Death registration in Nigeria: a systematic literature review of its performance and challenges.

BACKGROUND: Death registration provides an opportunity for the legal documentation of death of persons. Documentation of deaths has several implications including its use in the recovery of inheritance and insurance benefits. It is also an important input for construction of life tables which are crucial for national planning. However, the registration of deaths is poor in several countries including Nigeria. OBJECTIVE: This paper describes the performance of death registration in Nigeria and factors that may affect its performance. METHODS: We conducted a systematic literature review of death registration completeness in Nigeria to identify, characterize issues as well as challenges associated with realizing completeness in death registration. RESULTS: Only 13.5% of deaths in Nigeria were registered in 2007 which regressed to 10% in 2017. There was no data reported for Nigeria in the World Health Organization database between 2008 and 2017. The country scored less than 0.1 (out of a maximum of 1) on the Vital Statistics Performance Index. There are multiple institutions with parallel constitutional and legal responsibilities for death registration in Nigeria including the National Population Commission, National Identity Management Commission and Local Government Authorities, which may be contributing to its overall poor performance. CONCLUSIONS: We offer proposals to substantially improve death registration completeness in Nigeria including the streamlining and merger of the National Population Commission and the National Identity Management Commission into one commission, the revision of the legal mandate of the new agency to mainly coordination and establishment of standards. We recommend that Local Government authorities maintain the local registries given their proximity to households. This arrangement will be enhanced by increased utilization of information and communications technology in Civil Registration and Vital Statistics processes that ensure records are properly archived.

The Nigerian health information system policy review of 2014 : the need, content, expectations and progress.

BACKGROUND: Nigeria's national health information system (HIS) data sources are grouped into institutional and population based data that traverse many government institutions. Communication and collaboration between these institutions are limited, fraught with fragmentation and challenges national HIS functionality. OBJECTIVES: The objective of this paper was to share insights from and the implications of a recent review of Nigeria's HIS policy in 2014 that resulted in its substantial revision. We also highlight some subsequent enactments. REVIEW PROCESS AND OUTCOMES: In 2013, Nigeria's Federal Ministry of Health launched an inter-ministerial and multi-departmental review of the National Health Management Information System policy of 2006. The review was guided by World Health Organization's 'Framework and Standards for Country Health Information Systems'. The key finding was a lack of governance mechanisms in the execution of the policy, including an absent data management governance process. The review also found a multiplicity of duplicative, parallel reporting tools and platforms. CONCLUSION: Recommendations for HIS Policy revisions were proposed to and implemented by the Federal Government of Nigeria. The revised HIS policy now provides for a strong framework for the leadership and governance of the HIS with early results.

Implementing at-scale, community-based distribution of misoprostol tablets to mothers in the third stage of labor for the prevention of postpartum haemorrhage in Sokoto State, Nigeria: Early results and lessons learned.

BACKGROUND: Postpartum haemorrhage (PPH) is a leading cause of maternal death in Sokoto State, Nigeria, where 95% of women give birth outside of a health facility. Although pilot schemes have demonstrated the value of community-based distribution of misoprostol for the prevention of PPH, none have provided practical insight on taking such programs to scale. METHODS: A community-based system for the distribution of misoprostol tablets (in 600ug) and chlorhexidine digluconate gel 7.1% to mother-newborn dyads was introduced by state government officials and community leaders throughout Sokoto State in April 2013, with the potential to reach an estimated 190,467 annual births. A simple outcome form that collected distribution and consumption data was used to assess the percentage of mothers that received misoprostol at labor through December 2014. Mothers' conditions were tracked through 6 weeks postpartum. Verbal autopsies were conducted on associated maternal deaths. RESULTS: Misoprostol distribution was successfully introduced and reached mothers in labor in all 244 wards in Sokoto State. Community data collection systems were successfully operational in all 244 wards with reliable capacity to record maternal deaths. 70,982 women or 22% of expected births received misoprostol from April 2013 to December 2014. Between April and December 2013, 33 women (< 1%) reported that heavy bleeding persisted after misoprostol use and were promptly referred. There were a total of 11 deaths in the 2013 cohort which were confirmed as maternal deaths by verbal autopsies. Between January and December of 2014, a total 434 women (1.25%) that ingested misoprostol reported associated side effects. CONCLUSION: It is feasible and safe to utilize government guidelines on results-based primary health care to successfully introduce community distribution of life saving misoprostol at scale to reduce PPH and improve maternal outcomes. Lessons from Sokoto State's at-scale program implementation, to assure every mother's right to uterotonics, can inform scale-up elsewhere in Nigeria.

Mapping the Prevalence and Sociodemographic Characteristics of Women Who Deliver Alone: Evidence From Demographic and Health Surveys From 80 Countries.

Evidence has shown that quality skilled care during labor and delivery is essential to improve maternal and newborn health outcomes. Unfortunately, analyses of Demographic and Health Survey (DHS) data show that there are a substantial number of women around the world that not only do not have access to skilled care but also deliver alone with no one present (NOP). Among the 80 countries with data, we found the practice of delivering with NOP was concentrated in West and Central Africa and parts of East Africa. Across these countries, the prevalence of giving birth with NOP was higher among women who were poor, older, of higher parity, living in rural areas, and uneducated than among their counterparts. As women increased use of antenatal care services, the proportion giving birth with NOP declined. Using census data for each country from the US Census Bureau's International Database and data on prevalence of delivering with NOP from the DHS among countries with surveys from 2005 onwards (n = 59), we estimated the number of women who gave birth alone in each country, as well as each country's contribution to the total burden. Our analysis indicates that between 2005 and 2015, an estimated 2.2 million women, who had given birth in the 3 years preceding each country survey, delivered with NOP. Nigeria, alone, accounted for 44% (nearly 1 million) of these deliveries. As countries work on reducing inequalities in access to health care, wealth, education, and family planning, concurrent efforts to change community norms that condone and facilitate the practice of women giving birth alone must also be implemented. Programmatic experience from Sokoto State in northern Nigeria suggests that the practice can be reduced markedly through grassroots community advocacy and education, even in poor and low-resource areas. It is time for leaders to act now to eradicate the practice of giving birth alone-one of many important steps needed to ensure no mother or newborn dies of a preventable death.

A Report of At-Scale Distribution of Chlorhexidine Digluconate 7.1% Gel for Newborn Cord Care to 36,404 Newborns in Sokoto State, Nigeria: Initial Lessons Learned.

BACKGROUND: With an annual estimated 276,000 neonatal deaths, Nigeria has the second highest of any country in the world. Global progress in accelerating neonatal deaths is hinged to scaled-up interventions in Nigeria. We used routine data of chlorhexidine digluconate 7.1% gel utilized by 36,404 newborns delivered by 36,370 mothers, to study lessons associated with at-scale distribution in Sokoto State, North West Nigeria. METHODS AND FINDINGS: Under state government leadership, a community-based distribution system overseen by 244 ward development committees and over 3,440 community-based health volunteers and community drug keepers, was activated to deliver two locally stored medicines to women when labor commenced. Newborns and their mothers were tracked through 28 days and 42 days respectively, including verbal autopsy results. 36,404 or 26.3% of expected newborns received the gel from April 2013 to December 2013 throughout all 244 wards in the State. 99.97% of newborns survived past 28 days. There were 124 pre-verified neonatal deaths reported. Upon verification using verbal autopsy procedures, 76 deaths were stillborn and 48 were previously live births. Among the previous 48 live births, the main causes of death were sepsis (40%), asphyxia (29%) and prematurity (8%). Underuse of logistics management information by government in procurement decisions and not accounting for differences in LGA population sizes during commodity distribution, severely limited program scalability. CONCLUSIONS: Enhancements in the predictable availability and supply of chlorhexidine digluconate 7.1% gel to communities through better, evidence-based logistics management by the state public sector will most likely dramatically increase program scalability. Infections as a cause of mortality in babies delivered in home settings may be much higher than previously conceived. In tandem with high prevalence of stillborn deaths, delivery, interventions designed to increase mothers' timely and regular use of quality antenatal care, and increased facility-based based delivery, need urgent attention. We call for accelerated investments in community health volunteer programs and the requisite community measurement systems to better track coverage. We also advocate for the development, refinement and use of routine community-based verbal autopsies to track newborn and maternal survival.

Factors influencing the use of magnesium sulphate in pre-eclampsia/eclampsia management in health facilities in Northern Nigeria: a mixed methods study.

BACKGROUND: Eclampsia remains a major cause of perinatal and maternal morbidity and mortality worldwide. We examined facilitators and barriers to the use of magnesium sulphate (MgSO4) in the management of pre-eclampsia/eclampsia (PE/E) in health facilities in Bauchi and Sokoto States in Nigeria. METHODS: Data were collected from 80 health facilities using a cross-sectional, mixed method (quantitative and qualitative) design. We assessed health facility readiness to manage PE/E and use MgSO4 as the drug of choice, through provider interviews, in-depth interviews with facility managers and an inventory of equipment and supply in facilities. Bivariate and qualitative data analyses were performed to isolate the principal enabling factors and barriers to the management of PE/E and use of MgSO4. RESULTS: The majority of health facility providers correctly mentioned MgSO4 as the drug of choice for the prevention and termination of convulsions in severe PE/E (65 %). Sixty-four percent of the health facilities had service registers available. About 45 % of providers had been trained on the use of MgSO4 for the management of PE/E. Regarding providers' practices, 45 % of respondents indicated that MgSO4 was used to prevent and treat convulsions in severe PE/E in their facilities. Barriers to management of PE/E included inadequate numbers of skilled providers, frequent shortages of MgSO4, lack of essential equipment and supplies, irregular supply of electricity and water, and non-availability of guidelines and clinical protocols at the health facilities. Technical support to providers was inadequate. CONCLUSION: The study revealed that a constellation of factors adversely affect the management of PE/E and especially the use of MgSO4 by service providers. Efforts to improve the management of PE/E in facilities should include integrated programs that substantially improve provider and facility readiness to manage PE/E for better maternal and newborn health outcomes in Northern Nigeria.

Trends in delivery with no one present in Nigeria between 2003 and 2013.

PURPOSE: Skilled attendance at birth is a proven intervention to improve maternal and newborn health outcomes. Unfortunately, in Nigeria there are many women who give birth alone, with no one present (NOP). The purpose of this study was to document trends in women delivering with NOP between 2003 and 2013, and to identify the characteristics of women who are engaging in this risky practice. METHODS: We utilized pooled data sets from the 2003, 2008, and 2013 Nigerian Demographic and Health Surveys. Married women, who had given birth in the 5 years before each survey were included, resulting in a sample size of 38,949 women. We used logistic regression to assess the unadjusted and adjusted odds of a woman delivering with NOP over time, by socio-demographic characteristics. RESULTS: Prevalence of delivery with NOP in Nigeria declined by 30% between 2003 and 2013. The largest declines occurred in Sokoto State, where the number of women giving birth with NOP declined by almost 100% between 2003 and 2013. In the North West of the country, however, there was a 27% increase in the number of women giving birth alone over this time period. Older, poorer, less educated, higher parity, Muslim women residing in the Northern regions were significantly more likely to give birth with NOP. Women, who were involved in decisions surrounding their own health, and who had accessed antenatal care were significantly less likely to give birth with NOP. CONCLUSION: Although there have been improvements in Nigeria's Maternal Mortality Ratio since 1990, recent estimates suggest a stagnation in this trend. One reason for this protracted decline may be lack of access to skilled delivery care. The 2013 national prevalence of Nigerian women giving birth with NOP was 14%, equivalent to over 1 million births in 2013. Nigeria must implement interventions to ensure every woman's timely access to, and use of skilled care to reduce preventable maternal mortality and morbidity.

Factors influencing the selection of delivery with no one present in Northern Nigeria: implications for policy and programs.

This paper examines the effects of demographic, socioeconomic, and women's autonomy factors on the utilization of delivery assistance in Sokoto State, Nigeria. Data were obtained from the Nigeria 2008 Demographic and Health Survey (DHS). Bivariate analysis and logistic regression procedures were conducted. The study revealed that delivery with no one present and with unskilled attendance accounted for roughly 95% of all births in Sokoto State. Mothers with existing high risk factors, including higher parity, were more likely to select unsafe/unskilled delivery practices than younger, lower-parity mothers. Evidenced by the high prevalence of delivery with traditional birth attendants, this study demonstrates that expectant mothers are willing to obtain care from a provider, and their odds of using accessible, affordable, skilled delivery is high, should such an option be presented. This conclusion is supported by the high correlation between a mother's socioeconomic status and the likelihood of using skilled attendance. To improve the access to, and increase the affordability of, skilled health attendants, we recommended two solutions: 1) the use of cash subsidies to augment women's incomes in order to reduce finance-related barriers in the use of formal health services, thus increasing demand; and 2) a structural improvement that will increase women's economic security by improving their access to higher education, income, and urban ideation.

When women deliver with no one present in Nigeria: who, what, where and so what?

With the current maternal mortality ratio (MMR) of 630/100,000 live births, Nigeria ranks among the nations with the highest mortality rates in the world. The use of skilled assistants during delivery has been identified a key predictor in the reduction of mortality rates in the world over. Not only are Nigerian women predominantly using unskilled attendants, one in five births are delivered with No One Present (NOP). We assessed who, what, where and the so what of this practice using 2008 Nigeria DHS (NDHS) data. The study revealed that the prevalence of NOP is highest in the northern part of Nigeria with 94% of all observed cases. Socio-demographic factors, including, women's age at birth, birth order, being Muslim, and region of residence, were positively associated with NOP deliveries. Mother's education, higher wealth quintiles, urban residence, decision-making autonomy, and a supportive environment for women's social and economic security were inversely associated with NOP deliveries. Women's autonomy and social standing were critical to choosing to deliver with skilled attendance, which were further amplified by economic prosperity. Women's' economic wellbeing is entwined with their feelings of independence and freedom. Programs that seek to improve the autonomy of women and their strategic participation in sound health seeking decisions will, most likely, yield better results with improvements in women's education, income, jobs, and property ownership. As a short term measure, the use of conditional cash transfer, proven to work in several countries, including 18 in sub-Saharan Africa, is recommended. Its use has the potential to reduce household budget constraint by lowering cost-related barriers associated with women's ability to demand and use life-saving services. Given the preponderance of NOP in the Northern region, the study suggests that interventions to eradicate NOP deliveries must initially focus this region as priority.