Records from the World Health Organization (WHO) indicate that sub-Saharan Africa accounts for 66% of global maternal deaths, with a maternal mortality ratio (MMR) of 546 per 100,000 live births.1 The Nigerian MMR is 512 per 100,000 live births,2 while we report an MMR for Benue State, one of Nigeria’s 36 states, of 1,189 per 100,000 live births.3 The National Demographic and Health Survey reveals that Nigeria constitutes approximately 1% of the world population yet accounts for 10% of the world's maternal mortality rates.2 This trend has not improved: as of 2017 a Nigerian woman's chance of dying from pregnancy and childbirth is 1 in 13, whereas it is 1 in 5,000 in developed nations.4 The United Nation’s Sustainable Development Goal Number 3 aims for a reduction of MMR below 70 per 100,000 live births.5 Countries like Nigeria would need to make considerable progress before achieving this goal.
Access to skilled birth attendants (SBAs) is a necessary requirement in maternal healthcare as it holds the potential to reduce maternal and infant mortality and morbidity rates in regions where they are employed.6 For developing countries, there is a proposed target of one SBA for every 5,000 population or one SBA to attend 200 births annually,6–7 while a lower target was set for SBAs in advanced and high-resource countries to attend between 30–120 deliveries annually.8 An SBA is a health professional, such as a midwife, doctor, or nurse who has been educated and trained to manage pregnancies, childbirth, and the immediate postnatal period.9 Midwives and nurses make up the majority of SBAs, yet have the least amount of formal training.10
SBAs also assist in the identification and management of complications in women and newborns, in addition to identifying abnormalities, managing them, or making referrals. They provide counselling on postnatal contraception to the mothers and actively assist in the prevention of mother-to-child transmission of HIV infection and other prevalent diseases.11 Studies show that countries have successfully reduced maternal mortality by focussing on training, recruiting, and supporting SBAs at deliveries.1,12−14 SBAs play a vital role in monitoring and counselling pregnant women on diseases such as HIV, diabetes, and syphilis,11,15−17 which have been noted for their high prevalence throughout low-to-middle income countries, including Nigeria.18–20
Several Nigerian studies have revealed variation in access to and utilisation of SBAs. Regional surveys indicate that only one-third of births take place in health facilities with SBAs, with the lowest recorded in North-west Zone (12%) and highest in the South-east Zone (78%).21 Urban areas such as Makurdi and Nnewi have reported over 80% of childbirths attended by SBAs. Estimates by the WHO suggest that approximately 59% of births in Nigeria were assisted by SBAs in urban areas, compared to 27% in rural areas.22 Traditional birth attendants are also commonly involved in birth practices in Nigeria, assisting in 13.5% of the pregnancies in Sagamu and 4.8% in Kaduna.23–24 Pregnant women are encouraged to travel to primary healthcare centres (PHCs) to deliver with an SBA, however, the physical distribution of PHCs has a major role in access; there are inequalities in the provision of PHCs across Benue State, which may be a contributory factor impeding access to SBAs by pregnant women.25
Analysis of routinely collected maternal data can identify pregnant women who are at risk of mortality or morbidity.3 The Community Maternal Danger Score (CMDS) is a low-cost, evidence-based maternal risk analysis tool that was validated in Makurdi, Nigeria to predict the need for skilled birth attendance and identify high risk for maternal death.3 The CMDS is designed to help pregnant women make informed decisions about where they should deliver, and helps midwives identify women at risk. The CMDS has been developed into a scoring tool that is available as an Android application to encourage pregnant women to deliver with SBAs. Pregnant women are assessed by healthcare workers in PHCs who use this scoring system at their initial visit to obtain a prenatal score out of 5 and at the 3rd trimester to obtain a perinatal score also out of 5. The total score out of 10 points provides the midwives and the pregnant women with a quantitative measurement of their risk. A CMDS score of 3 out of 10 or higher is suggested to be the threshold of high risk for pregnant women.3
To strengthen the provision of risk information, women are provided their risk score in writing through SMS messages, while also advising them on ongoing antenatal care, being proactive about danger signs of their pregnancy, and other advice on seeking SBAs at PHCs and hospitals. This is done to encourage SBA-seeking behaviours prior to delivery, ultimately to reduce the incidence of maternal mortality in regions where it is implemented. The CMDS is based on 7 risk factors, however due to data collection in Benue State, only 3 of the 7 factors were noted to be routinely recorded in obstetrical assessments.26 These risk factors include age,27 parity,28 and co-existing medical conditions (human immunodeficiency virus (HIV) and diabetes).29–30