Colonial Structures and Midwife Schemes:
Midwifery and Birth in Nigeria
The state of midwifery and childbirth in Nigeria today demonstrates its complex history, from the converging pressures of colonialism, patriarchal oppression, and varied tribal groups. With its blending of various cultures and in light of its past colonialism, Nigeria has eclectic, heterogenous birthing practices, combining traditional home birth in the Northern part of the state, public hospitals with midwife attendants in the south, and NGO presence throughout. However, due to insufficient infrastructure, Nigeria has one of the highest maternal mortality rates (MMRs) in the world, with 560 out of every 100,000 women dying from birth. Much less than nations struggling with the technocratic model of birth and depersonalization of the birthing process, Nigerian midwifery struggles with its lack of access to patients, lack of skilled practitioners, and lack of healthcare standardization. Maternal outcomes in Nigeria reveal the differences in access to healthcare and infrastructure throughout the nation, and the lack of government support and resources available to midwives and birthing assistants.
Colonial efforts in Nigeria began in the 19th century, as British companies moved into the area, forming protectorates over the coastal region and the Niger River Valley. These colonial enterprises led to a series of expansions in Britain’s spheres of influences and protectorates through the 1870s-90s, until the crown formally annexed Nigeria in 1897. In the years between 1897–1960, when Nigeria gained its independence, Britain had a significant influence over Nigeria, shaping its medical and birthing facilities . At times, the medical control Britain brought to Nigeria improved outcomes for birthing parents, more often, British Imperialism hurt Nigerian mothers. British rule in Nigeria in the first half of the 20th century led to a coordination between British nurses and midwives and local Nigerian women, who began to be trained in European cities and colonial hospitals in Lagos and neighboring cities.
British colonial rule implemented formal training for many Nigerian midwives and by 1930 had accredited degrees available for Nigerian midwives and an average of 60 midwives graduating yearly out of Lagos. These international resources had the potential to uplift Nigerian midwives and birthing parents, but left vacuums in power and medical opportunity after colonialism ended. Although Nigerian women were able to obtain midwifery degrees, formal education was often limited to white British colonists. Similarly, only one Nigerian woman is reported to have entered into higher levels of governmental power under the British rule as the permanent secretary of education, and later became an undersecretary after Nigerian independence. The lasting effects of colonial rule shaped the Nigeria’s home rule medical infrastructure, which has held much of the shape it did in 1960.
In spite of the inequity in Nigeria throughout the colonial era, the infrastructure of Britain’s colonial enterprise gave some major cities in Nigeria access to resources unavailable in rural areas. The convergence of Britain’s religious, organizational, and medical resources gave Southern Nigerian mothers and midwives significantly different experiences from Northern Nigerian women, where colonial influence held a more tenuous grasp. Midwives coming out of British training programs often broke off from public hospitals and formed private practices, giving women in major cities a greater variety of options for prenatal and natal care. The prevalence of state-run clinics in major cities can be traced back to these colonialist models of care that linger in Nigeria’s public healthcare systems today; wherein major cities remain connected to public health whereas rural areas have limited access.
This lack of infrastructure in Nigeria explains why it has among the highest maternal and fetal mortality rates in the world. The African Population and Health Resource Center (APHRC) made a staggering report of the effects of geographic isolation birthing mothers face in birthing facilities. According to the APHRC in 2017, Nigerian women have a 1 in 13 lifetime probability of dying during childbirth, with Nigeria’s 40,000 yearly maternal deaths accounting for 14% of maternal deaths in the world.
With this high mortality rate in mind, and an MMR of 560 women for every 100,000 births, it is important to note that this does not capture the full picture of the danger women face from childbirth. For every woman killed in childbirth, the APHRC estimates another 30 to 50 face life-long disability or injury in the form of vesicovaginal fistulas or other serious gynecological issues. Without access to medical care, many women in isolated areas remain most at risk for high casualty rates in birth, disproportionately feeling the lack of public support of birth.
This divide between individuals living in Southern cities and those in villages and compounds in rural areas of Nigeria that began in the colonial era continues to today. It can be seen both in the birth practices and medical facilities and the birth outcomes for mothers. In major cities, NCBI reports that home births only account for between 35% and 37%of births, whereas in rural areas the number hovers around 75% and 90% give birth without a skilled assistant. Similarly, whereas in 2011, 53.1% of women in rural areas said they had some form of prenatal care in clinics, 86.2% of women in urban areas said that they received clinical prenatal care.
Despite most healthcare being run by the state, many women in rural areas feel that their hospitals are too far away for birthing parents to access these resources. The APHRC reports that compared to nationwide average of 560 maternal mortalities per 100,000, the Northeast has a maternal mortality rate of 1,549 per 100,000. The APHRC links this to the proliferation of home-births, unskilled birth attendants, and unsafe abortion practices. This rate holds up compared to other studies in similar regions. BMC reported in 2017 an MMR of 1,012 in Jigawa, a North central Nigerian state. In the bordering State of Kano, a study conducted by local scholars and doctors in 2003 found an MMR of 2,420 per 100,000. This drastically higher number may result from the study being conducted 14 years prior, but likely also demonstrates the variable nature of MMRs in Nigeria and the variance in care women are able to receive.
In spite of differences between rural and urban midwifery, there are numerous examples of traditional and western medicine intersecting. Traditional midwives often assume positions of leadership in public healthcare, mixing indigenous and western medicine and finding systems of care that bridge the gap between the two. Hajiya Asabe, a traditional midwife, and Hajiya Mai Magani, an herbalist, both work in the northern Nigerian city of Kaduna where they practice alongside western medical hospitals. Magani’s work has involved studies alongside the World Health Organization, and Asabe often performs outreach to rural communities and underserved populations within Nigeria. Although both of these women work within medical systems supported by the UN and western models of care, they incorporate traditional medicine and religion into their practices. The connections between religiosity and medicine run deeply, with many women, especially in rural areas, looking for a birth experience that combines the two.
Although traditional midwifery is often lauded as the solution to today’s overly interventionist birthing practices, looking towards Nigerian traditional birthing practices complicates the dichotomous model held by many back-to-nature medical practitioners that indigenous medicine is innately good and western is harmful. Many home birthing practices in Northern Nigeria contribute to high maternal and infant mortality rates and are more focused on upholding patriarchal power than providing for mothers. Patriarchal traditions can arise in any culture and are present throughout Nigeria, complicating the notion of “traditional” indigenous birth practices being more woman-centric. In Ibi, an Igbo village in Northern Nigeria, most families still follow traditional Igbo birthing methods, primarily led and organized by men in the family. These traditions include the rite of circumcision, wherein a female infant’s clitoral hood, and sometimes outer labia and clitoris are removed. According to the NCBI, over 41% of Nigerian women are circumcised, comprising the largest population of circumcised women in the world.
Beside the dangers and injustice of circumcision, traditional birthing practices often rely on women not seeking care outside the home, limiting women’s resources in cases of irregular birth. Some traditional practices and Northern Nigerian sects of Islam prevent women from being seen by male physicians, directly outlawing them from visiting hospitals where men may practice even if health necessitates the visit. Barring possible access to state-run all female birth clinics, these women’s options for birth are often limited to home birth with direct entry midwives or family.
The converging influences of Christianity, Islam, Baha’i faith, and traditional religions have each had varying effects on the birthing parent’s medical health. The shift from traditional religions to Christianity and Islam, each making up between 40 and 50 percent of the population, has both facilitated and hindered the expansion of education and roles in midwifery for Nigerian women. In 1991, authors Coles and Mack connected the expansion of Islam with an expansion of women’s opportunities to leave the home and pursue education. They saw the practice of veiling as a possible alternative to isolation in family compounds, which women are often unable to leave after marriage. The ability to travel freely remains a limiting factor in women’s ability to seek education or serve as midwives.
In many rural compound-based communities, midwifery is still a practice that is only available to older women, who do not face the same limitations in mobility as mothers and young wives . However, more recently, militant extremist groups such as Boko Haram have pushed back on the power of midwives in compound heavy areas. This year, two Muslim midwives working in the refugee city of Rann were killed as a political statement by the terrorist group. This comes alongside numerous examples of push-back to Northern women’s employment and education.
Numerous efforts have been made in recent years to improve midwifery in Nigeria, by the government, NGOs, and healthcare professionals. Nigeria’s National Primary Healthcare Development Agency established the Midwives Service Scheme (MSS) in 2009 to expand skilled birth attendance in maternal care across the country.
The program was designed to mobilize and educate midwives across the country to enter into Primary Health Care Facilities (PHCs) and general hospitals to provide a 24-hour care. Studies conducted in 2011 found that the project was then serving an estimated 15 million patients, at 652 PHCs and 163 general hospitals, with 2,488 midwives employed. The deployment of midwives to underserved areas in the North has also brought much needed resources to the area. However, MSS has faced numerous challenges and not always lived up to government expectations. With little coordination between states, there has been a varied level of governmental support for midwives leading to low retention rates of trained midwives.
Incredibly ambitious projections on the part of the midwife scheme have not been met, but the benefits of the scheme should not be downplayed. Although many home births without skilled attendants still occur, the results for hospitals where midwives have been stationed are very positive. In its first year, the scheme significantly dropped the MMR rate in many regions of Nigeria (admittedly to a suspicious degree in North Central Nigeria). The numbers elow demonstrate the fact that although some regions saw peaks in mortality- likely caused by the difficulties that the Midwives scheme faces, there has been a general drop in the country’s MMR since the adoption of the Midwives Service Scheme.
More directly, the positive results of the scheme can be seen from the prenatal care that the scheme has helped to facilitate. Through the Scheme, prenatal care rates have significantly increased, from under 250,000 visits to MSS facilities, to over 350,000 in just one year. This represents a small portion of the birthing women in Nigeria, but indicates progress for the country’s maternal care.
Along with government initiatives, some movements have been started by midwives on the ground in Nigeria. Midwives such as Hajiya Habibi have made efforts to improve the care they are able to provide for their patients, drawing from their own experiences in underserved populations. Habiba is a midwife in Niger State, in northern Nigeria, where she is the primary female practitioner for over 10,000 people. Until recently she worked in a hospital with no other skilled midwives or doctors and was expected to work over 10 hours a day. Through efforts facilitated by NGOs, the government has stepped in and promised to provide over 100 new midwives to Nigeria and four more care practitioners to Habiba’s hospital. Yet, these 100 new midwives only represent a small dent in the issue of access to primary care physicians and midwives for Nigerian women.
Other NGOs have made similar efforts to expand the number of midwives in Nigeria, often to varied and unreported effects. The British NGO Women for Health, Nigeria, has been working with Northern Nigerian states and local communities to find strategies to educate young women and provide midwifery support for women whose religious practices disallow them from seeing male physicians. This effort has reportedly trained over 6,000 new midwives, with over 1,500 employed. However, it also cites significant opposition to its education practices from men in rural communities, with many women reporting abuse and abandonment. Ultimately, this program has only released anecdotal data such as how “95% of students are optimistic about the future” rather than concrete improvements. Although these programs have made efforts to improve quality of care for women, they often fall into the trap of NGOs around the world; providing a model of care that fails to meet the realities of the host country.
In order to improve the lives of birthing parents and the education, opportunity, and safety of practicing midwives, Nigeria can continue working to provide greater institutional and structural support to women. This support must extend beyond simply deploying midwives, but instead strive to solve a slew of disparate issues; improving roadways and access to hospitals, providing greater access to all female hospital wards, effectively discouraging female circumcision, and providing greater educational resources that are integrated into communities.
These issues can not be solved all at once and represent larger structural changes that can work to better and understand and work with Northern communities, while incorporating more standardized levels of care and public medicine. The solutions to Nigeria’s maternal outcomes do not lie solely with western interventionist solutions, which often provide education and resources without understanding their spatiality. Nor do solutions lie solely in indigenous practice, which although integrated into many communities and models of care, often relies on harmful medical practices and can limit access to healthcare. Nigeria’s solution lies in working with these two models in conjunction and in providing greater structural support to long ignored portions of the population.
