Maternal mortality remains a critical problem in Nigeria. Many women face significant challenges in accessing high-quality healthcare during pregnancy and childbirth, contributing to alarming statistics. Addressing this dual challenge from both the demand side (users accessing facilities) and the supply side (improving services) is crucial, particularly at the primary healthcare center level.
Drawing on insights from prior research which highlighted issues like the attitude of healthcare workers, cost, and lack of health insurance as major barriers to using primary healthcare centers, the MRH organization conceived the MamaBase program. This data-driven, comprehensive intervention was developed to support the government’s efforts to reduce maternal mortality in Lagos state and significantly increase the uptake of public primary maternal health services by women and their families. The program operated its first phase in Lagos state between October 2023 and December 2024.
The MamaBase program targeted low-income, vulnerable pregnant women within communities, aiming to link them to primary healthcare centers, facilitate their registration, and support them throughout their pregnancy journey – from antenatal care (ANC) to delivery, immunization, and postnatal care.
Read Also: MRH’s MamaBase Initiative Significantly Reduces Maternal Mortality in Lagos
The MILES for Mothers Framework: A Five-Step Approach
To implement the program, the MILES framework was created:
- Mapping: Understanding communities and their context, using factors like high traditional birth attendant (TBA) use, high pregnancy rates, and high mortality rates to identify target communities.
- Identifying: Onboarding the target population onto the program with the help of trained community health workers.
- Linking: Ensuring access to skilled care by removing financial barriers, such as facilitating payment for registration, initial screening tests, and initial ultrasound scans.
- Educating: Improving the health-seeking behavior of enrolled women through community sensitization, outreaches, and tele-health messaging, addressing socio-cultural issues that prevent facility access or skilled care.
- Supporting: Ensuring women complete recommended ANC visits and deliver at health facilities with skilled birth attendants for a safe delivery.
Notable Achievements from Phase 1
Originally targeting 5,000 pregnant women, the program successfully registered 7,883 women in Phase 1. The highest registration numbers came from Alimosho and Kosofe local government areas.
Key outcomes reported include:
- Increased Registration: The registration rate at health facilities among enrolled women significantly increased from 47.8% at inception to 84% by the end of Phase 1.
- Improved Facility Delivery: A large majority of women delivered their babies in a facility (whether primary healthcare, private hospital, or general hospital). Out of 7,444 live births recorded among the registered women, 80% delivered in a facility. This is a marked improvement from the 16.9% facility delivery rate observed in prior research.
- Antenatal Care Attendance: 60% of enrolled women made four or more ANC visits, which is a recommended number.
- Utilization of Primary Healthcare: 86% of women registered on MamaBase attended primary healthcare in Lagos state.
- Reduced Mortality Ratios: The program reported a maternal mortality ratio (MMR) of 120 per 100,000 live births among participants (with 9 deaths recorded), which was compared favorably to the Lagos state figure of 555 and the national figure of 1,047 per 100,000 live births. Similarly, the neonatal mortality rate (NMR) was 18 per 1,000 live births (134 deaths recorded within 28 days after birth), compared to the Lagos state rate of 59 and the national rate of 41 per 1,000 live births. It was noted that these comparisons are between a community-based program study and broader state/national statistics, which may differ due to methodology. However, 99.9% of women registered on the program survived childbirth.
- Patient Satisfaction: Almost all women who delivered, regardless of location, were satisfied with the kind of delivery or services they received.
- Community Engagement: The program saw instances where women who benefited became advocates, encouraging their friends to register. Community health workers acted as vital ‘foot soldiers’ for identification and linking.
Persistent Challenges and Recommendations
Despite the successes, several challenges were encountered during implementation. The lack of health insurance stood out as a major barrier, leading to significant out-of-pocket expenses for women, particularly when referred to secondary facilities. Only about 15% of women in the initial research had health insurance. There is a lack of awareness about government health insurance schemes. Recommendations include intensifying education campaigns about the state health insurance scheme and advocating for it as the most sustainable way to address financial barriers.
Another significant challenge is emergency transportation. Many women lack birth plans or ways to access transportation, especially when labor begins at night, sometimes leading them to deliver with unskilled attendants nearby. Recommendations include the need for working ambulances, accessible emergency lines, and making this information known to women.
Socio-cultural issues are deeply rooted, with some women preferring home births, births at religious centers for spiritual cover, or traditional birth attendants. Lack of autonomy for women in deciding where to deliver, with decisions sometimes made by family members or spouses, is also a sad factor. Addressing this requires continuous education, engaging community leaders to pass the message, and informing women about registered versus unregistered traditional birth attendants. In some communities, actively engaging men is planned, particularly in areas like Northern Nigeria where women may have less autonomy.
Looking Ahead: Scaling Up and Expanding Impact
The MamaBase program is moving into Phase 2. Building on lessons learned, Phase 2 in Lagos will focus on targetting vulnerable women in the most disadvantaged communities within 12 selected local government areas. These communities were identified based on data indicating high death rates, high numbers of unlicensed TBAs, and low facility delivery rates. The MILES approach will continue to be used.
Excitingly, the program is also expanding to Kaduna state, a state with a very high maternal mortality rate. The target in Kaduna is to reach 10,000 women, also using the MILES model. Stakeholder engagement and planning have commenced in both locations.
The organization is actively seeking partners, stakeholders, and funders to join in this critical work and help expand the program. Partnerships with government, private entities, community groups, and other NGOs are vital to scale the model across Nigeria’s most vulnerable states and help reverse the increasing trend of maternal deaths. They are open to partnerships with other nonprofits and have implementation guidelines available. They also seek partners to cover associated costs that even women receiving free care may face, such as registration fees and items needed for delivery.
The program understands the importance of family planning and child spacing. While currently offering education and referrals, they are exploring public-private partnerships to expand services in this area.
The work is challenging, involving navigating cultural beliefs, financial constraints, and logistical hurdles, but the outcomes from Phase 1 demonstrate the potential for significant impact in saving lives and ensuring safe deliveries for Nigerian women.
