Health Research, Vol. 3, Issue 2, Jun  2019, Pages 1-12; DOI: 10.31058/j.hr.2019.31011 10.31058/j.hr.2019.31011

Trends in Maternal Mortality Burden in Nigeria

, Vol. 3, Issue 2, Jun  2019, Pages 1-12.

DOI: 10.31058/j.hr.2019.31011

İlker Etikan 1* , Ogunjesa Babatope 1

1 Biostatistics Department, Faculty of Medicine, Near East University, Nicosia, Turkey

Received: 30 October 2019; Accepted: 30 October 2019; Published: 27 November 2019

Abstract

One of the central focuses of the global health initiative of the United Nations (UN) is the reduction of the burden of maternal mortality especially in the developing countries. There are considerate record of disproportionate gap of maternal mortality between the developed and the development world which could be attributed to biological, economical and psycho-social factors. This study seeks to examine the trend of maternal mortality ratio (MMR) in Nigeria healthcare sector. The data used for the study was obtained from the World Bank data repository and the time series technique was used for modeling. The Ljung –Box ARIMA (0,1,0) time series model was then used to predict the MMR for the year 2016 through 2019.It was forecasted that there is a continuous decline in the country MMR.

Keywords

Maternal Mortality Ratio, Time Series, ARIMA, Stationarity, Forecast

1. Introduction

The Sustainable Development Goal (SDG) number 3 seeks to “ensure healthy lives and promote well-being for all at all ages”. This aforementioned goal also makes provision for the health of the mother and child. The wellbeing of mothers has been a central research theme in the society as a result of the prominent roles they played. In a bid to curtail the problem of maternal mortality, the Ending Preventable Maternal Mortality (EPMM) strategies of the World Health organization (WHO) in 2015 was initiated with the objective to counter and curtail the disparities in the health and social outcomes made women to be disadvantaged[22].

Maternal mortality can be defined as death occurrences attributable to pregnancy complications or child delivery [17] The maternal mortality ratio (MMR) which measures the number of maternal deaths per 100,000 live births has become a verifiable and widely accepted health metric to assess the well-being of women’s health within a national and international context [4]. This indicator reveals the disparities that exist between women socio-economic strata and environmental settings. According to the WHO, 830 deaths of women occur daily as a result of complications from pregnancy and child delivery processes which are considered to be preventable [21]. Though globally, there have been reduction (44%) in the cases of maternal mortality from its record of 385 deaths per 100,000 live births in the 1990 to 216 deaths per 100,000 live births in 2015, however, a high record of this type of mortality is still prevalent in the developing nations with the 99% occurrence of all global maternal mortality. Women from developing regions of the world are 33 times likely to die from maternal complications than their counterparts in developed economies [4].

Maternal and Child Mortality measures are very common indicators used to access the reproductive health and well- being of mother and child health globally. In line with this objective, the world government institutions such as the World Health Organization (WHO), United Nations for Children Fund (UNICEF), United Nations for Population Fund (UNPA) and other notable health NGOs such as Bill & Melinda Foundation are at the forefront of ensuring a safe world for mothers and the wellness of their wards. As a result of this, time- bound program initiatives and interventions (e.g. MDGs, SDGs) are tailored to wage war against many ill health of the society and notable among this catastrophic health problem to be combated is the maternal mortality records which still widens the gap between the developed and developing world [7].

There is a geographical variation in the occurrence of maternal death across different regions of the world. The disparity in deaths as a result of maternal mortality recorded is found to be higher in developing countries more than those in the developed countries of the world. And this health indicator is reputed to have the highest disproportional record among all other health indicators computed between the developing and developed countries [26]. In 1990, the maternal mortality ratio (MMR) in the Sub-Saharan Africa was 987 deaths per 100,000 live births and stood at 346 deaths in 2015.This was closely followed by the South Asia region with 558 deaths in 1990 and 182 deaths in 2015. The greatest burden of MMR is well pronounced in sub-Saharan region of Africa with 66% of maternal deaths recorded in 2015 [13].

2. Overview of Health and Social Indicator in Nigeria

Nigeria is a very important country in the sub-Sahara region and the Africa continent entirely. The country is a core economic and regional hub on the continent with more than 195,874,740 million people according to the World Bank 2018 estimate with different ethnic and language diversification. The estimated women population in the country for the year 2018 was 96,597,148 accounting for 50.68% of the total population.

In the WHO 2018 report, the life expectancy for women is 55.7 and the total life expectancy in Nigeria is 55.2 making the country number 178 out of the total 192 ranked nations of the world [2]. The country fertility rate according to the 2017 World bank estimate is 5.457 births per woman which places Nigeria number nine (9) in the Africa continent fertility profile only behind countries such as Niger (7.187), Congo DR (6.018), Mali (5.968), Chad (5.846), Angola (5.623), Burundi (5.615) and Uganda (5.457).

There is a about five years reduction in the lifespan of an average Nigerian woman in comparison to other women in the Africa sub-Saharan region and a risk to die much earlier by an average of 18 years in contrast to the average dying age recorded for their counterparts in the world at large [10]. These various health indicators show that Nigeria do not fare well relative to her economic potentials and richness like other countries with similar economic and demographic profile.

3. Maternal Mortality in Nigeria

Maternal mortality in Nigeria has been a reoccurring health challenge in the country with estimated 40,000 annual maternal deaths and about 14% of the global figure. The period of pregnancy and delivery is a gory phase for more than 9.2 million women and girls heavy with child annually in the country. The 2015 record of the nation’s maternal mortality ratio was 815 deaths per 100,000 live births. The risk of maternal death in the country is 1 in 13 in contrast to the 1 in 31 for sub-Saharan region of Africa at large. At least, for every 13 minutes, a Nigerian woman dies from avoidable deaths that borders on child bearing and pregnancy and between a range of 30 to 50 women will suffer a long-term health problem for each death recorded [10].

About 20% of the occurrence of maternal death recorded worldwide happen in Nigeria, making the country ranked the second position only after India as the major contributor to the burden of maternal mortality. [19] posited that women in Nigeria during child birth are 500 times at risk of dying in comparison to women in developed world. Diseases such as malaria, HIV/AIDs, Chlamydia and other venereal diseases have been reported to heighten the maternal mortality figures responsible for about 27% contribution to the burden of maternal mortality [16]. More than 600,000 maternal deaths and 900,000 close call incidents happened in Nigeria between 2005 through 2015.This record is more worse in the Northern region of the country where the maternal mortality ratio hit a peak of 1,549 per 100,000 live births. Three states in the Northern region of the country namely Kaduna, Kano, and Kastina accounts for 20% of the overall maternal and neonatal mortality figure in the country. Nigeria’s record of a yearly 40,000 pregnancy and other related cause of death made it to be listed in the first ten (10) nations where child bearing is considered a grave danger. The prevalence of maternal mortality is said to be worrisome such that child delivery is tantamount to an increase risk of dying in Nigeria [17]. The table below gave a descriptive insight on the challenges that characterize women and girls health problems in the country.

Table 1. Health problems related to reproductive profile of women and girls in Nigeria [10].

Before pregnancy

During pregnancy

During childbirth

After childbirth

44% of girls aged 15-19 years attend secondary school, compared to 52% of boys in the same age group

48% of mothers under age 20 receive antenatal care(ANC) from skilled provider

25% of girls under age 20 deliver their baby in a health facility

40% of mothers receive postnatal care(PNC) within two days of giving birth(32% among women under age 20)

28% of girls aged 15-19 are married,23% of whom have begun child bearing; 17% have had a child while 5% are pregnant with their first child

Only 5% of pregnant women receive two doses of intermittent preventive treatment for malaria, a major killer of pregnant women.

In 2013,traditional birth attendants were present in 22% of childbirths(Unchanged from NDHS 2008)

The proportion of infants (12-23 months) who are fully immunized by the age of one increased slightly to 25% in 2013 from 19% in 2018

Only 6% of girls aged 15-19 use any contraception method1

11% of women aged 15-19 have received HIV counselling and testing during ANC visits(down from 13% in 2008)

In the north-west regions, a high proportion of births occurs at home(88% and 79%,respectively).

250,000 babies die annually(25% of all under –five deaths)

Only 7.6% of 15-19 years old have best tested and given results

The overall fertility rate in Nigeria is among the highest in Africa(5.5 births per woman overall and 6.7 in rural areas)

The poor quality of care is made worse by lack of facilities. Only 4% of public health facilities meet EmOC standards. Only 2% of women delivered by C-section(1% among women under age 20)

Nigeria’s provision of postnatal care reaches only 42% of those who need it.

71% of women have a primary health care(PHC) facility within 5km of their home

The WHO recommends 5 EmOC facilities for every 500,000 people. Only Lagos state meets this standard

4. Health Care System and Maternal Care in Nigeria

The strength of a nation in keeping her population healthy and optimizing their standard of living and quality of life lies in the strength of a sustainable health care systems and delivery that meet different health needs of the society in close collaboration with other stakeholders. In Nigeria, there are quite numbers of stakeholders that play critical roles in the health system of the country. The Federal government , National health insurance scheme, National primary health care development agency, state ministries of health, local government councils, health maintenance organizations(HMOs), NGO’s and development partners, national and international donors are core examples of stakeholders in Nigeria health care system. Typically, the Nigeria healthcare system operates in a three (3) level division hinged on different types of services provisions, mode of operations as well as administrative control These divisions include the primary, the secondary and the tertiary heath care systems.

Firstly initiated in 1978, The Primary Health Care (PHC) was developed to address the health needs of people living in the grassroots communities as enshrined in the Alma Mata WHO declaration which posited primary health care as an “essential care based on practical, scientifically sound and socially acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation, and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination [25].

The primary focus of the PHC which are located strategically in all the 774 local council areas of Nigeria is to be the first responder to the health call of the population especially people in the rural communities while the state government operated health care facilities such as the state hospitals provide other services beyond the capacities of the PHCs. Services such as antenatal care, delivery and post –natal services are expected to be primarily received at PHCs that are more closer to the people. The tertiary health care institutions which are prominently controlled by the Federal government operate at the level of teaching hospitals and federal medical centers to cater for an advanced health need of the general population [18].

The PHC have been on the frontline of maternal health in the country accounting for about 85% of the health care facilities in the country [8]. As contained in the National Health Policy drafted in 1988, the PHCs are reckoned to be a platform for a wider open access to basic health request, that is geared towards health promotion and health equity in the society [9] .Thus, there are notable phases of optimizing the basic responsibilities of the PHC especially in the areas of addressing the maternal and child health challenges in the country.

Some of the various program initiatives that have been inculcated into the PHC operations by the Federal government include the midwives service scheme (MSS) primary aimed at reducing the nation’s maternal death and morbidities. Also, another scheme is the primary healthcare reviews, and the 2009 inaugurated bi-annual Maternal Newborn and Child Health Weeks (MNCHW) with the objective to create a streamline service for maternal and child health service delivery. Lately, the SURE-P maternal and child health initiative was developed with the aim of revamping the nation’s healthcare facilities, ensuring sustainable supplies of drugs and other medical supplies, subsiding health cost of maternal health , grassroots advocacy for modern health utilization and training of more medical staff [1].

Aside the Federal government initiatives to tackle the maternal death crisis, several state governments in the country have equally implemented various strategic health system models in their respective state. The Lagos state government for an instance in 2010 inaugurated the Maternal and Child Mortality Reduction Program (MCMR) in conjunction with the Society of Gynecologists and Obstetrics (SGON) to address the maternal death problem in the State. However, despite the various efforts aimed at reducing maternal mortality in the country, the figures reported are still relatively high. The prevalence of this problem is tied to many pluralistic factors that have continued to undermine efforts made so far.

5. Factors Responsible for High Maternal Deaths in Nigeria

The moribund condition of the health sector and the substantial inequities health outcomes in Nigeria is not unconnected with several factors from socio-economic status, inefficient policies implementations, cultural, economic and psycho-social factors that have kept the sector in comatose. A glaring indication of this failing health state is still well pronounced in the country’s maternal health outcomes. Aside the biological risk factors of malaria, hemorrhage, ectopic pregnancies, renal failure, and hypertension and so on, other non-medical factors influence maternal mortality [6].

The poor access and under-utilization of the available skilled birth attendants is a major driver of maternal mortality reported. This is further strengthened by the ignorance of women especially those from rural areas in attending government approved health care centers for prenatal, delivery or post-natal services [1].

According to the Nigeria 2018 DHS exercise, women who had a live birth in the 5 years preceding the survey exercise shows that 66.2% of birthing process in the urban center was handled by skilled provider while 21.9% of the birthing procedure in rural communities was handled by skilled professionals. Likewise, 83.6% of mothers residing in urban regions attended antenatal care from approved medical facilities while 56.1% of their counterparts in the rural communities did [14].

Most rural community lack health care facilities and thus the dwellers are more disposed to attend traditional birth attendants which abounds, owing to cultural belief and ancestral practice thus making women more susceptible to avoidable risks associated with birthing procedures [15]. Aside this, other factors such as transportation costs, high cost of medical attention, fear of modern medical intervention for women in rural communities could deter them from patronizing skilled birth attendants in approved medical facilities [20].

The incessant and the security challenge that pervade the country especially in the north east region of the nation have heavily contributed to the high maternal mortality recorded in the country. The insurgency activities of the Boko Haram armed group have resulted into over 40 percent damage of medical centers and equipment, forceful relocation of health workers and increase the figure of the internally displaced people. About 1.7 million women who are within the range of reproduction age are heavily affected with this ongoing crisis .Around 7.7 million people in the states of Borno, Adamawa and Yola alone are reported to be in dearth need of medical attention and about 10.2 million individuals in the whole of the region at large as a result of this insurgency violence [23].Thus, many of the pregnant women are unable to access maternal care services coupled with the ill-living conditions in many humanitarian camps and host communities they live in thus increasing the risk of maternal death and other form of maternal morbidity.

Cultural factors are equally key determinant of maternal health in Nigeria [7]. Some observed cultural practices in certain part of the country do not support the desire for mothers to seek proper maternal healthcare for their well -being and their pregnancies. Certain culture denies pregnant women some nutritional benefits by making them to avoid consumptions of foods such as eggs in their course of pregnancy. This in turn could result into health condition such as anaemia which could prove fatal [17]. Even during pregnancy, some women in certain regions of the country are still expected to continue demanding chores and farm work activities such as fetching woods in the forests and carrying of heavy loads most especially in rural communities.

Some faith based religion forbids their women to seek medical attention during pregnancy or in the course of child delivery. Some of these faith based mission convinced pregnant women to regard pregnancy and delivery process as a spiritual event which can only be attended to by spiritual exercises. Rather than take medically prescribed drugs and supplements, they are subjected to unregulated herbal drink intakes which could affect maternal and child health outcomes. Other factors with a definite mark on the nation’s maternal record include poverty, illiteracy, and shoddy program implementation, intervention duplicity, medical quackery, and corruption, domestic violence against women, fake drugs, poor nutrition, and geographical hazards.

6. Methods

Data for the Nigeria’s maternal mortality ratio covering the time from 1990 to 2015 was obtained from the World Bank repository webpage. The time series methodology was used to model the trend of maternal death over the 1990 - 2015 periods and forecasting will be made through the time series model. The Time series is one of the predictive tools use in time modeling with many applications in engineering, economics, epidemiological and financial fields [11,12].

Prior analyzing the data, the assumption of stationary was check which aimed to eliminate any form of sequence pattern in the data as a prerequisite before time series application. The yearly time lag trend was applied in the study. A seasonal trend was found in the data after plotting the trend series as shown in Figure 1 but this was however eliminated by a seasonal differencing order (1) as shown in Figure 2. The augmented Dickey Fuller (ADF) unit root test was used to evaluate the stationarity effect [3].

Figure 1. Time series plot of maternal mortality ratio.

An Autoregresssive Integrated Moving Average (ARIMA) was build using the Box-Jenkins transformation [5]. The ARIMA was specified by ARIMA (p,d,q). Where the p denotes the number of autoregressive parameters, d indicates the number of differences before the time series becomes stationary and q denotes the moving average parameters. The Time series model is given below:

         (1)

Where:

         (2)

         (3)

The B represents the backshift operator Zt denotes the non-stationary series.

The autocorrelation function (ACF) and the partial autocorrelation function (PACF) plots as a diagnostic tools were used as a basis to examine the goodness of fit of the time series models and residuals and identify the best fit model by examining the Akaike information criteria[AIC]and the Bayesian information criteria (BIC) [24]. The Gretl software at a 95%CI was used for all data analysis.

7. Results and Discussion

7.1. Data Analysis and Plot Series Examination for Stationarity

The time series plot of the Nigeria maternal mortality ratio (MMR) from1990 to 2015 indicated that the series is not stationary as it exhibited an irregular trend plot (Figure 1). This trend signifies a non-stationarity property. In order to transform this series to a stationary series, the difference (order 1) of the MMR was done and the result shows that the absolute value of the test statistic (-4.259) is greater than 0.013 value of the critical value at 5% by using the Augmented Dickey Fuller (ADF) unit root test. The new time series plot after differencing is shown in Figure 2.

Figure 2. Time series plot of maternal mortality ratio after 1st order differencing.

Figure 3. The ACF and PACF plot of the Residuals for the ARIMA (0,1,0) model.

The ACF for these data shows no spike beyond the 5% significance area of confidence limit. This pattern is typical of an autoregressive process. The Gretl software also generated a partial autocorrelation function with critical bands at approximately α = 0.05 for the hypothesis that the correlations are equal to zero. There is no significant spike in the generated lags outside the confidence limit which indicates that no evidence of a nonrandom process occurring in the series.

7.2. ARIMA Modeling

In 1976, Box and Jenkins, gave a methodology in time series analysis to find the best fit of time series to past values in order to make future forecasts. Basically, four steps are needed to achieve this which includes identification of model, examination of models parameters, evaluation best fit model and prediction.

After examining the ACF and the PACF, two models were proposed as shown in the table below.

Table 2. Information parameters and Ljung-box values for the two proposed models.

Model

Ljung-Box P-Value

AIC

BIC

ARIMA(0,1,0)

0.7571

233.5143

235.9521

ARIMA(1,1,1)

0.7546

236.6239

241.4994

For 95% confidence intervals, z (0.025) = 1.96

The Table 2 indicated that the Ljung Box Statistics for the two ARIMA models gives no significance p-values for the series lags thus inferring that the residuals for each of the residuals appeared to be uncorrelated. However, the ARIMA (0,1,0) is selected for forecasting model since it has a lower Bayesian Information Criteria(BIC) of 235.9521 and an Akaike Information Criteria (AIC) of 233.5142 when compared to the ARIMA(1,1,1) model.

The ACF and the PACF for the residuals of the ARIMA (0,1,0) shows no indication of non-stationarity. Also the ADF test value of 0.01333 indicated that there is no autocorrelation which confirm the use of ARIMA (0,1,0) as the final model for forecasting.

7.3. Forecasting

The ARIMA (0, 1, 0) model was used to forecast the MMR for the year 2016, 2017, 2018 and 2019 which is give below.

Figure 4. Forecast for the Nigeria Maternal Mortality at 95%CI.

Table 3. ARIMA (0,1,0) forecast.

Year

Prediction

std. error

95% interval

2016

792.560

24.3312

(744.872, 840.248)

2017

771.120

34.4095

(703.679, 838.561)

2018

749.680

42.1429

(667.082, 832.278)

2019

728.240

48.6624

(632.863, 823.617)

8. Conclusions

According to the forecasted time series plot, the predicted Nigeria maternal mortality ratio shows a decline for the year 2016, 2017, 2018 and 2019.

The need for the Nigeria government continue to take decisive actions in reducing the burden of maternal mortality is essential if the country have need to meet the United Nations’ sustainable development goals(SDGs) in the area of maternal health. There should be more decisive policies implementations that support the inclusiveness of stakeholders especially in the grassroots. Funding in health budget should be improved and custodians of such funding’s should be more accountable. There is need for the government to make maternal health care services centers more accessible to the general population and there should be an effective monitoring of the operations of tradition birth attendants.

Acknowledgments

The authors would like to acknowledge the United Nations Children’s Fund(UNICEF), The World Health Organisation (WHO), The World Bank, and the United Nations Department of Economic and Social Affairs (UN DESA ) Population Division for making the data available for the public.

Conflicts of Interest

The authors declare that there is no conflict of interest regarding the publication of this article.

Copyright

© 2017 by the authors. Licensee International Technology and Science Press Limited. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

References

[1] Adedokun Sulaimon T.; Uthman Olalekan A. Women who have not utilized health Service for Delivery in Nigeria: who are they and where do they live? BMC Pregnancy and Childbirth. 2019, 19(93).

[2] Nigeria: Life Expectancy in Nigeria Now 55 Years – WHO. Available online: https://allafrica.com/stories/201810240153.html (accessed on 16 April 2019).

[3] Akeyede Imam; Danjuma Habiba; Bature Tajudeen Atanda. On Consistency of Tests for Stationarity in Autoregressive and Moving Average Models of Different Orders. American Journal of Theoretical and Applied Statistics, 2016, 5(3), 146-153.

[4] Alkema L.; Chou D; Hogan D.; Zhang S.; Moller AB.; Gemmill A.; Fat DM.; Boerma T.; Temmerman M., Mathers C., Say L.; United Nations Maternal Mortality Estimation Inter-Agency Group collaborators and technical advisory group. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. Lancet. 2016, 387(10017), 462-474.

[5] George E.P. Box, Gwilym M. Jenkins, Gregory C. Reinsel, Greta M. Ljung. Time Series Analysis, Forecasting and Control, 5th ed. Prentice-Hall, New York, USA, 2015; pp.88-128, ISBN: 978-1-118-67502-1

[6] Der E.M.; Moyer C.; Gyasi R.K.; Akosa A.B.; Tettey Y.; Akakpo P.K. et al. Pregnancy related causes of deaths in Ghana: a 5-year retrospective study. Ghana Med J. 2013, 47(4), 158-63.

[7] Elem M.; Nyeche S. Health Inequality and the Empowerment of Reproductive Age of Women for Development in Rivers State Primary Health Care Strategy in the Reduction of Maternal Mortality (2007-2015). International Journal of Advanced Academic Research. Social and Management Sciences, 2016, 2(11).

[8] Federal Ministry of Health (FMOH), Nigeria, (2010). National Strategic Health Care Development Plan 2010-2015.

Available online: https://www.uhc2030.org/fileadmin/uploads/ihp/Documents/Country_Pages/Nigeria/Nigeria%20National%20Strategic%20Health%20Development%20Plan%20Framework%202009-2015.pdf (accessed on 28 April 2019).

[9] Federal Ministry of Health [FMOH] (2004), Nigeria. Revised National Health Policy in Abuja: Federal Ministry of Health.

Available online: https://www.healthpolicyproject.com/pubs/821_FINALNPPReport.pdf (accessed on 28 April 2019)

[10] Izugbara, C.O., Wekesah, F. M. & Adedini, S. A. (2016) Maternal Health in Nigeria: A Situation Update. African Population and Health Research Center (APHRC), Nairobi, Kenya.

Available online: https://aphrc.org/publication/maternal-health-in-nigeria-facts-and-figures/ (accessed on 28 April 2019)

[11] Juang, W. C.; Huang, S. J.; Huang, F. D.; Cheng, P. W.; Wann, S. R. Application of time series analysis in modelling and forecasting emergency department visits in a medical centre in Southern Taiwan. BMJ Open, 2017, 7(11), e018628.

[12] Małgorzata Murat; Iwona Malinowska; Magdalena Gos; Jaromir Krzyszczak. Forecasting daily meteorological time series using ARIMA and regression models. International Agrophysics, 2018, 32, 253-264.

[13] Merdad L.; Ali MM. Timing of maternal death: Levels, trends, and ecological correlates using sibling data from 34 sub-Saharan African countries. PLoS ONE, 2018, 13(1), e0189416.

[14] National Population Commission (NPC) [Nigeria] and ICF (2019). Nigeria Demographic and Health Survey 2018 Key Indicators Report. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF. Available online: https://dhsprogram.com/pubs/pdf/PR118/PR118.pdf (accessed on 28 April 2019).

[15] Negero M.G.; Mitike Y.B.; Worku A.G.; Abota T.L. Skilled delivery service utilization and its association with the establishment of Womens health development Army in Yeky District, Southwest Ethiopia: a multilevel analysis. BMC Research Notes, 2018, 11(1), 83.

[16] Okereke, H.; Kanu, I.; Nwachukwu, N.; Anyanwu, E.; Ehiri, J. and Merrick, J. Maternal and Child Health Prospects in Nigeria. Internet Journal of Nursing Science, 2005, 4(2), 45-48.

[17] Olonade O.; Olawande TI.; Alabi OJ.; Imhonopi D. Maternal Mortality and Maternal Health Care in Nigeria: Implications for Socio-Economic Development. Open Access Macedonian Journal of Medical Sciences, 2019, 7(5), 849-855.

[18] Omo-Aghoja L.O.; Aisien O.A.; Akuse J.T.; Bergstrom S,; Okonofua F.E. Maternal mortality and emergency obstetric care in Benin City, South-south Nigeria. Journal of Clinical Medicine and Research, 2010, 2(4), 055-60.

[19] Fapohunda B.M.; Orobaton N.G. When women deliver with no one present in Nigeria: who, what, where and so what? PLoS One. 2013, 8(7), e69569.

[20] Shah R.; Rehfuess E.A.; Paudel D.; Maskey M.K.; Delius M. Barriers and facilitators to institutional delivery in rural areas of Chitwan District, Nepal: a qualitative study. Reprod Health, 2018, 15(1), 110.

[21] Sofer, Dalia. Why Are Women Still Dying of Pregnancy and Childbirth? American Journal of Nursing, 2018, 118 (9), 12.

[22] United Nations International Children and Emergency Funds [UNICEF]. Report on maternal mortality, 2015.

Available online: https://www.unicef.org/publications/files/UNICEF_Annual_Report_2015_En.pdf (accessed on 28 April 2019).

[23] Delivering Supplies when Crisis strikes Reproductive Health in Humanitarian Settings.

Available online: https://www.unfpa.org/publication/delivering-supplies-crisis-strikes (accessed on 16 April 2019).

[24] Vrieze S.I. Model selection and psychological theory: a discussion of the differences between the Akaike information criterion (AIC) and the Bayesian information criterion (BIC). Psychol Methods, 2012, 17(2), 228-243.

[25] Declaration of Alma Ata’, Report on the International Conference on Primary Health Care, World Health Organisation, September 1978.

Available online: http://www.who.int (accessed on 16 April 2019).

[26] Yayla, M. Maternal mortality in developing countries. J Perinat Med, 2003, 31(5), 386-391.