because of long-standing relationships and trust within their communities.

Contrary to popular belief, Makinde said TBAs are not necessarily cheaper than formal health facilities. Rather, the preference is often driven by familiarity and perceived compassion. “Women go to TBAs because of the relationship and trust they have built over time,” she said.

Rather than excluding community-based providers, she suggested that health systems should integrate them into broader maternal care frameworks while ensuring they operate within defined guidelines and refer complicated cases to formal facilities.

Makinde also emphasised the critical role of Primary Healthcare Centres (PHCs), which serve as the first point of contact for many pregnant women. However, she noted that the potential of PHCs to improve maternal outcomes remains limited by staffing shortages, inadequate infrastructure and weak engagement with local communities.

According to her, rebuilding trust between communities and health facilities is essential for encouraging women to seek early antenatal care and skilled birth attendance. In some cases, women avoid health centres because of poor facility conditions such as lack of electricity, ventilation or functional toilets.

“These may sound like small issues, but they matter to women deciding whether or not to attend a facility,” she said.

Financial barriers further complicate access to maternal healthcare, as many families continue to rely on out-of-pocket payments that can delay treatment during emergencies. Makinde said the inability to provide initial deposits at hospitals often prevents women from receiving timely care when complications arise.

Health insurance schemes aimed at reducing these costs have begun to show some impact, she noted, particularly programmes that provide maternal services immediately after enrolment rather than imposing waiting periods. Such initiatives help reduce the financial burden on families and encourage women to seek professional care earlier.

However, she cautioned that isolated interventions are unlikely to produce nationwide improvements unless they are implemented on a larger scale and supported by sustained financing.

Makinde cited ongoing programmes such as Project Aisha as an example of how coordinated approaches can improve outcomes. The programme combines community education, health facility strengthening and quality improvement systems to address multiple drivers of maternal mortality simultaneously.

Through community outreach activities, nearly 200,000 women have been reached with information designed to help them recognise pregnancy complications and seek timely care.

These interventions have also been associated with increased antenatal care attendance in the communities where the programme operates.

Within health facilities, quality improvement initiatives have strengthened antenatal services, improved labour monitoring practices and enhanced referral systems for managing complications.

According to Makinde, some facilities participating in the programme have recorded significant improvements in maternal care quality and reductions in maternal deaths.

Digital tools have also been introduced to capture feedback from women about their experiences during pregnancy and childbirth, allowing healthcare providers to identify service gaps and improve patient-centred care.

The feedback systems, she said, have encouraged greater engagement between health facilities and communities and even increased male involvement in maternal healthcare in some areas.

Despite these improvements, Makinde emphasised that Nigeria’s maternal mortality challenge will only be resolved through coordinated national efforts that address the problem across all levels of the health system. This includes strengthening community awareness, improving transportation and referral systems, investing in health infrastructure and expanding financial protection for vulnerable women.

She also highlighted the importance of reliable data in guiding maternal health interventions. Currently, inconsistent reporting systems make it difficult to establish a unified national picture of maternal mortality.

Makinde said strengthening community-level surveillance systems that track maternal deaths and investigate contributing factors would help policymakers better understand where delays occur and how they can be prevented.