Introduction

COVID-19 (also called SARS-CoV-2) was first discovered in Wuhan, China in December 2019. Previous reports, particularly in the media, alluded to the virus being genetically engineered and a biological weapon but these claims were found to be false (Anderson et al., 2020). Like many other respiratory viruses, COVID-19 spreads through infected droplets which are projected from the mouth or nose when an infected person coughs, sneezes, talks or breathes (CDC, 2019). According to the World Health Organization (WHO), there have been an estimated 528,816,317 cases of COVID-19 globally, with 6,294,969 confirmed deaths as of 1st June 2022. 

In Nigeria, the National Center for Disease Control (NCDC) reports the confirmed cases of COVID-19 to be 256,148 with 3,143 deaths (report ongoing).COVID-19 has had both direct and indirect effects on the Nation. While the direct effects are related to morbidities and mortalities, the indirect effects of the pandemic on the economy were also quite high, with an estimate of Nigeria’s Gross Domestic Product (GDP) suffering a 34.1% loss during the lockdown period (a whopping USD 16 billion) (Andam et al., 2020). The subsequent shift in attention, funding and resources towards addressing the pandemic meant that other equally important healthcare services received little attention which adversely affected the health of citizens, particularly women and children.

Globally, maternal mortality was as high as 152 deaths per 100,000 live births in 2020 (BMGF, 2020) while in Nigeria, it was 197 deaths per 100,00 live births (NHMIS, 2020). The World Health Organisation (WHO) also estimates that the lifetime risk of a Nigerian woman dying during pregnancy, childbirth, postpartum or post-abortion, is 1-in-22 which is in contrast to the lifetime risk in developed countries at 1 in 4,900 (WHO, 2015). 75% of all maternal deaths occur due to unsafe abortions, severe post-partum bleeding, pre-eclampsia, eclampsia and complications from delivery (Say et al., 2014).

Generally, there are four delays that can lead to maternal deaths or complications and these include;

1. Delay in recognizing danger signs

2. Delay in deciding to seek necessary care

3. Delay in reaching health facility for the appropriate care

4. Delay in receiving care at the health facility

Since maternal deaths are largely preventable, these delays are vital in determining the maternal mortality rate in a country at any given time (Meh et al., 2019). Each of these delays could possibly have been further exacerbated by COVID-19 and its subsequent lockdown periods where movements were restricted and health workers were either too scared to go to work or were redirected towards emergency COVID-19 response services. The global response to COVID-19 particularly in low and middle-income countries like Nigeria had both direct (from the infection itself) and indirect (change in policy, social and economic) consequences. The implementation of lockdown as a result of the pandemic affected healthcare delivery for pregnant women and children who could not access the health facilities (Ahmed et al., 2021).

Research findings point toward a reduction in the utilization of Maternal, Neonatal and Child health services in Nigeria due to several factors such as resource constraints, fear of contracting the virus, and a shift of focus towards curtailing the pandemic at the detriment of other healthcare services (Ahmed et al., 2021). These findings were similar to that of a separate research to assess the challenges and satisfaction of Reproductive, Maternal, Neonatal and child health (RMNCH) services in Nigeria (Balogun et al., 2021). The consequences of poor utilization and delays in accessing healthcare facilities or receiving timely health interventions ultimately affect the well-being of the pregnant woman as well as her unborn child.

Data obtained from the National Health Management Information System (NHMIS) (see figure 1 below) shows that Nigeria is still a long way from achieving the target set by the sustainable development goals for maternal mortality (70 or less deaths per 100,000 live births). Particularly, some Northern states (Katsina, Zamfara, Kano, Jigawa and Sokoto) require more effort and attention as they continue to record high maternal mortality figures. Katsina State recorded the highest maternal mortality rate of 653 deaths per 100,000 live births (NHMIS, 2020).

Figure 1: Maternal mortality ratio in Nigeria (Source; the MSDAT)

In an effort to monitor maternal health data during the pandemic, the Federal Ministry of Health (FMoH) developed a National Health analytical tool which shows health service uptake during the COVID-19 pandemic (also called the HUC dashboard). It allows for the comparison of health service uptake on a monthly basis using key metrics as reported by health facilities across Nigeria using the NHMIS. The recent data from the HUC dashboard is used in this report to elucidate some of the maternal health indicators in Nigeria at the National and state level as well as to compare related health indicators.

Figure 2: National antenatal care attendance (Source; the MSDAT)

Figure 3: National deliveries by Skilled Birth Attendance (Source; the MSDAT)

The presence of a skilled birth attendant (SBA) at delivery is crucial in averting maternal mortality and morbidity (Ayele et al., 2019). National deliveries where SBA’s were present (figure 3 above) point towards fairly similar figures between January and June of 2019 and 2020, which was around the time the pandemic began. However, July 2020 recorded the highest value (195,362) of the three years so far. This high value may be an outlier as there was a sharp decline in SBA deliveries in the month of August through December compared to the preceding year 2019. The number of deliveries by SBA dropped significantly in 2021 compared to the previous years, with February 2021 (101,038) having the lowest national recorded value when compared with 2020 and 2019. The data obtained so far in 2022 (January to April) showed a slight rise in SBA deliveries although this still falls short of values recorded in 2019 and 2020.

Figure 4: Comparison between deliveries by SBA and National postnatal clinic visits (Source; the MSDAT)

The figure above shows a comparison of two indicators extracted from the HUC dashboard for the years 2019 to 2022. Increased ANC attendance (Fig. 2) did not translate into equally increased deliveries by SBA. This still indicates that many women still give birth with little or no supervision from SBAs, which does not particularly bode well for Nigeria and her maternal mortality rate. In both recorded indicators, there was a decline in postnatal clinic visits and deliveries by SBAs in the year 2020 during the height of the pandemic. Surprisingly, the number of deliveries by SBAs dropped significantly in the year 2021 compared to 2020 and 2019. Alternatively, postnatal clinic visits improved greatly in 2021 compared to the year 2020 with data from 2022 having a higher value. This could mean that more women are taking their children to health facilities for routine immunization.

Figure 5: A comparison of deliveries by SBA for Kaduna and Lagos states (Source; the MSDAT)

Figure 5 above compares the SBA deliveries in Lagos and Kaduna states. It can be inferred that there was a progressive decline in deliveries recorded from 2019 with 2021 being the lowest. December 2021 recorded figures as low as 3021 recorded births by SBAs while the corresponding period in 2019 and 2020 were 7,097 and 6,109 respectively. The post-pandemic years in Kaduna state recorded a better performance in terms of deliveries by SBAs. Although the 2022 data recorded so far show a slight improvement in SBA deliveries recorded, it is not enough to draw adequate conclusions.

Given that 5 states (Katsina, Zamfara, Kano, Sokoto and Jigawa) had poor maternal mortality indicators, it is important to establish a pattern of maternal health indicators in these states. Zamfara state and Jigawa state, in particular, recorded a wide decline in attended births by SBAs and this may be explained by the lack of access to health facilities particularly worsened by the COVID-19 pandemic. Although the National ANC attendance remained fairly stable in the three years under review, data available for the 5 states helped establish a trend of a decline in ANC attendance.

ANC attendance in Zamfara dropped in 2020 and further dropped in 2021 with the exception of December while in Kano state, although the ANC attendance dropped in 2020, there was a rise in attendance in 2021. 

Postnatal clinic visits (Fig. 6 below) show an improvement on a National Level in 2021 compared to the previous year while on average, the year 2020 which was the height of the lockdown and curfew period indicates a low postnatal clinic visit at the National level. ANC attendance was also much higher than postnatal clinic visits for the years under review. This may be attributed to women not going back to the health facilities for medical checkups after successfully giving birth. The observed improvement in ANC attendance and postnatal clinic visits in 2021 compared to the year 2020 may be explained as an effect of improved government policies to tackle maternal mortality as well as the willingness of women to seek maternal and child health services following the easing of lockdown.

Fig 6: Postnatal clinic visits versus ANC attendance in Nigeria (Source; MSDAT)

Conclusion

The recent maternal mortality ratio for Nigeria (196.6 per 100,00 live births) falls short of the target set by the WHO’s Sustainable development goals (SDG) of < 70 deaths per 100,000 live births (NHMIS, 2020). Statistics on major indicators of maternal health such as ANC coverage and delivery by SBAs show a low health service uptake since the emergence of COVID-19. Five states in the North-West zone (Kano, Jigawa, Katsina, Sokoto and Zamfara) are among the lowest-performing states in Nigeria. Given the challenges faced by Nigeria as regards maternal mortality, efforts need to be made to address the factors that may have led to the poor utilization of health facilities by pregnant women. Accessibility, poverty and social autonomy are some of the determinants that need to be addressed by the Federal Ministry of health and by extension, the Federal Government of Nigeria to prevent unwarranted delays that may lead to a rise in maternal deaths nationwide.

Recommendations

1. Continuous training of Reproductive, Maternal, Neonatal and Child Health (RMNCH) providers especially on the use of personal protective devices, and provision of support for pregnant women.

2. Appropriate communication and encouragement from the top backed by a commensurate remuneration package will instill confidence, boost morale and motivate health workers in the fulfillment of their duties.

3. The World Health Organization has released some operational guidelines for sustaining the administration of essential health services and adapting the modes of healthcare delivery to prevent further disruptions (WHO, 2020). Adhering to these guidelines should be encouraged by the Federal Ministry of Health and other Nigerian health agencies.

4. Creating awareness of the need for pregnant women to keep attending ANC services regardless of COVID-19. Media platforms and various modes of telecommunication should be leveraged to raise awareness about the importance of securing maternal and child health during and after the pandemic period. This would reassure pregnant women that they will receive the requisite care at all times.

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