Content uploaded by Adaeze Oreh
Author content
All content in this area was uploaded by Adaeze Oreh on Aug 04, 2022
Content may be subject to copyright.
2021-2022 Edition 95
By Dr Adaeze Oreh
Dr Adaeze Oreh is
a Consultant Family
Physician, Country
Director of Planning,
Research and Statistics
for Nigeria’s National
Blood Service
Commission (NBSC)
and Senior Health
Policy Advisor with Nigeria’s Federal Ministry of
Health. She has over 18 years of private and public
healthcare experience and sits on the Governing
Council of Pamo University of Medical Sciences -
Nigeria’s first private university of Medical Sciences.
She is a Fellow of the West African College of
Physicians, the Aspen Institute, Royal Society of
Tropical Medicine and Hygiene, Royal Society of
Public Health and is a Member of the
White Ribbon Alliance for Safe Motherhood
Global Strategy Advisory Group and the
International Society for Blood Transfusion
COVID-19 Working Party.
She advocates for respectful, dignified
quality healthcare, health equity, universal health
coverage and quality medical education; and spoke
on Universal Health Coverage at the 74th United
Nations General Assembly in New York. In early
2021, Dr Oreh was one of 15 accomplished Amujae
Leaders awarded by the Ellen Johnson Sirleaf
Presidential Center for Women and Development
and was named a Neglected Tropical Diseases
Champion by the Global First Ladies Alliance and
The END FUND.
She recently won a Best Poster Prize at
the International Society for Blood Transfusion
2021 Congress in Amsterdam for research she
feature
Maternal Health in Nigeria – Biosocial
Theory, History & Implications of COVID-19
led and coordinated on blood services in 34
tertiary hospitals in Nigeria during the COVID-19
pandemic, and a Best Poster Prize in the Blood
Donation category at the 2021 British Blood
Transfusion Society Conference for research
she also led and coordinated on the impact of
COVID-19 on Nigeria’s National Blood Service.
Dr Adaeze Oreh was also recently named a
recipient of the 2021 Montegut Global Scholars
award by the World Organization of Family Doctors
and the American Board of Family Medicine.
Abstract
According to the World Health Organization,
nearly 830 women die from preventable causes
daily. About 99% of these deaths take place
in low- and middle-income countries, and
more than half of those occur in sub-Saharan
Africa alone. The target of the Sustainable
Development Goals is to improve maternal
and reproductive health outcomes and reduce
global maternal mortality rates to fewer than
seventy deaths per 100,000 live births by 2030.
Every woman has the right to live and thrive.
To accept the tragedy that one woman in the
world dies every two minutes from pregnancy
or childbirth due to preventable causes is to
deny their basic right to life. This article,
based on the Nigerian context, identifies
biosocial theories, historical antecedents,
metrics relevant to maternal health, and the
impact of the COVID-19 pandemic, describing
the potential of policy for rights-based inter-
ventions that address (1) inequity in access to
safe basic and emergency obstetric care; (2)
disenfranchisement and disempowerment of
women; and (3) women’s rights and respectful
maternal care in health care settings. The
96 Africa Policy Journal
article also describes how innovative strategies
that are multisectoral, community-oriented
and people-centered can help accelerate
the response towards ending preventable
maternal deaths for a more balanced and
prosperous world.
Introduction
Nigeria has been described as one of the
most dangerous places in the world for a
woman to give birth.1 Maternal death rates
are 556 women for every 100,000 live births,
accounting for one of sub-Saharan Africa’s
highest maternal mortality rates.2 These are
women of reproductive ages, 15-49 years,
and often younger in communities where
early marriage takes place.3 While attended
skilled deliveries have gradually risen in the
last decade, approximately 60% of all child
births happen at home and unattended.4 In
fact, every 10-13 minutes, one Nigerian woman
dies – that is approximately 150 women dying
each day – from preventable causes related to
pregnancy and childbirth.5 For every woman
who dies, up to fty women will experience
life-long complications and disabilities. This
equates to more than ve hundred women who
will either die or face severe disabilities daily.6
Bleeding, infections, hypertension, obstructed
labor, and unsafe abortions constitute the
main causes of death and disability.7 With a
population of over 200 million people, where
51.4% of people live in the rural areas, the
majority of Nigeria’s women reside in rural
and semi-urban areas.8 The challenge of high
maternal morbidity and mortality thus results
in untold hardships for them, their children,
families, and communities.
Decades of military rule, entrenched
corruption, poor investment in development
programs, and a broken health system have
led to these poor maternal health indices.9 A
gap therefore exists for the improvement of
healthcare delivery at the community level,
a fundamental right to health that so many
are denied, to address poor maternal health
and strengthen the healthcare system.
An Analysis of Biosocial Factors
Research on non-medical factors affecting
maternal mortality in Nigeria identified
payment of treatment costs, health facility
location, and access to antenatal care as sig-
nicant.10 Nigeria’s Health Insurance Scheme
offers nancial coverage to barely 5% of the
population, leaving most citizens to pay for
healthcare out-of-pocket.11,12 Poverty, low edu-
cational levels, paucity of information, harmful
cultural practices, inaccessible facilities, and
poor road networks and transportation limit
the accessibility of the antenatal and delivery
care which many pregnant women need.13
Additionally, harmful cultural factors present
barriers to health care through norms which
disallow women access to healthcare outside
their homes.14,15 These gendered domestic
power structures, resource allocation dynamics
and limited decision-making therefore exert
negative impacts on women’s health-seeking
behavior, health, and wellbeing.16 A lack of
consideration for these factors in the respectful
delivery and efcacy of care compromises
healthcare quality and the actualization of
women’s fundamental human rights.17
Several biosocial theories are thus relevant
to an analysis of Nigeria’s maternal mortality
challenges.
According to the theory of social suffering,
social violence from political, economic,
and institutional powers leads to inequity.18
The theory is comprised of four interrelated
concepts: the origin of suffering from wider
social issues; the limitation of free will and
potential; the impact of health challenges
beyond the individual alone; and lastly, the
worsening of social and health challenges by
society and the institutions set up to alleviate
them.19
2021-2022 Edition 97
In many Nigerian communities, cultural
beliefs and traditions enshrined within value
systems have regarded women as lesser beings
in the family hierarchy.20 This misogynistic
outlook prevents many women from seeking
antenatal care or childbirth services unless
their husbands or male family members are
present to permit it.21 This results in late
identication of medical conditions associated
with high-risk pregnancies, ultimately leading
to maternal deaths from bleeding, infection,
high blood pressure, obstructed deliveries, and
miscarriages.22 For many, simply accruing
delayed healthcare is unjust if the wider social
issues are not addressed. These notions of social
difference in gender like race, ethnicity, class,
and sexuality have propagated and perpetu-
ated structural violence across the world. By
labelling certain groups as different or “less
than,” social institutions developed to alleviate
suffering in individuals end up aggravating
their anguish.23 Infamous examples include
segregation-era United States of America,
apartheid South Africa, and homophobia and
violence against homosexuals.24 These social
groups therefore endure double burdens of
social suffering from health challenges where
they exist, and the structural violence directed
at them from society.25
Another biosocial theory, the local moral
world theory, describes values shared by people
in a shared space or environment at a partic-
ular moment in time, albeit temporarily or
permanently, which may conict with one’s
own personal values and beliefs.26 The rele-
vance of this to maternal mortality in Nigeria
is illustrated by the concept of the ‘purdah
woman’ in Islam and the ‘Hebrew woman’ in
Christianity. In many Pentecostal Christian
settings in Africa, it is believed that the Bible
promises every Christian woman ‘delivery
like the Hebrew woman’ – meaning a quick,
painless, and intervention-free process. Find-
ings from a study on perceptions surrounding
cesarean (surgical) deliveries in south-eastern
Nigerian women support this.27 In both belief
systems, women are often discouraged from
seeking medical interventions that could be
lifesaving. While she may not believe in that
concept, she may be conicted because of the
inuence of her ‘moral world’. These beliefs
and actions then become institutionalized in
their socially constructed worlds, are perpetu-
ated within communities, and often continue
from generation to generation.28
In the unintended consequences of purpo-
sive action theory, unanticipated outcomes
of an intervention can arise.29 In Nigeria,
primary healthcare centers are often poorly
located in communities.30 Important factors
such as population demographics and trans-
portation logistics are not often considered
due to political inuences and vested interests,
leading to low facility utilization rates. The
placement of these health facilities therefore
sometimes results in preventable hardships for
the intended beneciaries such as vehicular
accidents, robberies and even sexual assaults
encountered en route such centers. When
communities and deployed healthcare workers
abandon such facilities, unsupervised or poorly
supervised births among local women continue
unabated, thereby feeding the vicious cycle
of high maternal mortality rates.
Journey from History to the Present
Nigeria rst encountered orthodox medicine
in 1472 when Portuguese navigators first
arrived to its shores.31 With the country’s
establishment as a British colony in 1861,
hospitals and healthcare dispensaries were
subsequently built.32 These were, however,
mostly located in the urban centers where the
colonial administrators worked and resided.
The health system was regionalized, and most
public hospitals provided free healthcare
for colonial government workers and their
dependents while church-owned hospitals
98 Africa Policy Journal
provided care for the indigent, creating an
imbalance between healthcare in urban
towns compared to rural areas.33 This legacy
of colonialism can still be observed in several
African countries such as South Africa and
Tanzania.34-36
Following the country’s independence
from British rule in 1960, the healthcare system
continued to develop, albeit modeled on the
colonial system, with a focus on urban-located
hospitals and health facilities.37 This left
millions of Nigerians in the rural areas unable
to access quality healthcare and thus reliant
on traditional care, often within the context
of gendered cultural beliefs and norms.
The turbulent 1970s, with ghts for equal-
ity from marginalized populations in America
and across the world, brought the theme of
primary health care to the fore worldwide.38 By
1975, attempts at broadening the availability
of healthcare to include rural communities
commenced with the Basic Health Services
Scheme (BHSS), followed by the establish-
ment of fty-two model primary healthcare
centers across Nigeria between 1986 and
1992, and the National Primary Healthcare
Development Agency (NPHCDA) in 1992 by
former Minister of Health Professor Olukoye
Ransome-Kuti.39 These laudable attempts
have been severely challenged by poor road
networks, inadequate health personnel deploy-
ment, insufcient nancing, vested interests
and widespread corruption.40
Successive military governments under-
mined the objectives of these centers by
situating them based on the influence of
powerful military ofcers, rather than on
population, need, and access.41 Many of these
facilities were developed to raise the prole
of government ofcials without consideration
for effectiveness and value-creation. With
the advent of democracy in 1999, the trend
continued with ministers, senators, governors,
and other political ofce holders. Thus, even
where foreign and local non-governmental
organizations (NGOs) sought to provide aid
through collaborative health intervention
programs, these foundationally challenged
facilities were unable to provide the base for
implementation.
Cost-free healthcare for only government
workers drawn from the colonial era remains
an issue today, as it is mainly registered workers
in the formal sector who are covered by public
health insurance.42 Postcolonial power struc-
tures maintain these imperial dynamics with
high-level government ofcials and their staff
working predominantly in cities with access
to health nance protection.43 In addition
to the attractions of city life, urbanization
has been driven by increasing numbers of
young, under-employed Nigerians on a quest
for employment opportunities and security
because of terrorism and communal clashes
in rural areas.44
Power Structures and Dynamics
Behind Maternal Health in Nigeria
Custodians of the power structures and power
dynamics responsible for Nigeria’s maternal
health include the Nigerian Federal and
State Ministries of Health, National Primary
Healthcare Development Agency (NPHCDA),
the Society of Obstetricians and Gynecologists
of Nigeria (SOGON) and national traditional,
religious, and political leaders. International
power holders have included the World Bank,
UNFPA and the World Health Organization
(WHO).45 These power holders have, however,
been predominantly based in the urban centers
and healthcare facilities.46 Whereas most of the
women affected by maternal health challenges
are in rural communities served by primary
healthcare centers, the decisions and policies
regarding their health and wellbeing have
been predominantly determined in a top-down
fashion by experts and specialists in urban
centers and ministries of health. Community
2021-2022 Edition 99
decision makers, especially religious and tra-
ditional leaders, have ultimately perpetuated
many of the assumptions, cultural norms,
religious norms, institutionalized beliefs, and
behaviors that have inuenced policies and
interventions in maternal health.47, 48
Maternal Health in the COVID-19
Pandemic
The COVID-19 pandemic has considerably
impacted reproductive and perinatal health
in multiple ways. First, through a direct
effect of the infection itself, and second,
because of the changes that have occurred in
health care, social policy, and socioeconomic
circumstances.49
Globally, increased severity of presenta-
tion and outcomes in pregnant women with
symptomatic COVID-19 and variations in
clinical guidelines for labour, delivery, and
breastfeeding for COVID-19 positive patients
with a likelihood of increased uncertainty and
possible harm have been reported. Prenatal
care visits decreased, healthcare systems were
strained, and potentially harmful policies
were implemented with little evidence in
high-, middle-, and low-income countries.50,51
Several studies revealed reductions in health-
facility based deliveries and an increase in
rates of admission of pregnant women to
intensive care units during the pandemic
and substantial numbers of women had in-
adequate antenatal visits. Lockdowns and
fear of contracting COVID-19 led to delays
in seeking healthcare, ultimately resulting in
complications in nearly half of pregnancies
in some settings.52 An urban-based study
conducted in Nigeria revealed that nearly half
of the women studied encountered at least
one challenge with accessing reproductive
and maternal health services either due to
inability to leave their houses owing to lock-
down restrictions or unavailable transportation
services. Other deterrents included high cost of
transportation, fear of contracting COVID-19,
the idea of potentially being in proximity to
patients with COVID-19 receiving care in the
facility, and the mandatory use of facemasks
at health facilities.53 Pre-pandemic research
has highlighted quality of care issues, such as
poor staff attitude, long waiting times, poor
attention to women in labour, and high cost
of services in sub-standard facilities as sources
of dissatisfaction with modern facility-based
maternity care and as reasons why traditional
care is often preferred.54 The fear and un-
certainty surrounding COVID-19 and the
state of maternal healthcare services likely
heightened these sentiments.
The results are ndings of increased ma-
ternal stress, maternal morbidity/mortality,
and neonatal and infant mortality during
the pandemic, most notable in LMICs.55-60
Additionally, with COVID-19’s socioeconomic
impact, namely job losses, economic disem-
powerment, and increased domestic violence,
the incidence of maternal mental health
problems, such as anxiety and depression have
spiked in many countries.61-66 The reports of
maternal deaths are most worrisome given
the fact that they largely affect populations
who already carry the majority of the global
burden of maternal mortality.67-69
These ndings are not entirely surprising,
especially given that during the widespread
Ebola outbreak in West Africa, poor maternal
health outcomes were reported.70 However,
due to the far-reaching socio-economic con-
sequences of the pandemic, the combined
effects of undernutrition, lack of vaccination,
inadequate breastfeeding, and inability to
access healthcare services substantially in-
creased mortality rates among women and
children in low-income and middle-income
countries (LMICs).71 Therefore, any progress
that had been made in improving the quality of
maternal health services prior to the pandemic
could be lost for a long time to come.
100 Africa Policy Journal
A Framework to Curb Maternal
Deaths
Community Involvement
Engaging and mobilizing communities was
critical to addressing the socio-cultural hin-
drances in communities that werehesitant to
the polio vaccine. This strategy can be used
to address maternal mortality in Nigeria by
building trust, understanding community
values, and working with communities to
espouse those values in a way that safeguards
life. The NPHCDA’s recently launched Com-
munity Health Inuencers and Promoters of
Services (CHIPS) initiative aims to facilitate
task sharing and improve community health
services coordination.72 To strengthen service
provision, these Community Health Workers
(CHWs) should be distributed amongst de-
ned community catchment areas, receive
standardized training for identication of
risk and management of reproductive health
challenges, monitoring and evaluation tools, in
addition to supervision and research skills from
specialist family physicians and obstetricians
and gynecologists.73 This task-shifting model
would address the dearth of expert training and
supervision of community health workers in
rural areas that limits the provision of respectful
maternal care in rural Nigeria. Additionally,
the unintended consequences of purposive
action, such as poor transportation logistics,
would be addressed by a network of health
workers spread across several catchment areas
in the community, and through the implemen-
tation of transportation arrangements using
remunerated local community members or
through the provision of transportation fees
to transport women to health facilities, as is
done in rural Haiti and Liberia.74
Education, Skills Acquisition
and Empowerment of Rural
Women
The focus of this intervention recognizes that
social suffering originates from wider social
issues, such as poverty, gender bias, lack of
education, and economic opportunities which,
if not addressed in the context of maternal
mortality, will undermine opportunities for
addressing preventable maternal deaths. As
structural violence is often worsened by society
and institutions set up to alleviate these issues,
the involvement of the community in the
design and implementation of the intervention
would serve to alleviate suffering by taking into
cognizance the unique sociocultural barriers
and constraints of communities.75 Similarly, by
empowering women with education and skills
that increase their awareness of their health
and their agency, they are better positioned
to defy dictates of their local moral world,
or institutionalized thoughts and actions, to
seek out healthcare services to improve their
health and wellbeing.
A Revision of the Assessment
of Negative Maternal Health
Outcomes
The metrics that measure maternal deaths
include number of deaths per 100,000 live
births (maternal mortality ratios), coverage
of specic reproductive healthcare services,
and assessment of observed-versus-expected
maternal mortality as a function of Socio-de-
mographic Index (SDI), an indicator derived
from measures of income per capita, edu-
cational attainment, and fertility.76 These
metrics have not accounted for a majority
of the burden of non-fatal health outcomes
associated with pregnancy and childbearing
which due to further illness or disability up
to one year post-childbirth negatively im-
pact the health of the woman, her baby, her
other children, and the social and economic
standing of her family.77,78 For a more robust
evaluation of maternal health interventions,
disability-adjusted life years (DALYs) could
2021-2022 Edition 101
be used to compare outcomes in women
exposed to certain interventions and those
unexposed.79,80
Similarly, indicators of social suffering and
structural violence such as poverty, paucity of
information, cultural practices, inaccessible
health facilities, and transportation chal-
lenges are not evaluated. Person-centered
and open-ended qualitative methods such
as focus group discussions, one-on-one inter-
views and household surveys could provide
insights into these indicators, in addition to
the subjective perceptions and experiences
of women in response to reproductive health
interventions.81 These methods would give a
clearer picture of the true burden of maternal
health challenges.82
Likely Barriers to this Community-
Oriented Empowerment Framework
for Addressing Poor Maternal Health
Outcomes in Nigeria
The prevailing power dynamics behind
maternal mortality in Nigeria could pres-
ent the first source of a challenge to the
framework. Typically, the power holders of
maternal health have been top-level govern-
ment ofcials, public health specialists, and
specialist obstetricians and gynecologists.83
Expanding decision-making to include spe-
cialist family physicians, who have hitherto
been solely providers of care in the Nigerian
health system, could present inter-specialty
conict.84 Effective advocacy and dialogue
could circumvent this challenge. Secondly,
securing international donor funding could
prove challenging, due to other competing
demands and a trend toward diminishing aid to
developing countries.85 Convincing proposals
that align with funders’ goals and show clear
metrics to assess outcomes would be crucial
to counteract this obstacle. Additionally,
public-private partnerships with indigenous
private companies can plug funding gaps.86,87
A third challenge could be opposition from
spouses, religious, traditional and community
leaders who may view the intervention as
antithetical to their socio-cultural or religious
norms.88 Advocacy and engagement of these
groups would be helpful.89 Fourth, resistance to
change may arise from health practitioners and
stakeholders who are accustomed to the status
quo and may have beneted from corruption,
nepotism, and system inefciencies.90 Lastly,
generating the necessary political will to sup-
port and drive the implementation and scale-
up of such empowerment interventions across
the country would be challenging. Rigorous
management, transparency, and accountability
of these interventions with evidence-based
reports of achievement would simultaneously
counteract corruption and serve as advocacy
tools to drive political support.91
Conclusion
Any worthwhile interventions capable of
delivering positive maternal health outcomes
in Nigeria must be designed with consider-
ation of the broader economic, geographical,
and social factors that affect the access of
rural Nigerian women to quality maternal
health services, in order to provide culturally
appropriate care with community participa-
tion. Utilizing a nuanced understanding of
the rural woman’s unique experiences and
problems with existing services would ensure
that solutions are derived from a community
perspective. This would lead to the provision
of services in a respectful and person-centered
manner for women and their families along
the continuum of care in their reproductive
lives and thereafter. This way, their individual
values and fundamental human rights are
protected and assured.
Endnotes
1 Gates, Bill. 2018, “Speech given at Expanded
National Executive Council Meeting presided
102 Africa Policy Journal
by Vice President Osinbajo,” Presidential Villa
Abuja, Nigeria, March 21, 2018. https://www.
thecable.ng/bill-gates-nigeria-one-dangerous-
places-give-birth.
2 National Population Commission and ICF
Macro, Nigeria Demographic and Health
Survey 2018, (Abuja: NPC and ICF Macro,
2019), https://dhsprogram.com/pubs/pdf/
FR359/FR359.pdf.
3 Ghazali B. Abubakar, “Condition of women in
Nigeria: Issues and challenges,” Arts and Social
Sciences Journal 8 (2017):293.
4 African Population and Health Research
Center, Maternal health in Nigeria Facts and
Figures, (Nairobi: APHRC, 2017), http://aphrc.
org/wp-content/uploads/2017/06/APHRC-
2017-fact-sheet-Maternal-Health-in-Nigeria-
Facts-and-Figures.pdf.
5 World Health Organization, Trends in
maternal mortality 2000 to 2017: estimates
by WHO, UNICEF, UNFPA, World Bank
Group and the United Nations Population
Division, (Geneva: WHO, 2019), https://www.
who.int/reproductivehealth/publications/
maternal-mortality-2000-2017/en/
6 Chimaraoke Izugbara et al, “Maternal health in
Nigeria: A situation update. African Population
and Health Research Center,” (Nairobi:
APHRC, 2017), https://aphrc.org/wp-content/
uploads/2019/07/Maternal-Health-in-Nige-
ria_Final-Report.pdf.
7 World Health Organization, Maternal mortality
fact sheet, (Geneva: WHO, 2019), https://
www.who.int/news-room/fact-sheets/detail/
maternal-mortality.
8 United Nations Population Fund, Unfinished
business – The pursuit of rights and choices for
all: State of the world population 2019 report,
(New York: UN Publications, 2019), https://
www.unfpa.org/sites/default/files/pub-pdf/UN-
FPA_PUB_2019_EN_State_of_World_Pop-
ulation.pdf.
9 World Health Organization, Trends in
maternal mortality 1990 to 2015: estimates
by WHO, UNICEF, UNFPA, World
Bank Group and the United Nations
Population Division (Geneva: WHO,
2015), https://www.unfpa.org/publications/
trends-maternal-mortality-1990-2015.
10 Dominic Azuh et al, “Factors influencing
maternal mortality among rural communities
in southwestern Nigeria,” International Journal
of Women’s Health 9 (2017):179.
11 Chima Onoka et al, “Promoting universal
financial protection: constraints and enabling
factors in scaling-up coverage with social
health insurance in Nigeria,” Health Research
Policy and Systems 11 (2013):20.
12 Gbadegesin Alawode and David Adewole,
“Assessment of the design and implementation
challenges of the National Health Insurance
Scheme in Nigeria: a qualitative study among
sub-national level actors, health care, and
insurance providers,” BMC Public Health
21, no. 124 (2021):1, https://doi.org/10.1186/
s12889-020-10133-5.
13 World Health Organization, WHO rec-
ommendation on respectful maternity care
during labor and childbirth, (Geneva: WHO,
2018), https://extranet.who.int/rhl/topics/
preconception-pregnancy-childbirth-and-post-
partum-care/care-during-childbirth/who-rec-
ommendation-respectful-maternity-care-dur-
ing-labour-and-childbirth.
14 Friday Okonofua, “Factors associated with
adolescent pregnancy in rural Nigeria,” J Youth
Adolescence 24, no. 4 (1995):419 https://doi.
org/10.1007/BF01537189.
15 Abubakar, “Condition of women in Nigeria:
Issues and challenges,” 293.
16 Sanni Yaya et al. “Gender inequity as a barrier
to women’s access to skilled pregnancy care
in rural Nigeria: a qualitative study,” Interna-
tional Health 11, no. 6 (2019):551. https://doi.
org/10.1093/inthealth/ihz019.
17 Jonathan Dapaah and John Nachinaab,
“Sociocultural Determinants of the Utilization
of Maternal Health Care Services in the
2021-2022 Edition 103
Tallensi District in the Upper East Region of
Ghana.”Advances in Public Health (2019):1.
https://doi.org/10.1155/2019/5487293.
18 Bridget Hanna and Arthur Kleinman, “Un-
packing Global Health: theory and critique,”
in Reimagining global health: An introduction,
ed. P. Farmer et al (Berkeley, CA: University of
California Press, 2013), 30.
19 Hanna and Kleinman, “Unpacking Global
Health: theory and critique,”30.
20 Abubakar, “Condition of women in Nigeria:
Issues and challenges,” 294.
21 Abubakar, “Condition of women in Nigeria:
Issues and challenges,” 293.
22 World Health Organization, Trends in maternal
mortality 1990 to 2015: estimates by WHO,
UNICEF, UNFPA, World Bank Group and the
United Nations Population Division.
23 Hanna and Kleinman, “Unpacking Global
Health: theory and critique,”30.
24 Paul Semugoma, Steave Nemande and Stefan
D Baral, “The irony of homophobia in Africa,”
The Lancet 380 no. 9839 (2012):312, https://doi.
org/10.1016/S0140-6736(12)60901-5.
25 Hanna and Kleinman, “Unpacking Global
Health: theory and critique,”31.
26 Arthur Kleinman, What really matters: Living a
moral life amidst uncertainty and danger. (New
York: Oxford University Press, 2006), 25.
27 I Sunday-Adeoye and CA Kalu, “Pregnant
Nigerian women’s view of cesarean section,”
Nigerian Journal of Clinical Practice 14 no. 3
(2011):278.
28 Hanna and Kleinman, “Unpacking Global
Health: theory and critique,”30.
29 Robert Merton, “The unanticipated conse-
quences of purposive social action,” American
Sociological Review 1 no. 6 (1936): 895.
30 Bolaji Aregbeshola and Samina Mohsin Khan,
“Primary health care in Nigeria: 24 years after
Olikoye Ransome-Kuti’s leadership,” Frontiers
in Public Health 5 no. 48 (2017), https://doi.
org/10.3389/fpubh.2017.00048.
31 Ajovi Scott-Emuakpor, “The evolution of
health care systems in Nigeria: Which way
forward in the twenty-first century,” Nigerian
Medical Journal 51 no. 2 (2010):55.
32 Scott-Emuakpor, “The evolution of health care
systems in Nigeria: Which way forward in the
twenty-first century,” 56.
33 Scott-Emuakpor, “The evolution of health care
systems in Nigeria: Which way forward in the
twenty-first century,” 57.
34 Jeremy Greene et al, “Colonial medicine and
its legacies,” in Reimagining global health: An
introduction, ed. P. Farmer et al (Berkeley, CA:
University of California Press, 2013), 61.
35 Harriet Deacon, “Racism and Medical
Science in South Africa’s Cape Colony in the
Mid- to Late Nineteenth Century,” Osiris 15
(2000):200, https://doi.org/10.1086/649326.
36 William C. Bissell, “Disease, Environment,
and Social Engineering: Clearing Out and
Cleaning Up the Colonial City,” in Urban
Design, Chaos, and Colonial Power in Zanzibar
(Bloomington: Indiana University Press, 2011),
165.
37 Scott-Emuakpor, “The evolution of health care
systems in Nigeria: Which way forward in the
twenty-first century,” 58.
38 Matthew Basilico et al, “Health for all?” in
Reimagining global health: An introduction,
ed. P. Farmer et al, (Berkeley, CA: University of
California Press, 2013), 75.
39 S Olawale, “History of Primary
Healthcare in Nigeria,” Naija Quest,
February 5, 2018. https://naijaquest.com/
history-primary-health-care-nigeria/.
40 Yetunde Kolawole, “Problems of Nigeria’s
health sector and possible solutions,” Info
Guide Nigeria, April 9, 2018, https://infoguid-
enigeria.com/problems-of-nigeria-health-sec-
tor-and-possible-solutions/.
41 Emmanuel Anyika, “Challenges of implement-
ing sustainable health care delivery in Nigeria
under environmental uncertainty,” Journal of
Hospital Administration 3 no. 6 (2014):113.
42 Benjamin Uzochukwu et al, “Health care
104 Africa Policy Journal
financing in Nigeria: Implications for achieving
universal health coverage,” Nigerian Journal of
Clinical Practice 18 (2015):438.
43 Scott-Emuakpor, “The evolution of health care
systems in Nigeria: Which way forward in the
twenty-first century,” 56.
44 Isah Mohammed Abbas, “Trends of rural-urban
migration in Nigeria.” European Scientific
Journal 8 no. 3 (2012):97 – 125,http://dx.doi.
org/10.19044/esj.2012.v8n3p%25p.
45 National Primary Healthcare Development
Agency, About the National Primary Healthcare
Development Agency, (Abuja: NPHCDA,
2020), https://nphcda.gov.ng/about-us/.
46 Scott-Emuakpor, “The evolution of health care
systems in Nigeria: Which way forward in the
twenty-first century,” 56.
47 John Sotunsa et al, “Community health
workers’ knowledge and practice in relation
to pre-eclampsia in Ogun State, Nigeria: an
essential bridge to maternal survival,” Repro-
ductive Health. 13 no. S2 (2016):108-14, https://
doi.org/10.1186/s12978-016-0218-9.
48 Abubakar, “Condition of women in Nigeria:
Issues and challenges,” 293.
49 Bethany Kotlar et al, “The impact of the
COVID-19 pandemic on maternal and
perinatal health: a scoping review,” Repro-
ductive Health 18, no. 10 (2021):1, https://doi.
org/10.1186/s12978-021-01070-6.
50 Kotlar et al, “The impact of the COVID-19
pandemic on maternal and perinatal health: a
scoping review,” 35.
51 Rafael Pérez-Escamilla, Kenda Cunningham
and Victoria Hall Moran, “COVID-19 and
maternal and child food and nutrition insecu-
rity: a complex syndemic,” Maternal & Child
Nutrition 16, no. 3 (2020): 16e13036, https://doi.
org/10.1111/mcn.13036.
52 Manu Goyal et al, “The effect of the
COVID-19 pandemic on maternal health due
to delay in seeking health care: Experience
from a tertiary center,” International Journal of
Gynecology & Obstetrics 152, no. 2 (2021): 232,
https://doi.org/10.1002/ijgo.13457.
53 Mobolanle Balogun et al, “Challenges in
access and satisfaction with reproductive,
maternal, newborn and child health services
in Nigeria during the COVID-19 pandemic:
A cross-sectional survey,” PLoS ONE 16, no.
5 (2021): 10, https://doi.org/10.1371/journal.
pone.0251382.
54 Friday Okonofua et al, “Qualitative assessment
of women’s satisfaction with maternal health
care in referral hospitals in Nigeria,” Repro-
ductive Health 14, no. 44 (2017): 1, https://doi.
org/10.1186/s12978-017-0305-6.
55 Barbara Chmielewska et al, “Effects of the
COVID-19 pandemic on maternal and
perinatal outcomes: a systematic review
and meta-analysis,” Lancet Global Health
9, no. 6 (2021): e759, https://doi.org/10.1016/
S2214-109X(21)00079-6.
56 Vinayak Smith et al, “Maternal and Neonatal
Outcomes Associated with COVID-19
Infection: a Systematic Review,” PLoS ONE 5,
no. 6 (2020): e0234187, https://doi.org/10.1371/
journal.pone.0234187.
57 Marian Knight et al, “Characteristics and
Outcomes of Pregnant Women Admitted
to Hospital with Confirmed SARS-CoV-2
Infection in UK: National Population Based
Cohort Study,” BMJ 369 (2020):2107, https://
doi.org/10.1136/bmj.m2107.
58 Nicholas Bottan, Bridget Hoffmann and Diego
Vera-Cossio, “The unequal impact of the cor-
onavirus pandemic: evidence from seventeen
developing countries,” PLoS One 15, no. 10
(2020): e0239797, https://doi.org/10.1371/jour-
nal.pone.0239797.
59 P Casadio et al, “Increased rate of ruptured
ectopic pregnancy in COVID-19 pandemic:
analysis from the North of Italy,” Ultrasound in
Obstetrics & Gynecology 56, no. 2(2020): 289.
60 Sara Werner and Adi Katz, “Change in ectopic
pregnancy presentations during the COVID-19
pandemic,” International Journal of Clinical
Practice (2020): e13925, https://doi.org/10.1111/
2021-2022 Edition 105
ijcp.13925.
61 Miaomiao Xie et al, “Alteration in the
psychologic status and family environment
of pregnant women before and during the
COVID-19 pandemic,” International Journal of
Gynecology and Obstetrics 153, no. 1 (2021):71,
https://doi.org/10.1002/ijgo.13575.
62 Yanting Wu et al, “Perinatal depressive and anx-
iety symptoms of pregnant women during the
coronavirus disease 2019 outbreak in China,”
American Journal of Obstetrics & Gynecology
223, no. 2 (2020): 1.
63 Nicholas Berthelot et al, “Uptrend in distress
and psychiatric symptomatology in pregnant
women during the coronavirus disease 2019
pandemic,” Acta Obstetricia et Gynecologica
Scandinavica 99, (2020): 848.
64 Vincenzo Zanardo et al, “Psychological
impact of COVID-19 quarantine measures in
northeastern Italy on mothers in the immediate
postpartum period,” International Journal of
Gynaecology and Obstetrics 150, no.2 (2020):
184.
65 Gemma Biviá-Roig et al, “Analysis of the
impact of the confinement resulting from
covid-19 on the lifestyle and psychological
wellbeing of Spanish pregnant women: an
internet-based cross-sectional survey,” Inter-
national Journal of Environmental Research &
Public Health 17, no. 16 (2020): 5933.
66 Shunji Suzuki, “Psychological status during
the first trimester of pregnancy under the
COVID-19 epidemic in Japan,” Journal of
Maternal Fetal & Neonatal Medicine (2020):1,
https://doi.org/10.1080/14767058.2020.1793319.
67 Chmielewska et al, “Effects of the COVID-19
pandemic on maternal and perinatal out-
comes: a systematic review and meta-analysis,”
e759.
68 Seid Getahun Abdela et al, “Essential
healthcare services in the face of COVID-19
prevention: experiences from a referral hospital
in Ethiopia,” American Journal of Tropical
Medicine & Hygiene 103, no. 3 (2020): 1198.
69 Duncan Shikuku et al, “Early indirect impact
of COVID-19 pandemic on utilization and
outcomes of reproductive, maternal, newborn,
child, and adolescent health services in Kenya,”
medRxiv (2020) Preprint. https://www.medrxiv.
org/content/10.1101/2020.09.09.20191247v1.
70 Piper Yerger et al, “Barriers to maternal health
services during the Ebola outbreak in three
West African countries: a literature review,”
BMJ Global Health 5, no. 9 (2020): e002974,
https://doi.org/10.1136/bmjgh-2020-002974.
71 Gabriel Oke et al, “Impact of COVID-19
Pandemic on Maternal and Child Health,”
Modern Care Journal 17, no. 4 (2020): e110808,
https://doi.org/10.5812/modernc.110808.
72 National Primary Healthcare Development
Agency, About the National Primary Healthcare
Development Agency.
73 Akinwale Moses et al, “The role of family med-
icine and family physicians in The Nigerian
health sector,” Everyday Nigeria, July 4, 2017,
https://everyday.ng/2017/07/04/the-role-of-fam-
ily-medicine-and-family-physicians-in-the-ni-
gerian-health-sector/.
74 R Panjabi and P Farmer, “Healthcare systems
and Ebola in Liberia,” Presentation for Global
health delivery online course, Harvard’s Office
of the Vice Provost for Advances in Learning
Online Campus, August 2017.
75 Kleinman, What really matters: Living a moral
life amidst uncertainty and danger, 24.
76 Nicholas Kassebaum et al, “Global, regional,
and national levels of maternal mortality,
1990–2015: a systematic analysis for the global
burden of disease study 2015,” Lancet 388 no.
10053 (2016): 1781.
77 Carla AbouZhar, “Global burden of maternal
death and disability,” British Medical Bulletin
67 (2003): 4.
78 Marge Koblinsky et al, “Maternal morbidity
and disability and their consequences:
Neglected agenda in maternal health,” Journal
of Health and Population Nutrition 30 no. 2
(2012): 124.
106 Africa Policy Journal
79 Lorretta Ntoimo et al, “Prevalence and risk fac-
tors for maternal mortality in referral hospitals
in Nigeria: a multicenter study,” International
Journal of Women’s Health 10 (2018): 70.
80 Anne Becker et al, “The unique challenges of
mental health and MDRTB – Critical perspec-
tives on metrics of disease,” in Reimagining
global health: An introduction, ed. P. Farmer
et al, (Berkeley, CA: University of California
Press, 2013), 225.
81 Ochieng Atieno, “An analysis of the strengths
and limitations of qualitative and quantitative
research paradigms,” Problems of Education in
the 21st Century 13 (2009): 16.
82 Wendy Graham et al, “Diversity and
divergence: the dynamic burden of poor
maternal health,” Lancet 388 no. 10056
(2016): 2164-75, http://dx.doi.org/10.1016/
S0140-6736(16)31533-1.
83 National Primary Healthcare Development
Agency, About the National Primary Healthcare
Development Agency.
84 Moses et al, “The role of family medicine
and family physicians in The Nigerian health
sector.”
85 Adaeze Oreh, “Moving the goal post:
Sustainability and the global goals in Nigeria,”
American Journal of Public Health Research 4
no. 6 (2016): 209.
86 Adaeze Oreh, “Nigeria’s foreign aid addiction,”
Medium, March 26, 2018, https://medium.
com/@Adaeze_Oreh/some-of-the-factors-
that-have-been-alluded-as-responsible-for-the-
apparent-failure-of-aid-involve-a70481e7ce03.
87 U Anyaehie et al, “Constraints, challenges
and prospects of public-private partnerships in
health-care delivery in a developing econ-
omy,” Annals of Medical and Health Science
Research 4 no. 1 (2014): 62.
88 Eleri Jones, Samantha Lattof and Ernestina
Coast, “Interventions to provide culturally
appropriate maternity care services: Factors
affecting implementation,” BMC Pregnancy
Childbirth 17 no. 267 (2017): 268, https://10.1186/
s12884-017-1449-7.
89 Xiaohui Hou and Ning Ma, “The effect
of women’s decision-making power on
maternal health services uptake: evidence from
Pakistan,” Health Policy and Planning 28 no.
2 (2013): 183. https://doi.org/10.1093/heapol/
czs042.
90 M Lewis, Governance and corruption in public
health care systems - The World Bank Center for
Global Development Working Paper Number
78 (Washington, DC: World Bank 2006), http://
www1.worldbank.org/publicsector/anticorrupt/
Corruption%20WP_78.pdf.
91 Adriane Hilber et al, “Strengthening account-
ability for improved maternal and newborn
health: A mapping of studies in Sub‐Saharan
Africa,” International Journal of Gynecology
and Obstetrics 135 no. 3 (2016): 355.
