This document presents Nigeria's Millennium Development Goals Acceleration Framework and Action Plan for improving maternal health (MDG 5). It identifies five priority interventions: family planning, skilled birth attendants, emergency obstetric and newborn care, universal antenatal and postnatal care coverage, and improved referral services. Bottlenecks hindering each intervention are analyzed. Acceleration solutions proposed to address bottlenecks include scaling up sensitization, establishing youth centers, training more skilled birth attendants, and decentralizing ambulance services. The plan estimates implementation will cost 65.5 billion naira. A monitoring and evaluation plan is also outlined to track progress, with key recommendations to convene an emergency meeting on commitments and responsibilities for the action

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NIGERIA MDGs ACCELERATION
FRAMEWORK ANDACTION
PLANFOR MATERNAL HEALTH
(MDG5)
April 2013

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Table of Contents
Acknowledgement
Foreword
Abbreviations/Acronyms
Executive Summary 8
List of Tables
List of Figures
Chapter 1: Introduction 17
Chapter 2: Nigeria MDGs Status: An Overview with A Focus on MDG5 26
Chapter 3: Key Interventions to Accelerate MDG5 in Nigeria 34
Chapter 4: MDG5 Bottlenecks Analysis and Prioritization 47
Chapter 5: Acceleration Solutions 50
Chapter 6: Monitoring & Evaluation Plan 63
Chapter 7: Recommendations 68
References 97
Appendices 100
MDG – MAF Plan of Action & Budget Matrix

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List of Tables
Table 1 MDG 5 Focus
Table 2 Bottlenecks affecting the Prioritised Interventions
Table 3 Bottleneck Assessment Scorecard
Table 4 The Prioritized Bottlenecks are Scrutinised based on the Scorecard Schema
Table 5 MAF Prioritized Solutions and Responsibilities
Table 6 MAF Monitoring and Evaluation Calendar
List of Figures
Figure 1 CGS Implementation Structures
Figure 2 Ratio of Girls to Boys in Primary Schools 2008 (%)
Figure 3 Under-5 Rate by Geo-political Zone, Nigeria 2011
Figure 4 Infant Mortality Rate by Geo-political Zone, Nigeria, 2011
Figure5Maternal Mortality Rate
Figure 6 Proportion of Births attended by Skilled Health Personnel
Figure 7 Contraceptive Prevalence Rate
Figure 8 Antenatal Care Coverage
Figure 9 Unmet need for Family Planning
Figure 10 Trends in Maternal and Child mortality (1990 -2008)
Figure 11 Challenges: Coverage of High Impact Interventions for MNCH
Figure 12 MSS Cluster Model
Figure 13 Overview of MSS Progress
Figure 14 Flow of MDG5 monitoring data and information

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Acknowledgement

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ABBREVIATIONS/ACRONYMS
ANC Antenatal Care
APHPN Association of Public Health Physicians of Nigeria
BCC Behaviour Change Communication
BEOC Basic Emergency Obstetrics Care
BFHs Baby Friendly Hospitals
BFI Baby Friendly Initiative
CAP Country Action Plan
CBNC Community-Based Newborn Care
CBO Community Based Organization
CDS Countdown Strategy
CEOC Comprehensive Emergency Obstetrics Care
CGS Conditional Grant Schemes
CHEWs Community Health Extension Workers
CLMS Core Lab Management System
CMDs Chief Medical Directors
CPR Contraceptive Prevalence Rate
CSO Civil Society Organization
DFID Department for International Development
ELSS Expanded Life Saving Skills
EmONC Emergency Obstetrics and Newborn Care
ETAT Emergency Triage Assessment and Treatment
FANC Focused Antenatal Care
FBO Faith-Based Organizations
FCT Federal Capital Territory
FHC Facility Health Committees
FMoE Federal Ministry of Education
FMoH Federal Ministry of Health
FMoWA Federal Ministry of Woman Affairs
FP Family Planning
GSM Global System for Mobil Communications
HDI Human Development Index
HF Health Facility
HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome
ICT Information Communications Technology
IDPs International Development Partners
IEC Information, Education and Communication
IPT Intermittent Preventive Treatment
IYCF Infant and Young Child Feeding
JCHEWs Junior Community Health Extension Workers
LGA Local Government Area
LSTM Liverpool School of Tropical Medicine
LSS Life Saving Skills
MAF Millennium Accelerated Framework
MDAs Ministries, Departments and Agencies
MDCN Medical and Dental Council of Nigeria
MDGs Millennium Development Goals

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M & E Monitoring and Evaluation
MICS Multiple Indicator Cluster Survey
MLSS Modified Life Saving Skills
MMR Maternal Mortality Rate
MNCH Maternal, Neonatal and Child Health
MPSS Minimum Package of Service and Standards
MSS Midwives Service Scheme
NCC National Communications Commission
NCCGS National Committee on Conditional Grants Scheme
NDHS Nigerian Demographic and Health Survey
NGOs Non-Governmental Organization
NHRC National Human Rights Commission
NHIS National Health Insurance Scheme
NNPC Nigerian National Petroleum Corporation
NMCN Nursing and Midwifery Council of Nigeria
NMIS Nigeria Malaria Indicator Survey
NOA National Orientation Agency
NPC National Planning Commission
NPoC National Population Commission
NPHCDA National Primary Health Care Development Agency
NSHDP National Strategic Health Development Plan
NURTW National Union of Road Transport Workers
NYSC National Youth Service Scheme
NV National Vision
ODA Overseas Development Assistance
OSSAP-MDGs Office of the Senior Special Assistant to the President on Millennium
Development Goals
PAN Pediatric Association of Nigeria
PCAMMDGs Presidential Committee for the Assessment and Monitoring of the MDGs
PHC Primary Health Care
PHCs Primary Health Centers
PHS Primary Health Service
PMTCT Prevention of Mother-to-Child Transmission
PNC Post-Natal Care
SBA Skilled Birth Attendants
SBAs Skilled Birth Attendance
SMoH State Ministry of Health
SMoLG State Ministry of Local Government
SOGON Society for Obstetricians and Gynecology
SOPs Standard Operating Procedures
SP SulphadoxinePyrimethamine
SPARC State Partnership for Accountability, Responsiveness and Capability
SPHCDA State Primary Health Care Development Agency
SSAP Senior Special Assistant to the President
SURE-P Subsidy Reinvestment and Empowerment Programme
TOT Training of Trainers
TT Tetanus Toxoid
TWG Technical Working Group
UN United Nations
UNDP United Nations Development Programme
UNFPA United Nations Population Fund

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UNGASS United Nations General Assembly Special Session
UNICEF United Nations Children‘s Fund
UNO United Nations Organization
VPF Virtual Poverty Fund
VVF Vesico-Vaginal Fistula
WDC Ward Development Committee
WHO World Health Organization
YFHS Youth Friendly Health Services

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FOREWORD

9. APPENDIX 4
9
EXECUTIVE SUMMARY
In September 2010 the United Nations Organization (UNO) under its United Nations General Assembly
Special Session (UNGASS),provided a platform for a comprehensive review of progress made so far in the
implementation of Millennium Development Goals (MDGs) in the last decade. The review of the MDGs+10
afforded the participating nations the opportunity to peer review progress on the implementation of the
MDGs and to further refresh their commitment to the attainment of the MDGs by 2015.
Like other nations, the Federal Republic of Nigeria presented her own Five-Year Countdown Strategy (CDS)
at the UNGASS with the overarching objective of outlining a roadmap for accelerating progress towards
achievement of the MDGs by 2015. But due to a variety of factors, implementation of the CDS did not gain
the expected momentum and has thus caused MDGs that were once promising to suffer some set-backs.
The MDG Acceleration Framework (MAF) which was a key outcome of the MDG+10 review is a process
that involves the preparation of a focused, agreed upon Action Plan to address specific lagging MDGs. This
plan also requires the cooperation and support of all stakeholders that include the governments, the
developments partners, civil society organizations and the private sector in providing the resources and other
services needed to advance key policy reform and overcome identified constraints to achieving a given MDG
target.
The key strategy of MAF is to identify and prioritize interventions with the potential for delivering the
highest impact; analyse and prioritise bottlenecks hindering success of interventions and identify solutions
and their sequencing. Based on these three steps, an accelerated action plan, along with an implementation
and monitoring plan is then developed. Due to the overwhelming evidence of the synergies that progress with
improved maternal health engenders for other MDGs and overall economic progress, Nigeria has chosen
MDG 5 for MAF.
To refresh memory, the Goals, Targets and Indicators of MDG 5 which the MAF will focus on are presented
in tabular form below:
MAF-MGD5 Focus
Goal: 5 Target Indicators
Improve
Maternal Health
Target 5.A: Reduce by 3/4th between
1990 and 2015, the maternal mortality
ratio
1. Maternal mortality ratio
2. Proportion of births attended by skilled
health personnel
Target 5.B: Achieve, by 2015, universal
access to reproductive health
3. Contraceptive prevalence rate
4. Adolescent birth rate
5. Antenatal care coverage (at least one visit
and at least four visits)
6. Unmet need for family planning

10. APPENDIX 4
10
MAF Process Methodology
Understandably the roll-out of MAFinvolves a rigorous process, more so in a federal and populous country
like Nigeria. This process got the highest level of political endorsement from the Presidency through a
stakeholder forum. Three key decisions that established the methodological point of departure were (a) the
setting up of the institutional framework for effective coordination of the MAF process jointly driven by the
Office of the Senior Special Assistant to the President on MDGs (OSSAP-MDGs), Federal Ministry of
Health, and International Development Partners (IDPs), (b) the engagement of consultants to drive the
technical process, and (c) the planning and organization of the stakeholders‘ consultation technical workshop
of which the Federal Ministry of Health played a catalytic role. The preparation of a comprehensive desk
review provided the main input for the stakeholders‘ technical workshop. Participants at this workshop were
carefully selected to cover not only the geographical spread, but also different layers of professionals in the
medical fields with hands-on experience in the implementation of the MDG 5. (See the list of participants in
the appendix attached to the main report). The participants discussed and through elaborate process chose
five prioritized interventions and also identified the prioritized bottlenecks.Subsequently, atwo-day intensive
bilateral discussion meetings between the consultants and key policy drivers and implementers (with support
from IDPs), developed the suggested solution indicators, targets, timelines, the costing of MAF and the
assignment of responsibilitiesfor the implementation of the solutions contained in the Action Plan. The
preparation of the final report benefitted further from the Validation workshop organised for critical policy
makers, stakeholders and supporting IDPs.
Prioritization of Key Interventions
Following stakeholders‘ consultation to accelerate the achievement of MDG5, the under-listed five key
priority areas were selected out of a list of over twenty major interventionswithout prejudice to state-level
preferences in re-ordering the priorities:
a) Family Planning
b) Skilled Birth Attendants
c) Emergency Obstetric and New-born care
d) Universal Coverage of Ante-Natal and Post-Natal care
e) Improved Referral System

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11
Bottleneck Analysis and Prioritization
The bottlenecks that impede the success of prioritized interventions were identified as shown in the
tabulation below.The tabulation shows two broad types of bottlenecks: sector-specific and cross-cutting.
Sector-specific bottlenecks are under the control of the Federal and State Ministries of Health and Local
Government Health Departments or affiliated agencies. Cross-cutting bottlenecks are inter-sectoral and
economy-wide problems that affect the results-based implementation of the MDG5 interventions.

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12
Bottlenecks Impeding Prioritised Interventions
Prioritised
bottleneck
Bottleneck
category
Prioritised Interventions
Family
planni
ng
service
s
Skilled
birth
attendant
s
Emergency
Obstetric
&Newborn
Care
Universal
Coverage of
Antenatal
and
Postnatal
Care
Improve
d Referral
Services
Socio-cultural religious
barrier
Cross cutting
and systemic
Inadequate trained
personnel
Service delivery
Low male
involvement/ uptake
Systemic
Inadequate Skilled
Birth Attendants
Service delivery
Uneven distribution of
available Skilled Birth
Attendants (SBA)
Service Delivery
Inadequate Referral
Training for Skilled
Birth Attendants
(SBA)
Service delivery
Lack of functional
equipment and
facilities
Service delivery
Poor incentives
especially in rural area
Budget and
financing
Shortage of skilled
health personnel
Service Delivery
Inadequate equipment
and supplies
Service
Delivery
Delay in accessing care
services
Service
Utilization
Inadequate political
will
Cross-cutting
Poor access to health
facilities in rural areas
Service
Utilization
Poor attitude of health
workers
Service
Delivery
Lack of Legislation Policy and
Planning
Inadequate ambulance
services
Service
Delivery
Poor communication
and feedback system
Service delivery

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13
Prioritised
bottleneck
Bottleneck
category
Prioritised Interventions
Family
planni
ng
service
s
Skilled
birth
attendant
s
Emergency
Obstetric
&Newborn
Care
Universal
Coverage of
Antenatal
and
Postnatal
Care
Improve
d Referral
Services
System delay Service
Delivery

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14
Acceleration Solutions
With due regard to cultural sensitivity, the acceleration solutions proposed for each of the five prioritized
interventions and their numerous bottlenecks inter alia are listed as follows:
Family Planning Intervention
a) Scale-up sensitization of traditional leaders, religious leaders, Community Based Organizations
(CBO), Faith Based Organizations (FBO) through appropriate media.
b) Reinforce teaching of family life education in secondary schools curriculum.
c) Establish more functional youth friendly centres.
a) Sensitization and mobilization of the male folk to take leadership in health matters
Skilled Birth Attendants/Attendance Intervention
a) Recruitment, Training and retraining of more Skilled Birth Attendants (SBA).
b) Task shifting/sharing for Skilled Birth Attendants (SBA).
c) Scale up supply of basic equipment of supply for Skilled Birth Attendance.
d) Strengthening, reactivating and formation of Ward Development Committees (WDC).
Emergency Obstetric and New-Born Care Intervention
 Additional Incentive for Health workers in hard to reach areas/difficult terrain/rural areas.
 Scale up of in-service training and implementation of Life Saving Series (LSS) and Community Based
Newborn Care (CBNC).
 Incorporation of the Life Saving Series (LSS) and Community Based Newborn Care (CBNC) into
the pre-service Skilled Birth Attendants curriculum.
 Regular maintenance of adequate Emergency Obstetrics and Newborn Care (EMONC) equipment
and services.
Universal Coverage of Ante-natal and Post-natal Care Intervention
 Identified interest groups/ civil society should be trained to demand for their rights.
 Civil society organizations should demand for their right of the vulnerable groups.
 Creating outreaches closer to the people.
Improved Referral System Intervention
 Decentralization of ambulance to rural areas.
 Improvisation of functional ambulance services. E.g. Tricycles, Donkeys, Speedboats, cows and
Camels.
 Engagement of NURTW members or any community volunteer for a reward.
 Effective Two way referral system.

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15
The Budget
Details of the recommended accelerated solutions to each of the identified bottlenecks are contained in the
main report. It is estimated that the Acceleration Solutions and constituent activities would cost
NGN65,521,997,572 (Sixty-Five Billion, Five Hundred and Twenty-One Million, Nine Hundred and
Ninety-Seven Thousand, Five Hundred and Seventy-Two Naira). The mobilization of this amount is
crucial to the successfulimplementationof the Action Plan.
Monitoring and Evaluation Plan
A well-functioning results-based monitoring and evaluation system, established as integral element of
implementation management, is central to the success of the MAF Action Plan. The Monitoring and
Evaluation plan recommended for MAF has three main thrusts which are to:
a) Provide programme managers and stakeholders with data and information about the pace, nature and
levels of progress in service delivery and service use;
b) Supply credible evidence base for management responses in bridging gaps, correcting weaknesses
and consolidating gains in the implementation of the agreed solutions and actions;
c) Deliver a reporting and feedback system for tracking progress on MDG5 through 2015 based on the
MAF results chain – inputs, outputs, outcomes and impacts – with respect to MDG 5.

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16
Key Recommendations
It is recommended that an emergency meeting of the Presidential Committee on MDGs be
convened to deliberate on the budget and commitments, as well as confirmation of
responsibilities, as provided in the report, to various tiers and agencies of government for the
implementation of the MAF Action Plan. International Development Partners (IDPs) are
requested to make their specific commitments to the implementation of MAF Action Plan. With
respect to the implementation of the overall MDGs it is recommended, among others, that the
attainment of the MDGs be made the central focus of ongoing Centennial celebration.

17. APPENDIX 4
17
CHAPTER 1
INTRODUCTION
Background
1. A remarkable push in the global drive towards fast-tracking the achievement of the
Millennium Development Goals (MDGs) was made in 2010 when the United Nations
Organization (UNO) provided a platform for a comprehensive review of progress made so
far within a decade of its implementation. This global platform was the United Nations
General Assembly Special Session (UNGASS) on MDGs+10 that took place in September
2010. The decade‘s stock taking event came on the heels of new challenges and realities, such
as the global economic and financial crises, climate change, as well as new evidence and
innovations that needed to be factored into the MDGs implementation trajectory. The
MDGs+10 as it were, was an epoch-making event that afforded different nations the
opportunity to refresh their commitment to the MDGs, peer-review progress and redouble
effort towards meeting the goals by 2015 in the light of new risks and challenges.
2. The Federal Republic of Nigeria was among the nations that presented a Five-Year
Countdown Strategy (CDS) at the UNGASS on MDGs+10. The overarching objective of
the CDS was to outline a roadmap for accelerating progress towards achievement of the
MDGs by 2015. The specific objectives of the CDS were:
a) To identify the most effective mechanisms and interventions that have made
progress against the MDGs
b) To re-emphasize the roles and responsibilities of all agencies, stakeholders, and each
tier of government
c) To guide the institutional improvements, policies and human resources required
d) To chart the trajectory of MDGs financing and investment to 2015
e) To interface with Vision 20:2020 and (the then 7-Point Agenda) Transformation
Agenda.
3. The CDS was designed to identify the gaps and lay out the policy actions, investments, and
milestones that would help Nigeria scale-up its successes and remedy weaknesses. Whilst the
CDS acknowledged the progress made up to 2010 including a notable ―success story‖ (the
Conditional Grant Scheme), it also addressed the critical challenges and gaps that accounted
for the overall average/slow status in respect of the eight MDGs. In addition to the strategic
initiatives that the government would introduce to tackle the challenges highlighted, sharply-
focused strategies for scaling up the implementation of each of the eight goals (or a
combination thereof) were spelled out in the CDS.
4. In its review of government‘s investment plans, priorities and choices, the CDS highlighted
the folding of the MDGs into the implementation plans of NV20-2020 and stresses the
imperative of nurturing a combination of public and private investments to ensure
acceleration of progress towards achieving the MDGs by 2015. Furthermore, it re-examined
the existing costs assessment for achieving the MDGs and also highlighted the need to adopt
a new financing strategy that would involve all the three levels of government as well as the
arms of government and all relevant stakeholders to make solid commitment through a
national partnership and fiscal compact for MDGs in the next five years. Finally, a roadmap
for coordination, and monitoring & evaluation (M&E) is provided with an ―Indicative
Roadmap Matrix of Actions, Lead Responsibilities and Timeframe‖ covering only 2010 and

18. APPENDIX 4
18
2011 – thereby leaving room for any refinements and modifications that a new
administration might decide to introduce after presidential and legislative elections in 2011.
5. So far, owing to a variety of factors, implementation of the CDS has not gained adequate
momentum to deliver the envisaged amount of progress; instead, some MDGs that were
once promising have suffered set-backs. The Millennium Accelerated Framework (MAF)
offers another avenue to resume and also accelerate progress. It enables nations to:
a) assess and identify their interventions with the aim of scaling up those with higher
impact; (b) analyse and prioritise bottlenecks hindering success of others;
b) identify solutions and their sequencing;
c) develop an accelerate action plan, along with an implementation and monitoring
plan.
6. Presently, MAF has become the fastest tool which any nation can adopt to operationalize her
MDGs implementation strategy, and in the case of Nigeria, her Countdown Strategy. The
MAF helps countries to analyze why they are lagging behind on specific MDGs, prioritize
the bottlenecks to progress, and identify collaborative solutions involving governments and
all relevant development stakeholders. It could also help to address new challenges related to
meeting the MDGs in a particular country context; and integrate new evidence such as the
strategic importance of energy and technology, the centrality of gender equality and women‘s
empowerment in relation to specific MDGs targets and indicators, and innovations in
national and sub national efforts to accelerate and sustain progress towards the MDGs. In
countries where rates of progress vary sharply across geographic regions and/or population
groups, the MAF can help understand the reasons behind such differences in progress, and
thereby address them through tailored solutions.
7. The MAF results in the preparation of a focused, agreed upon Action Plan to address the
specific MDGs that rallies the efforts of governments and its partners, including civil society
and the private sector, on providing the investments and services needed to advance key
policy reform and overcome identified constraints.
8. The Office of Senior Special Assistant to the President on MDGs (OSSAP-MDGs) in
collaboration with the Federal Ministry of Health and the International Development
Partners (IDPs) (notably the United Nations Development Programmes (UNDP) and the
United Kingdom‘s Department for International Development–supported State Partnership
for Accountability, Responsiveness and Capability (DFID/SPARC) along with other UN
bodies) established a Technical Working Group (TWG) charged with the application of
MAF in the operationalization of the CDS.

19. APPENDIX 4
19
9. In line with the Federal Government‘s
recognition of the multiplier effects of the
MDGs health goals to the overall success of
the entire MDGs in Nigeria, and given the
enormous time and resources involved in the
application of MAF exercise, the OSSAP-
MDGS selected Goal 5 (Improve Maternal
Health) for a special focus in the acceleration
efforts. It is against this background that the
OSSAP-MDGs, UN Country Team in Nigeria,
DFID, and other partners are collaborating in
the application of MAF to MDG Goal 5. More
specifically, the assignment seeks to develop in
close collaboration with the Expert Technical
Working Group, a Country Action Plan (CAP)
to accelerate the implementation of goal 5
which involves:
a) Partnering with relevant sector agencies
and other stakeholders to identify and
prioritize high impact interventions
required to achieve the MDG Goal 5;
b) Conducting research, gathering data and
holding workshops to ascertain what
constitute bottlenecks to the
implementation of Goal 5 and
consequently, proffer solutions to the
bottlenecks;
c) Develop a comprehensive MAF action
plan including an implementation and
monitoring plan to accelerate the
achievement of Goal 5;
d) Produce recommendations on the next
steps with the remaining 7 goals.
Nigeria’s Country Profile
10. The Federal Republic of Nigeria is located in
the West African sub-region and is composed
of 36 states and the Federal Capital Territory
(FCT) Abuja. The 36 states are further divided
into 774 local governments which are regarded
as governments at the grassroots. For political
purposes and convenience also, Nigeria is
divided into six geo-political zones which are
utilized to share some political appointments at
the federal level. With a total land area of
923,768 square kilometers, Nigerian shares
boundaries with the Republic of Niger to the
north, Chad to the northeast, Cameroon to the
east and southeast, Benin to the west, and the Gulf of Guinea to the south. By 2006
Box 1: Overview of situation with Goal 5
With the current estimated maternal mortality
ratio (MMR) of 545 per 100, 000 live births (NDHS,
2008), Nigeria still has one of the highest MMR in
the world. It is estimated that about 4 maternal
deaths occur in Nigeria per hour, 90 per day, and
2,800 per month for a total of about 34,000 deaths
annually, with wide regional and local variations. A
little over a half (57.7%) of pregnant women aged
between 15-49 years receive antenatal care from
skilled providers. Skilled attendance at birth
remains low at 39%; with great diversity, for
example, with Imo State showing 98% skilled
attendants at birth to only 5% in Jigawa State.
Available data puts delivery in health facilities at
35% while home deliveries was rated at 62.1%,
underscoring the need for improved access and
utilization for health facilities-based maternal
health services It is also estimated that for every
maternal death, at least 30 women suffer short-to-
long term disabilities such as vesico -vaginal fistula
(VVF). Each year, some 50,000-100,000 women in
Nigeria sustain obstetric fistulae. Over 600,000
induced abortions are also estimated to take place
in Nigeria annually, and these are often performed
under unsafe conditions, with an estimated 40%
performed in privately owned health facilities.
As illustrated in Figure 1, the major causes of
maternal deaths are: haemorrhage; infection;
malaria; toxemia/eclampsia; obstructed labour;
anaemia; and unsafe abortion.
Goal: 5 Target Indicators
Improve
Maternal
Health
Target 5.A:
Reduce by 3/4
th
between 1990
and 2015, the
maternal
mortality ratio
1. Maternal
mortality ratio
2. Proportion of
births attended by
skilled health
personnel
Target 5.B:
Achieve, by
2015, universal
access to
reproductive
health
3. Contraceptive
prevalence rate
4. Adolescent birth
rate
5. Antenatal care
coverage (at least
one visit and at
least four visits)
6. Unmet need for
family planning

20. APPENDIX 4
20
population census, Nigeria‘s population was put at 140 million, and a 2011 projected
population figure of approximately 168 million (NPC, 2011), Nigeria is the most populous
country in Africa and in the entire black race. At a conservative growth rate of 3.2%,
Nigeria‘s projected population in the year 2020 is 221 million. Of the latest population
projection of 168 million, it is estimated the females constitute 82 million, while the males
account for 85 million. The 2011 projected figure represents a shift in the hitherto nearly 50-
50 male-female ratio in the population census of 2006.
11. Politically, Nigeria has been running an uninterrupted presidential democracy since 1999.
This is a significant departure from decades of military dictatorship and gross
underdevelopment of healthy democratic culture. Socially, Nigeria is multi-ethnic in
composition and has over 250 different ethnic groups.
12. Economically, Nigeria has a gross national product (GNP) of about US$195 billion in 2007
which rose to US$353.2 billion in 2009. The GDP per capita as at 2010 estimate stood at
$1,324, and a real GDP per capita at purchasing power parity estimated at US$2,289. Crude
oil is the main source of revenue, accounting for about 63 percent of government revenue
and about 97 percent of export income. Besides crude oil, other fairly large deposits are
natural gas, coal, tin, columbite, iron ore, limestone, lead, and zinc. The main non-oil exports
include cocoa beans, palm oil, rubber, textiles, hides and skins.
13. Educationally, Nigeria has an adult literacy rate of 72 percent and average life expectancy of
48.4 years down from 51 years over a decade ago. Nigeria‘s rank in the Human Development
Index (HDI) of the United Nations Development Programme (UNDP) has been
disappointingly low over the years. From 141st
position (Human Development Report of
1997), to 159th
position in 2006, it moved to 142nd
in 2010. Nigeria‘s HDI of 0.423 however
placed it above the Sub-Saharan regional average of 0.389 in 2010. Taken together, along
with an Inequality-adjusted HDI value of 0.246, intensity of deprivation of 57.9% (in terms
of poverty) and 70% of the population living below poverty line (2007 estimate), the
governance and developmental challenges facing Nigeria remain enormous.
High Level Endorsement of MAF
14. Given the inter-governmental character of the implementation of MDGs in Nigeria, any
effort to accelerate the achievement of the MDGs not only requires the support of the
Federal Government, but also requires both the support of the States and Local
Governments as well as other critical stakeholders such as the international development
partners, private sector, civil society organizations, community and faith-based organizations.
In actual fact, in countries where there has been successful application of MAF to the
MDGs, there was high level endorsement by their governments and critical stakeholders.
15. It was as a result of this that a Stakeholders Briefing on the Application of MAF in Nigeria
was organized by OSSAP-MDGs in collaboration with international development partners
on January 17, 2013 at the Transcorp Hilton Hotel, Abuja. The event was declared open by
His Excellency, Arch. NamadiSambo (GCON) the Vice-President of the Federal Republic of
Nigeria. Arch. Sambo restated the commitment of the Federal Government to fast-track the
implementation of the MDGs. He stated that the Federal Government welcomed the
application of MAF to fast-track the progress of the MDGs and in particular Goal 5. Also,
the National Assembly through the chairman of the Senate Committee on MDGs Senator
Mohammed Ali Ndume restated the commitment of its members to offer the necessary
assistance in the application of MAF. In actual fact, Senator Ndume made a case for a special

21. APPENDIX 4
21
allocation to the MDGs in order to realise the acceleration since as he rightly noted, Nigeria
started five years behind schedule in the commencement of the implementation. The
Honourable Minister of Health Prof.OnyebuchiChukwu meticulously chronicled the key
interventions in the health sector generally and in MDG 5-Improving Maternal Health
specifically in Nigeria.
16. During the Stakeholders Briefing, the Nigeria Governors Forum, the UN System in Nigeria,
DFID, Federal Ministries of Health, Finance, Education and Women Affairs, restated their
commitments in the acceleration efforts. Also the presence of the Minister of Water
Resources, Mrs. Sarah Ochekpe and that for Housing, Land and Urban Development,
Ms.AmaPepple, as well as Heads of parastatals under the Ministry of Health, and a host of
other development partners was an encouraging demonstration of their support in the
application of MAF in Nigeria.
Institutional Frameworks for the Implementation MDGs in Nigeria
17. Institutional Structures at the Federal Level: Nigeria maintains robust institutional frameworks for
the implementation of MDGs. At the Federal level, the executive and legislative arms of
government have institutional mechanisms that work jointly for the implementation of
MDGs. Unlike what obtains in some other countries, the Federal Government established
the MDGs Office in 2005 and appointed a Senior Special Assistant to the President (SSAP)
to head the Office. The establishment of the OSSAP-MDGs which was meant to give
MDGs both priority and visibility demonstrated government commitment to the
achievement of the MDGs. In addition, the government established a Presidential
Committee for the Assessment and Monitoring of the MDGs (PCAMMDGs). The members
of the Presidential Committee (chaired by the President) include representatives of state
governors, National Planning Commission (NPC), local and international Non-governmental
organisations (NGOs) and ministers of implementing agencies of DRG programmes and
projects. The Office of the SSAP serves as the secretariat of the Committee. Furthermore,
some Ministries, Departments and Agencies (MDAs) were designated MDGs
implementation Ministries through which the OSSAP-MDGs channelled funds for the
MDGs implementation.
18. In order to give life to this institutional framework, MDG implementation was given a huge
boost when the government pledged to apply the savings accruable from the Paris Club
Debt Relief Deal in 2005 (labelled Debt Relief Gains, DRG) to pro-poor programmes and
projects that would enhance the prospects of achieving the MDGs. To this end, a Virtual
Poverty Fund (VPF) was adopted in the FGN‘s budget to report on the nature of Debt relief
expenditures. (The VPF is a coding system within an existing budget classification structure
that enables the ―tagging‖ and ―tracking‖ of poverty-reducing spending). The reporting
platform was provided by the Office of the Accountant General of the Federation through
the Accounting Transaction Recording and Reporting System (ATRRS). In concrete terms,
the VPF tracks the portion of federal government expenditures dedicated to supporting
poverty-reducing activities.
19. At the National Assembly, both the Senate and the House of Representatives established
MDGs committees that have been working in collaboration with OSSAP-MDGs and the
relevant MDAs to fast-track the implementation of MDGs.

22. APPENDIX 4
22
Inter-Governmental Institutional Arrangements
20. At the inter-governmental level, the Federal Government through the OSSAP-MDGs
established structures for the implementation of one‘s MDGs‘ intervention success stories
namely the Conditional Grants Scheme (CGS).The Conditional Grants Scheme operates
through specific Federal, State and Local Governments‘ structures shown in figure 1 below.
Figure 1: CGS Implementation Structures.
Source: OSSAP-MDGs, CGS Implementation Manual, Revised edition, 2012s
21. A very brief description of these structures follows:
a) The Presidential Committee on the Assessment and Monitoring of MDGs (PCAM-
MDGs). The PCAM-MDGs is chaired by Mr. President. Membership of the Committee
is drawn from public and private sectors, civil society and the international development
partners. It assesses and monitors progress of CGS projects towards the achievement of
the MDGs in Nigeria.
b)The National Committee on Conditional Grants Scheme (NCCGS). The NCCGS is
chaired by the Minister of Finance. Its membership is composed of the Minister of the
National Planning Commission; the Ministers of key MDG line Ministries; the Director
General of the Budget Office of the Federation; the Accountant General of the
Federation; and the Senior Special Assistant to the President on MDGs.
c)The Office of the Senior Special Assistant to the President on MDGs (OSSAP-MDGs)
which serves as the Secretariat to the PCAM-MDGs and NCCGS.
d)State Government Structures include (i) State CGS Implementation Committee, (ii) State
CGS Project Support Unit, and (iii) Relevant State Ministries, Departments and
Agencies.

23. APPENDIX 4
23
e)Local Government Structures include(i) LGA MDGs Planning Committee, (ii) LGA
MDGs Technical Team, (iii) Community, Traditional and Faith Based Institutions &
Organizations, and iv) Civil Society Organizations.
Objectives of MAF
22. A critical assessment of the operational effectiveness of these structures in the
implementation of MDG 5 in the past decade is key to the application of MAF. Some
important questions need to be examined in comprehending why critical interventions failed
in many states and local governments. For example, to what extent were the structures at
both the state and local government levels sufficiently empowered and enabled to perform
their responsibilities? Secondly, to what extent did lack of effective collaborations between
the state and their local governments impede the implementation of MDG 5? Thirdly, are
grass root structures for the implementation of MDG 5 merely symbolic rather than
substantive in their existence? Since the success of MDG 5 depends largely on the
effectiveness of structures at the primary health care level, these questions are critical in the
implementation of Nigeria‘s MAF Action Plan
23. The overarching objective of MAF is to build partnership around maternal health issues in
Nigeria especially among the various tiers of Governments (federal, State and Local
Governments), within MDAs, CSOs, the private sectors, the UN agencies and other
development partners working on neonatal and maternal health in the country. It primarily
aims at providing deeper understanding of the key bottlenecks to the implementation of
maternal health interventions in the country, collectively identifies key local solutions and
develop an action plan that can help to reduce the risks impeding progress on maternal
health in the country.
24. Specifically, the MAF seeks to:
a) assess past and existing maternal health policies and interventions;
b) identify the key bottlenecks to and gaps in the implementation and attainment of Goal 5;
c) develop feasible and cost-effective solutions that can accelerate progress towards
maternal health in the country; and
d) prepare an action plan for implementing collectively identified interventions, monitor
and evaluate progress.
Methodology of MAF Preparation and Roll-out
25. The preparation of MAF in a federal and populous country like Nigeria necessarily entails a
complex methodological framework of operations. The sheer complexity of planning and
organizational requirements in such a large and heterogeneous country no doubt require a
multi-pronged methodological foundation that can maximize the highly competing goals in
MAF preparation and its eventual roll-out. Be that as it may, three key decisions that
established the methodological point of departure were (a) the setting up of the institutional
framework for effective coordination of the MAF process jointly driven by OSSAP-MDGs
and IDPs, (b) the engagement of consultants to drive the technical process, and (c) the
planning and organization of the stakeholders‘ consultation technical workshop of which the
Federal Ministry of Health played a catalytic role.
26. The establishment of the Technical Working Committee composed initially of members
from OSSAP/MDGS, UNDP and DFID-SPARC and subsequently enlarged to involve

24. APPENDIX 4
24
Federal Ministry of Health, (when MDG 5 became the main focus) and other IDPs, was one
the milestones of the three-pronged methodological foundation meant to ensure quality
assurance in the MAF preparation process. The second milestone was the actual engagement
of four national consultants with wide-ranging expertise on MDGs in Nigeria to manage the
technical process. The third milestone was the hosting of the MAF stakeholders‘ workshop
for wide consultative and participatory engagements.
27. The management of the technical process by the consultants began with a desk review of an
array of existing relevant national and international policy documents and reports made
available by OSSAP-MDGs, Federal Ministry of Health, UNDP, DFID-SPARC, other key
UN of agencies as well as documents and reports assembled by consultants themselves. The
completion of the desk review paved the way for the organization of the Stakeholders‘
technical workshop.
28. The technical ground work for the workshop began when Dr.AyodeleOdusola, (MDG
Advisor, Regional Bureau for Africa, UNDP, New York) met with the Consultants.
Consequently a tripartite meeting of OSSAP-MDGs, UNDP and DFID-SPARC was called
for further brainstorming with Dr.Odusola and the consultants. This meeting which was
hosted by DFID-SPARC turned out to be one of the most fruitful meetings in the
commencement of the MAF process in Nigeria. It was at this meeting that a careful and
detailed selection of stakeholders for the workshop was carried out.
29. The selection of the stakeholders for the workshop involved a complex set of criteria aimed
at ensuring representativeness of major voices that need to be heard on issues relating to the
improvement of maternal health. There was a selection of key stakeholders in the health
sector reflecting (a) wide geographical spread and geo-political zones (e.g. the selection
ensured that all the 36 states and the FCT were represented); (b) occupational sub-sectors
(e.g. doctors, nurses and midwives, CHEWs and traditional birth attendants were all
represented in the selection); (c) tiers of government (federal, state and local governments
were all involved); (d) professional associations (Nigerian Medical Association, and Nurses
and Midwives Association selected); (e) grass roots representations and civil society
organizations (PPFN, and Society for Family Health representing the marginalized interests);
(f) key policy makers and executors in the MDGs line ministries, parastatals, OSSAP-MDGs
and the National Assembly, and (g) host of international development partners comprising
UNDP, DFID, DFID-SPARC, DFID-PRRINN-MNCH, WHO, UNFPA, UNICEF,
UNMC, UN Women, One UN, World Bank, European Union, USAID, and CEDAR. A
matrix showing the criteria for selection of key stakeholders from all the states and
representing diverse interests enumerated above is in the appendix section of this Report.
30. The data gathering instruments for the MAF Stakeholders‘ workshop were adapted from the
United Nations-developed MDG Acceleration Framework-Operational Note made available to the
consultants by MDG Advisor Dr.Odusola. Four main instruments in line with the four
stages involved in the preparation of MAF were developed based on the UN generic
templates. The first instrument, which was on the step 1 of the MAF process relates to the
Priority Intervention on Maternal Health as well as the Intervention Selection Guidelines.
Key selection guidelines are incremental outputs and outcomes, beneficiary population,
impact ratio, speed of impact, and evidence of impact, all of which were geared towards the
objectivity of the selection process. The second instrument on step 2 of the MAF process
focused on the identification and prioritization of the bottlenecks, while the third set of
instruments was on step 3 of the process. The three instruments provided (a) the solution
impact evaluation guidelines, (b) the solution feasibility evaluation guidelines, and (c) the

25. APPENDIX 4
25
solution prioritization scorecard. The fourth instrument is a template for the MAF Action
Plan.
31. This successful holding of the Stakeholders‘ Technical workshop on February 20-21, 2013,
was a major milestone in the preparation of MAF in Nigeria. There was high level
participation of Federal Government officials and the UN System. Such high level
participants included the Honourable Minister of Health (represented by an official of his
ministry); the Senior Special Assistant to the President on Millennium Development Goals;
Resident Coordinator of the United Nations in Nigeria; Head of DFID in Nigeria (by
representation); Country Director of UNDP in Nigeria, and Country Director of UNDP in
Ghana among others.
32. Participants at the Stakeholders‘ workshop identified list of all the key interventions on
maternal health and identified 5 of them as prioritized interventions. Secondly, they
identified all the bottlenecks impeding success and thereafter identified 5 of them as
prioritized bottlenecks. Thirdly and lastly, they also identified a list of acceleration solutions
to the prioritized bottlenecks.
33. The next major activity was the hosting of a 2-day intensive Bilateral Discussion meeting on
February 27-28, 2013. The participants at the meeting principally involved the consultants on
one side, and the key policy drivers and implementers in the Federal Ministry of Health and
its Parastatals, as well as representatives from the World Health Organization (WHO) on the
other side. But more importantly, the planning of the Bilateral Discussion meeting was
coordinated by OSSAP-MDGs, while DFID-SPARC hosted it. The UNDP as usual
provided the technical backstopping, while the Federal Ministry of Health played the major
role of mobilizing the participants for the discussions.
34. Based on the identified acceleration solutions, participants at the Bilateral Discussion
meeting proceeded to identify the solution indicators, targets, timelines and responsible
partners that would be involved in the implementation of the solutions and the Action Plan.
It was at these meetings that the costing parameters emerged and costing experts who were
in attendance commenced work immediately.
35. The MAF Validation workshop which was held on March 12, 2013 was another milestone in
the application of MAF to MDG 5 in Nigeria. Like the Stakeholders‘ workshop it also
attracted a high level participation which involved the Honourable Minister of Health, Senior
Special Assistant to the President on Millennium Development Goals, Honourable
Minister/Vice Chairman of National Planning Commission; the Honourable Minister of
State for Health, Resident Coordinator of the United Nations in Nigeria, Head of DFID in
Nigeria; Executive Director/CEO, NPHCDA among others.

26. APPENDIX 4
26
CHAPTER 2
NIGERIA MDGs STATUS: AN OVERVIEW WITH A FOCUS ON MDG 5
Overview
36. Since the MDGs was mainstreamed in national planning and budgeting, there have been
successive country-level assessment and monitoring reviews, given by MDGs Status Reports
2004, 2005, 2006, 2007and 2010. The Reports show progress, trends and challenges in the
march toward the MDGs 2015 targets. This overview of Nigeria MDGs status therefore
draws from the cumulative and collective assessments in these reports, supplemented with
updates based on recent statistics and with a special focus on why the MDG 5 is chosen for
MAF.
37. Overall, Nigeria‘s progress toward the achievement of the MDGs is a mixed bag especially
when comparison is made across the different sub-national jurisdictions, as well as between
urban and rural populations. With regard to MDG 1 to Eradicate extreme poverty and
hunger, recent statistics show that the national poverty incidence increased from 54.4% in
2004 to 69.0% in 2010. Against the background of a rapidly rising population this percentage
translates to 112.47 million people living in poverty in the country. In terms of zonal
differences the poverty incidence varies from 59 per cent in Southwest to 78 per cent in
Northwest. The significant point to note is that the poverty incidence whether by zone or
rural comparison is way above 50 per cent. With respect to ‗hunger‘ dimension of MDG 1,
recent statistics estimate the proportion of under-5 children that are underweight at 24.0% in
20111
, suggesting a reduction by at least two per cent annually to be able to meet the 2015
target of 17.85 per cent. If current trends continue, Nigeria is likely to achieve this target
employing strategies that are sensitive to, the sharp differences between geopolitical zones
and between states within a zone.
38. The MDG 2 which is toAchieve universal basic education has also witnessed a staggered
progress. The net enrolment ratio in primary education which improved from 80 per cent in
2004 to 90 per cent in 2007 has continued to experience a steady decline since then to a low
of 70.1% in 20102
and thus reseeding further from the target of 100 per cent set for 2015.
39. Similarly, both the ‗ratio of pupils starting primary 1 who reach primary 5‘ which was well
over 90 per cent in 2001 dropped to 72.3 per cent in 2008 while the ‗primary 6 completion
rate‘ that rose to 80 per cent in 2004 also declined to 67.5 per cent in 2008 and both have
continued to suffer setbacks in the years since then. In terms of differences between zones
and states, while the net enrolment in primary education is as high as 87% in Ekiti State in
the Southwest and 83% in Abia State in the Southeast, it is as low as 18% in Zamfara State in
the Northwest and 21% in Borno State in Northeast Nigeria.
40. On MDG 3 which is toPromote gender equality and empower women, Nigeria is
currently on track and has bright prospects of meeting MDG 2 with regard to the ratio of
girls to boys in primary education as well as the ratio of girls to boys in secondary education.
There are currently 90 girls per 100 boys in primary schools in 20103
, as against the baseline
of 70 girls per 100 boys in 1990; similarly, there are currently 93 girls per 100 boys in
secondary schools in 2010, against the baseline of 75 girls per 100 boys in 1990. On these
two indicators, consistent progress has been sustained over the years. There continue to be
1
Multiple Indicator Cluster Survey (MICS) 2011.
2Nigeria DHS EdData Survey 2010.
3 Nigeria DHS EdData Survey 2010

27. APPENDIX 4
27
high disparities across zones and states on progress toward MDG 3. For example, gender
parity in primary school has been achieved in Ekiti, Delta, Abia and Imo, but disparity
persists in Sokoto, Jigawa, Katsina and Kebbi. These patterns are mirrored in the Figure 2
below:
41. The progress on MDG 4 toReduce child mortality is uneven between zones and states as
with other MDGs. Recent statistics4
estimate the under-5 mortality rate at about 158 per
1000 live births in 2011, against the 2015 target of 64 per 1000 live births. The most recent
estimate for infant mortality rate is 97 per 1000 live births in 2011 against the 2015 target of
30 per 1000 live births. The wide zonal differences are illustrated graphically below:
Figure 3: Under-5 Rate by Geo-political Zone, Nigeria 2011
Figure 4: Infant Mortality Rate by Geo-political Zone, Nigeria, 2011
4
Multiple Indicator Cluster Survey (MICS) 2011

28. APPENDIX 4
28
42. Nigeria is on track to meeting the MDG 6 which is to Combat HIV/AIDS, malaria and
other diseases with particular regard to the target ‗to halt and reverse the spread of
HIV/AIDS‘. Latest statistics, though in arrears, show that the country is progressing well
and will likely achieve the target, if current trends continue. The HIV/AID prevalence rate
declined from about 5.4% in 2000 to about 4.1% in 2008. However, critical challenges persist
with regard to access to treatment for persons living with HIV/AIDS (PLWA) that are
receiving treatment and prevention of mother-to-child transmission (PMTCT). Only one out
of three persons living with HIV/AIDS gets treatment currently, against the target of
universal coverage. Regarding the prevention of mother-to-child transmission, the country
currently achieves a meagre 16%, against the 2015 target of 90%. Nigeria is also on track
with respect to reducing malaria prevalence, given that malaria prevalence declined by 42.8%
from 2024 per 100,000 in 2000 to 1157 per 100,000 in 2004.
43. Nigeria‘s status on MDG 7 which is to Ensure environmental sustainability is widely
divergent across the respective constituent indicators. On the one hand, there is modest
progress on the 2015 target of halving the proportion of the population without sustainable
access to safe drinking water and basic sanitation. About 58.5% of Nigerians has access to
improved drinking water source in 20105
, as against the 2015 target of 77%. Similarly, about
42.6% of Nigerians have access to improved toilet/latrine facility in 20106
, as against the
2015 target of 70%
44. On the other hand, the situation is not satisfactory with respect to halting deforestation and
gas flaring. Only about 10% of gas produced is used domestically primarily for power
generation while 24% is flared7
. Gas flaring from joint venture oil companies represents
roughly 60% of all emissions from Nigeria‘s oil and gas sector. Equally, tackling the growing
tide of slum dwellings will become even more challenging amidst the urbanisation wave
sweeping across the country. It is estimated that Nigeria‘s urban population would rise to
about 60% by 2025, given the current growth rate of 5.8% per annum.
45. Nigeria is successful on MDG 8 to Develop a Global Partnership for Development as
evidenced by the Paris Club debt relief as the primary source of funding of MDGs in
Nigeria. But, overseas development assistance (ODA) has been lagging behind levels desired
for meeting the MDGs. ODA to Nigeria increased from US$4.49 per person in 2004 to
US$81.67 per person in 2006 and 2007, but, much of this increase came from the debt relief
rather than from additional ODA from international development partners. Estimates show
that per capita ODA was US$8.53 in 2008, but is still far short of the volume of funds
required to make appreciable progress on the MDGs.
46. Nigeria‘s progress on access to ICTs has been rising sharply, fuelled by the deregulation of
the telecommunications subsector and market entry by private sector GSM operators. In
1990, there were only 0.3 telephone lines per 100 people in Nigeria. The number of GSM
(Global System for Mobile Communications) lines increased from 0.27 million in 2001 to
more than 1.57 million in 2002 and about 32 million in 2006. Thus, access to cellular
phones increased from only 2 out of 100 persons in Nigeria in 2000 to nearly 42 per 100 in
2008. As of October 2012, Nigeria had a total 109,499,882 active telephone lines (mobile
GSM, mobile CDMA and fixed wired/wireless), representing a teledensity of 78.21%, up
5 Nigeria Malaria Indicator Survey (NIMS) 2010.
6 Nigeria Malaria Indicator Survey (NIMS) 2010.
7NNPC 2010.

29. APPENDIX 4
29
from 1.89% in 2002. However, internet access lags far behind the growth of telephone
lines. Internet users per 100 persons increased from 0.32 in 2002 to 15.86 in 2009. Despite
this increase, the access to internet remains low, signifying large scope for improvement.
Focus on MDG 5: Improve maternal health
Figure 5: Maternal Mortality Rate
47. Improvement in maternal health is another area where the country has made an appreciable
impact. The data (Figure 5.1) shows that maternal mortality has been reducing steadily: 800
per 100,000 in 2004; 545 per 100,000 in 2008; and 350 per 100,000 live-births in 2012.This
represents about 56.2%and 35.8 per cent declined in 2004 and 2008 figure respectively.
When compared with the 2015 benchmark, the 2012 figure is about 28.6 per cent away from
the 250 target.
Figure 6: Proportion of births attended by skilled health personnel
48. The 35.8 per cent decline in 2012 in the number of women that die during child birth is in
part attributable to the increase in coverage of births attended by skilled health personnel in
the country. A skilled health professional (doctor, nurse or midwife/auxiliary midwife,
community health worker) can administer interventions, either to prevent or manage life-
threatening complications during child births. In Nigeria, the proportion of deliveries
800
545
350
250
2004 2008 2012 2015
Perthousandlivebirths
Maternal mortality rate (per 1000 live birth)
0
20
40
60
80
100
2004 2008 2012 2015
36.3 38.9
53.6
100
Proportion of birth attended by skilled health
personnel (%)

30. APPENDIX 4
30
attended by skilled health personnel increased from 36.3 per cent in 2004 to 38.9 per cent in
2008. It further rose to 53.6 per cent in 2012.
Figure 7: Contraceptive prevalence rate
49. Increased access to safe, affordable and effective methods of contraception is providing
individuals with greater choice and opportunities for responsible decision-making in
reproductive matters. In addition, contraceptive use has contributed to improvements in
maternal and infant health by serving to prevent unintended or closely spaced pregnancies.
Contraceptive prevalence increased rapidly to 17.3 per cent from 8.2 per cent in 2004 but
dropped to 14.6 per cent in 2008 (Figure 5.3). There is still room for improvement given that
various unmet family planning need is progressively rising since 2004 – particularly in the
rural areas where awareness is relatively low.
Figure 8: Antenatal care coverage
50. Antenatal care coverage is among the health interventions capable of reducing maternal
morbidity. It is critically important to reach women, and timely too, with interventions and
information that promote health, wellbeing and survival of mothers as well as their babies.
Coverage (at least one visit) with a skilled health worker significantly increased to 67.7 per
cent in 2012 from a decline of 61 per cent in 2008. The 2012 figure represents 6.7 per cent
and 12.8 per cent increase over 2004 and 2008 figures. In addition, antenatal coverage – at
0
2
4
6
8
10
12
14
16
18
2004 2008 2012
8.2
14.6
17.3
Contraceptive prevalence rate (%)
0
20
40
60
80
2004 2008 2012
61
54.5
67.7
47 44.8
57.6
Antenatal care coverage %
Antenatal coverage (at least once by any provider)
Antenatal coverage (at least four times by any provider)

31. APPENDIX 4
31
least four visits in 2012 rose to about 57.8 per cent; an increase from 17 per cent in 2004 and
20.2 per cent in 2008 respectively (Figure 5.4). However, this spectacular success is skewed to
urban areas. Like in other indicators, the rural areas are also lagging in antenatal coverage.
The coverage rate in the rural areas is about 56.5 per cent for at least one visit and 47.7 per
cent for four visits.
Figure 9: Unmet need for family planning
51. The unmet need for family planning remains persistently high. The unmet need for family
planning—expresses the percentage of women aged 15 to 49, married or in a union, who
report the desire to delay or avoid pregnancy, but are not using any form of contraception.
In 2004, the figure was about 17 per cent, while the 2008 figure was 20.2 per cent which
further decelerated marginally to 21.5 per cent in 2012 (Figure 5.5).
52. As can be deduced from the overview in this chapter, there are a number of clear
justifications for the choice of MDG5 for Nigeria‘s MDG Acceleration Framework (MAF):
a) Focusing on MDG 5 is consistent with the Government’s Transformation
Agenda. At inception, the present administration launched an agenda for addressing
the most pressing development challenges facing the country. The Agenda identified
healthcare, among others, as a key development and policy challenge. In the gamut of
the health challenges, poor maternal health is iconic. For Government, the underpinning
policy for the inputs toward achieving the human capital development goal of the Vision 20: 2020
Strategy is the National Strategic Health Development Plan (NSHDP). The NSHDP is the
vehicle for actions at all levels of the health care service delivery system which seeks to foster the
achievement of the MDGs and other local and international targets and declaration commitments.
b) The choice of MDG 5 for MAF will address persistent zonal disparities in
health outcomes. Disparities in the achievement of the goals of the MDGs across
states and between the six geo-political zones of the country abound, but much more
dramatic with respect to MDG Goal 5 on maternal mortality, given especially its
immediate impact on human lives. Whereas a zone like the South West, standing
alone, had virtually met the target even as early as at 2008, others, especially the
North West and North East showed performances way below the national average.
By focusing on MDG 5, lessons from regions with good outcomes can be used in
areas of poor outcomes.
c) Sustaining and Improving Progress on MDG 5.As already indicated, on the
average some progress was made on all the three maternal health indicators between
2003 and 2008. On the basis of this development, and factoring in what appeared to
be good prospects for achieving Goal 5, the 2010 MDGs +10 Report suggested that
0
5
10
15
20
25
2004 2008 2012
17
20.2 21.5
Unmet need for family planning (%)

32. APPENDIX 4
32
MDG 5 could be a candidate for realisation if the momentum was sustained.
President Goodluck Jonathan in his Foreword to the 2010 MDG+10 Report,
declared the achievement in MDG 5 up to 2008 as ‗unprecedented‘.
d) As can be seen from the graphical projections reproduced below, the expectation was
that if the average performance on the MDG 5 is sustained, the target would be met
by 2015. This performance-based projection was the basis for the official optimism
that was shared with the rest of the world by President Jonathan in September 2010.
The Countdown Strategy (CDS) provided a roadmap, targeted investment and
ingredients of effective partnership which implementation would have helped to
sustain the observed trend of the three years to 2008 and which formed the basis for
the optimistic projection to meeting the target by 2015. For a number of reasons
associated with transition in administration, the implementation of the CDS was
delayed. A number of otherwise laudable initiatives like the MSS programme were
not anchored effectively on the roadmap of the CDS. Even with the latest NBS data
showing an MMR of 350 as a national average, there are still wide differences within
the least performing zones. The political commitment and the associated resources
devoted to the attainment of MDG 5 still remain a matter of great concern. Added to
the above is the largely unexpected eruption of violence, especially the North East
Zone on a scale never before seen in the history of peace-time Nigeria. The North-
East Zone has had recurrent troubled performance on MDG Goal 5 in particular.
This violence and the resulting social and economic instability have contributed to a
loss of the momentum towards the attainment of MDG 5 in some parts of the
country. The healthcare initiatives that held the promise of raising the national
average performance on MDG 5 - Midwifery Services Scheme, Routine
Immunisation, Rollback Malaria, HIV/AIDS Control Programme, Health Systems
Strengthening, Infrastructure and even the SURE-P--- appear overwhelmed by
insecurity in parts of the county where their operations are needed most for the
achievement of the health MDGs and in particular goal 5.
e) MDG 5 is a proximate means of progress on other MDGs. Maternal health is
highly linked to other MDGs like child health, gender and women empowerment and
poverty reduction. It means that accelerating progress on MDG 5 could lead to
gaining some mileage with the other MDGs in which progress is currently slow. A
healthier mother is better able to work, earn a living, participate in household
decision making and provide better for a child. Available data demonstrate this
correlation. For example, when national maternal mortality rate declined from 800
deaths per 100,000 live births to 545 deaths over the period 2003 to 2008, it
correlated with declines in infants and under five mortality rates as illustrated in
below. The focus on MDG 5 is therefore expected to have salutary effects on the
performance of other goals, especially Goal 4. Hence, for the good health of our
women in the vibrant age group of between 18 and 45 and for political
accountability, the choice of the MDG 5 for MAF is considered appropriate and
timely.

33. APPENDIX 4
33
Figure 10: Trends in Maternal and Child mortality (1990 -2008)8
Source: OSSAP-MDG
8Chart adapted from ‗The Health MDGs (4, 5 & 6): Achievements and Lessons Learnt” Office Of The Senior Special Assistant to
The President On MDGs (2012)
704
49
87
192
800
52
100
201
545
40
75
157
0
100
200
300
400
500
600
700
800
900
MATERNAL NEONATAL INFANT UNDER 5
1990
2003
2008

34. APPENDIX 4
34
CHAPTER 3
KEY INTERVENTIONS TO ACCELERATE MDG-5 IN NIGERIA
53. In Nigeria, MDG5 specific interventions are being delivered using the principles of
integration of services along a continuum of life stages of care starting with: pre-pregnancy
period; pregnancy period; intrapartum period (delivery); and the postnatal period. And over
the years, a series of Health-MDG response frameworks and plans have been produced in
concerted efforts to rise to the challenge of meeting the MDG targets by 20159,10,11,12
. The
packages of interventions that have been identified and implemented towards meeting the
target for MDG-5 consist of the following:
a) Provision and facilitating demand for basic and sometimes comprehensive essential
obstetric care services in health facilities to treat pregnancy and delivery-related
complications such as eclampsia, haemorrhage, obstructed labour, sepsis, and abortion-
related cases, and other causes of maternal mortality identified earlier. Government and
development partners have stepped up initiatives to increase availability of Basic
Emergency Obstetric and Newborn Care (BEONC) interventions projects across the
country.. These are among other things addressing at least 3 well-known delays: delays in
decision making to seek treatment; delays between decision-making and reaching a health
facility; and delay between arrival at the health facility and receiving appropriate
treatment. A number of interventions have been put in place, responding to addressing
these delays and in addressing the demand-side of the challenge to reproductive health
services. For example, one such program, the Maternal and Child Health Integrated
Program (MCHIP) addresses delays associated with maternal and newborn deaths by
seeking to improve household and care-seeking practices, empowering the community to
create and maintain an enabling environment for increased utilization of maternal and
newborn care services wherever they are available, with the main thrust being
improvement of EmONC services, with a recognition that response to potential
pregnancy and child delivery complications starts in the antenatal period and continues
through childbirth and the postnatal period.
b) Developing and implementing a coordinated behavioral change communication strategy
to promote essential newborn care practices at community level through women‘s
groups, religious organizations and other community mobilization structures; scaling up
the use of trained household counselors (for example in several northern states;
educating women and their families about the danger signs in pregnancy, during and after
childbirth; scaling up the use of trained male birth spacing motivators to educate men
about the benefits of healthy timing and spacing of births and the use of long-acting
contraceptive methods; implementing community systems to respond to immediate
referral to primary health clinics and hospitals in the case of complications.
9 FMOH: Health Sector Reform Programme, 2004-2007.
10FMOH: Achieving Health Related Millennium Development Goals in Nigeria. A Report of the Presidential
Committee on Achieving MDG in Nigeria
11 FMOH: National Strategic Health Development Plan (NSHDP) 2010-2015,
12
NPC-OSSAP: 5-Year Countdown Strategy: Roadmap to Accelerate Nigeria‘s Progress towards Achieving the
Millennium Development Goals

35. APPENDIX 4
35
c) Equipping Community health workers with kits to visit pregnant women at home
counsel them and encourage them on ANC, danger signs in pregnancy, delivery and after
delivery to both mother and baby, birth preparedness with the family including the
various preparations for facility delivery e.g. transportation, delivery with a skilled birth
attendant and saving towards emergencies, birth spacing and appropriate referrals. These
CHWs support the women in labour to the prearranged facility, and make home visits to
support the new mother and baby and treat or refer promptly and appropriately in case
of mother or baby needing care they cannot render. They counsel and support on
appropriate feeding practices and encourage exclusive breastfeeding. This program is
called Community based maternal and newborn care (CBNC).
d) Improving access to quality essential obstetric care services. Health facilities providing
maternal and reproductive health services are few and unevenly distributed across the
country. Not only are facilities insufficient, majority of the available ones do not have the
minimum required health staff (doctors, nurses, mid-wives, CHEWS and JCHWES, etc.),
equipment and life-saving skills, to function properly and respond to patient‘s needs and
expectations, especially during emergencies.
e) Establishing mentoring linkages between tertiary and primary care facilities and health
workers to improve quality of obstetrics and newborn care.
f) Improvement of reproductive health/family planning services and usage. The lack of
ready access, affordability and usage of reproductive health services, such as family
planning is largely attributed to poverty and the lack of funds to procure these services.
Interventions addressing these deficiencies improve usage of reproductive/family
planning services and significantly improve maternal health and reduce maternal
mortality.
g) Improved financial access to vulnerable groups, especially women. This has involved the
implementation of various models of financial protection schemes, notably: conditional-
cash-transfer schemes for pregnant women; and NHIS (Community Health Insurance
Scheme), to address and ameliorate women‘s financial access to services.
h) Improving access through improved geographic equity and access to health care services.
Government at the Federal level, through the NPHCDA has been involved in the
expansion of the construction of new PHC facilities. A number of States Governments
have also launched various forms of initiatives, including free health care to targeted
groups in addressing expansion and access to health care services.
i) Development of a network of PHC centers linked to secondary referral health facilities
that are well equipped and staffed to facilitate access to emergency obstetric care facilities
in case of emergency.
j) Renovation of health facilities with a focus on areas such as Antenatal Clinics, labour
wards and general maternity sections, and provision of basic drugs, commodities,
including equipment for treatment of common MNCH illnesses to improve the delivery
of MNCH services.
k) Construction of boreholes for provision of portable water supply to improve quality of
care in health facilities

36. APPENDIX 4
36
l) Pregnancy period interventions, consisting of: focused Antenatal care (FANC); and
Prevention of Mother to Child Transmission of HIV. The goals of focused antenatal care
are to promote maternal and new-born health and survival through: Early detection and
treatment of problems and complications, Prevention of complications and diseases,
Birth preparedness and complication readiness and Health promotion.
m) Strengthening referrals: identification and capacity building of referral systems including
focal persons at community and in health facilities to effectively refer clients to the
appropriate level of health facility.
n) Adolescent/Pre-pregnancy intervention consisting of: Family Planning services;
prevention of unsafe abortion and post abortion care; prevention and management of
sexually transmitted infections; and prevention of cancer of the cervix.
o) Prevention of Mother-To-Child Transmission (PMTCT) of HIV: Nigeria accounts for
about 30% of Global burden of mother to child transmission of HIV. The risk of
transmission of HIV through heterosexual means is higher during pregnancy. HIV can
be transmitted to the unborn child during pregnancy, labour and delivery and through
breastfeeding. ARV prophylaxis, provided during pregnancy and post natal period
through breastfeeding in accordance with the recent WHO guidelines can reduce
transmission below 5% and accelerate virtual elimination of mother to child transmission
of HIV. Nigeria has an elimination plan for mother to child transmission of HIV.
p) Prevention of Cancer of the Cervix. Cancer of the cervix is the commonest cancer and
the leading cause of cancer mortality among women in developing countries. About
270,000 women die from cancer of the cervix annually, 85% of which occurs in resource
poor settings due to – late diagnosis and presentation in advance stages of the disease. In
Nigeria – WHO has estimated that about 14, 550 new cases occur in 2008, 8 out of 10
presenting with an advanced disease and with mortality rate of about 23%. It is believed
that HPV types 16 &18 are responsible for most cases in Nigeria as in other countries
worldwide. Other risk factors may include: Tobacco use, lack of screening and adequate
treatment of precancerous lesions and Human Papilloma Virus and Human
immunodeficiency Virus (HIV) co-infection. The National cervical cancer control policy
centered on Public Health approach employs a combination of vaccination, education,
screening, treatment and linkages with other programmes. Primary prevention include
the use of Bivalent Vaccine which acts against genotypes 16 and 18 - Cervarix –GSK and
is recommended for ages 9-15 years and this delivered through School; Health Centre;
and community outreach programmes. Secondary Prevention consists of screening for
pre-cancerous lesions and early diagnosis followed by adequate treatment; and Visual
Inspection with Acetic Acid/Lugol‘s Iodine- VIA/VILI. Over 1000 service providers
(Doctors and Midwives) have been trained on VIA/VILI. The focus is to integrate VIA
into SRH and HIV services at PHCs level
q) Intrapartum (Delivery) care intervention, consisting of access and use of skilled birth
attendants, Emergency Obstetric and Neonatal care, and Referral.
r) Postnatal Care interventions, consisting of: Family planning; Prevention and
management of post-partum sepsis and anaemia. A large proportion of maternal and
neonatal deaths occur during the first 24 hours after delivery. Thus, prompt postnatal
care is important for both the mother and the child to treat complications arising from
the delivery, as well as to provide the mother with important information on how to care

37. APPENDIX 4
37
for herself and her child. It is recommended that all women receive a health check within
three days of giving birth. According to NDHS 2008, 56% of women did not receive
postnatal care up to 6 weeks after delivery. This intervention needs to be scaled up to
avert maternal death occurring during the first 24 hours.
s) Improving access to health facilities for women and children in the community by
training volunteer drivers to transport them to health facilities during emergencies (the
Emergency Transport Scheme).
t) Developing, and distributing of service delivery protocols and job aids to health facilities
and training of health workers to manage MNCH conditions according to standard
protocols.
u) Setting up and building the capacity of Facility Health Committees (FHCs) to hold health
facilities accountable to deliver quality care to the community and to participate in
improving community response to the facility needs and care seeking. The members of
these committees include community members and health providers.
v) Midwives Service Scheme: Deplored 2,488 midwives with 2323 retained as at April 2010.
Seen as excellent initiative which promises good impact if kept on track.
w) Community Health Insurance Scheme: An excellent initiative targeting women and
children and removing financial barriers to demand and utilization of health services.
x) Bi-annual Maternal, Newborn and Child Health Week(MNCHW) all over the country to
improve coverage of selected high impact interventions and promote key MNCH
household and community practices.
54. As illustrated in the chart below current coverage for all high impact interventions fall short
of expected levels. With the exception of the South-West Zone with 165/100,000 MMR,
which is below the MDG5 target of 250/100,000 MMR for Nigeria, other zones carry
substantial burden of maternal mortality. Nigeria needs to do more in ANC, Skilled Birth
Attendance, EmONC and PMTCT.
Prioritization of Key Interventions
55. Following stakeholders consultation to accelerate the achievement of MDG5, the under-
listed intervention areas have been identified as key priority areas of work for the accelerated
achievement of MDG5.
f) Family Planning
g) Skilled Birth Attendants
h) Emergency Obstetric and New-born care
i) Universal Coverage of Ante-Natal and Post-Natal care
j) Improved Referral System

38. APPENDIX 4
38
Fig. 11
Challenges: Coverage of high impact interventions
for maternal, newborn and child health
(NDHS2008) still remains low
45%
45%
7%
10%
39%
2%
38%
38%
68%
13%
0% 10% 20% 30% 40% 50% 60% 70% 80%
ANC (at least 4)
TT2+
IPT
PMTCT mother
Skiiled Birth Attendance
Delivery by C-Section
PostNatal Care (2days)
Initiation BF 1hour
Initiation BF 1day
Excl. BF <6mths
Coverage for
universal access
Table 1: MDG 5 Focus
MDG5 Target Indicators MAF Key Intervention Area
Improve
Maternal
Health
Target 5.A:
Reduce by 3/4th
between 1990
and 2015, the
maternal
mortality ratio
1. Maternal mortality
ratio
2. Proportion of
births attended by
skilled health
personnel
Emergency Obstetric and
Newborn Care
Skilled Birth Attendant
Improving Referral System
Target 5.B:
Achieve, by
2015, universal
access to
reproductive
health
3. Contraceptive
prevalence rate
4. Adolescent birth
rate
5. Antenatal care
coverage (at least
one visit and at
least four visits)
6. Unmet need for
family planning
Family Planning
Family Planning
Focused Ante-Natal Care
Family Planning
56. Family Planning: Family planning is defined as a way of thinking or living that is voluntarily
adapted based upon knowledge, attitude and responsible decision of an individual or couples
in order to promote health and welfare of the family and thereby contributing to the socio
economic development of the country. Family Planning (FP) is one of the fundamental
pillars of safe mother hood and one of the quick wins in addressing maternal morbidity and
mortality. Studies have shown that effective FP programme will reduce maternal deaths 30%
and 20% for child deaths, currently FP utilization is low with CPR of 17.3% (MICS, 2012)
and unmet need 21.5% (MICS, 2012). FP addresses the high risks pregnancies which
constitutes about two-thirds of pregnancies.
57. Prevention of unsafe abortion and post abortion care consists of health care services, family
planning counseling and referral services offered to unmarried adolescents to prevent

39. APPENDIX 4
39
unwanted pregnancies and to a woman as a result of complication arising from an induced or
spontaneous abortion which could be inevitable, incomplete or septic. Unsafe abortion
accounts for 11% of maternal deaths in Nigeria. In Nigeria, abortion is legally restricted to
life threatening conditions affecting the mother. Approximately 610,000 abortions occur
annually and 80% of patients with abortion complications are adolescents. Currently the
Provision of Post abortion care services are being provided only in 12 States.
58. Effective family planning plays a pivotal role in the delay of first pregnancy, child-spacing
and the prevention of sexually transmitted infections (STIs), including the Human
Immunodeficiency Virus (HIV). Delaying first pregnancy requires the provision of adequate
adolescent reproductive health information, including family planning, to all adolescents or
young adults (15–24 years), preferably prior to marriage. Nigeria has a high total fertility rate
of 5.7, with rates as high as 6.3 in the rural areas. Nigeria also has a high rate of early
marriages and a low rate of modern contraceptive use. Only 17.3% of married women report
use of modern contraceptives.Over 20% of Nigerian women have an unmet need for family
planning, 15% for spacing and 5% for limiting pregnancies. Children born too soon after a
previous birth, especially if the interval between the births is less than two years, have an
increased risk of sickness and death at an early age. Yet 8% of births are less than 18 months
apart and 24% have an interval of less than two years. Government has approved a policy on
the distribution of free contraceptive commodities in all public health facilities to
eliminate financial barrier to services, in addition to a Counterpart contribution of $3m
annually from 2011 to support the free distribution of contraceptive commodities. At the
London 2012 FP Summit commitments; Government has made a commitment to provide
additional $8.35 million annually over the next four years for a dedicated budget line item for
Life Saving UN Commission commodities. This increases Nigeria’s total commitment
for the next four years from $12 million to $45.4 million, a significant increase.
Government has further approved the integration of FP commodities in the National
Health Insurance Scheme (NHIS) package
59. Skilled Birth Attendants: The skilled-birth attendant intervention refers to the process by
which a pregnant woman and her infants are provided with adequate care during labour,
birth and the post natal period by an accredited health professional who possesses the
knowledge and a defined set of cognitive and practical skills that enable the individual to
provide safe and effective health care during childbirth to women and their infants in the
home, health center, and hospital settings. Skilled attendants include midwives, doctors, and
nurses with midwifery and life-saving skills. This definition excludes traditional birth
attendants whether trained or not (WHO, 2006). In order for this process to take place, the
skilled birth attendant must have the necessary skills on Expanded Life Saving Skills
(Doctors), Life Saving Skills (Midwives) and Modified Life Saving Skills (CHEWS) and must
be supported by an enabling environment at various levels of the health care system,
including a supportive policy and regulatory framework, adequate supplies, equipment and
infrastructure. Emergency Obstetric and Newborn Care services ensure that care is provided
by skilled birth attendants to pregnant women with obstetrics complications and their
newborn. Generally, 85% of women will have safe delivery without complication with only
15% experiencing obstetric complications and it is this that contributes to the high maternal
mortality ratio. According to W.H.O, Emergency Obstetric care can be divided into Basic
and Comprehensive Emergency Obstetric care. The six Basic Emergency Obstetric Care
service functions to be provided at the PHCs includes: Administer parenteral antibiotics;
Administer uterotonic drugs (i.e. parenteral oxytocin); Administer parenteral anticonvulsants
for preeclampsia and eclampsia (Magnesium sulphate); Manual removal of placenta; removal
of retained products (e.g. manual vacuum aspiration, dilation and curettage); perform assisted

40. APPENDIX 4
40
vaginal delivery (e.g. vacuum extraction, forceps delivery). And in addition to the 6 functions
of Basic Emergency Obstetric Care, Comprehensive Emergency Obstetric Care services are
to: perform surgery e.g. Caesarean section; and perform blood transfusion services.
Currently, there is no data in NDHS 2008 that capture the % of facilities providing Basic and
Comprehensive Emergency obstetric services.
60. The Midwives Service Scheme (MSS) represents, to date, the most visible response, from
Government, to address the issue of putting skilled birth-attendants to the reach of pregnant
women. The innovation was launched in 2009 to reduce the high rates of maternal and child
mortality. Significant changes have become apparent since launching the scheme with
attendant challenges. Within the programme, key health systems issues are also being
addressed such as the availability of essential health care commodities in addition to the
redistribution of skilled human resources to remote rural areas, addressing some of the
inequities in the health system.
61. The MSS specifically addresses the human resource needs for SBAs in rural primary care,
based on the evidence that when the number of skilled-birth-attendants (SBAs) increases,
utilisation of services increases, women‘s satisfaction with care improves, and maternal and
newborn mortality decrease.
62. The MSS engages three categories of midwives: the newly graduated, the unemployed and
the retired but able. They are posted for one year (renewable subject to satisfactory
performance) to selected primary healthcare centres (PHCs) in rural communities. The
scheme is the largest of its kind on the continent of Africa; increasing the coverage of skilled
birth attendants (SBAs) through the recruitment of 4,000 midwives and 1000 community
health workers as frontline workers, for the provision of MNCH services including family
planning. The scheme is being further expanded with additional 3,426 Midwives/CHEWs
under the 2012 Subsidy Reinvestment and Empowerment Program (SURE-P) of the Federal
Government
63. The scheme has encountered several challenges whilst making good progress towards
achieving its objectives.Currently there is the need to fill existing gaps with midwives
particularly in the North East and North West zones and this is mainly because of the
inadequate production of midwives by the two zones and the recent security challenges in
these zones. The specific objectives of the scheme remains:
a) To increase the proportion of primary health care facilities manned by midwives offering
24Hr service by 80% in MSS target areas by December 2015.
b) To ensure that all midwives recruited under MSS are trained on Life Saving Skills (LSS).
c) To increase the proportion of primary health care facilities providing Basic Emergency
Obstetric and Newborn Care (BEmONC) in MSS target areas by 60% by December
2015.
d) To increase the proportion of pregnant women receiving focussed antenatal care in MSS
facilities by 80% by December 2015.
e) To increase the proportion of deliveries attended to by Skilled Birth Attendants in MSS
target areas by 72.6% by December 2015.
f) To increase Family Planning attendance in MSS target areas by 50% by 2015.
g) To reduce Maternal, Newborn and Child mortality by 60% in the MSS target areas by
December 2015.

41. APPENDIX 4
41
64. Operationally, the MSS adopts a ―Cluster Model‖ or a ―Hub and Spoke‖ structure wherein
four (4) selected primary health centres with the capacity to provide Basic Emergency
Obstetric Care (BEmOC) are clustered around a General Hospital with the capacity to
provide Comprehensive Emergency Obstetric Care (CEOC) which serves as the referral
facility. Presently there are 250 Clusters comprising 1000 PHCs and 250 General hospitals.
This needs to be considerably scaled up.
Fig. 12 MSS Cluster Model
65. Each of the PHC facility within the Cluster has a compliment of four (4) midwives for 24
hour coverage. The midwives and community health workers (CHWs) provide facility and
community based maternal, newborn and child health services including outreaches in rural
hard to reach areas. In the existing MSS response, the CHWs are deployed to the North
East, North West zones and some hard to reach facilities in the North Central zone where
the mortality burden is highest. This is to compliment the services of the midwives in the
communities.
66. As an intervention, the MSS has made tremendous progress since inception and is now
beginning to show benefits to the women and families in rural communities in Nigeria. The
MSS has:
a) engendered a better nationwide coordinated response, resulting in the Governors of the
36 States and the FCT signing a Memorandum of Understanding (MOU) with the
Federal Government to support and sustain the MSS by providing accommodation and
supplementing the allowances paid to the midwives in the scheme; the scheme has begun
to share its successes and challenges with states across the country and encouraging them
to replicate the scheme in other rural PHC facilities. This will enable sustainability and
coverage of the scheme‘s services to communities in rural areas;
b) fostered the emergence of viable Ward Development Committees established around all
MSS facilities for the purpose of engendering community participation and ownership
which is an important component of the Scheme. The committees also have the
responsibility of monitoring the presence of the midwives in the communities, providing
them with accommodation, security and an enabling environment to provide services for
their communities.
c) resulted in the provisioning of essential commodities as incentives to pregnant women
and supports the smooth running of facilities. These include the provision of; Mama kits,

42. APPENDIX 4
42
Midwifery kits, Drugs, basic equipment like ―Blood Pressure‖ apparatus, Stethoscopes,
weighing scales, facility/community registers, protocols and service guidelines to all PHC
facilities under the Scheme. For example, 588,000 doses of Misoprostol tablets with
other relevant materials were distributed to all MSS facilities nationwide. This ensured
availability of the drug in MSS facilities
d) piloted the use of ICT innovation in 160 MSS PHC facilities and 40 referral General
hospitals connected with ICT facilities such as voice over rural telephony, data
transmission and internet/video conferencing and remote training and mentoring. In
addition the scheme utilizes a mobile health technology called ―Mobile Application Data
Exchange System‖ (MADEX) for the collection of data from rural MSS facilities and
onward transmission to a central place for collation, analyses and reporting.
e) resulted in quarterly cluster monitoring of the MSS facilities and midwives/community
health workers and biannual Integrated Supportive Supervision (ISS) to mentor and
support the midwives in the field.
f) trained 4000 Midwives on Emergency Life Saving Skills to enhance the quality of care
provided to the communities.
g) conducted Expanded Life Saving Skills (ELSS) for Medical Officers from the designated
referral General Hospitals in the 36 States and the FCT to strengthen their capacity on
comprehensive emergency obstetric care.
h) engaged 1000 CHWs and trained them on Essential basic obstetric and new born care.
They have been deployed to rural and hard to reach communities in the North East,
North West and part of the North Central zones. All trainings were done in partnership
with the Schools of Midwifery and Health Technology in the 36 States and Federal
Capital Territory (FCT) of Nigeria.
i) trained Ninety Four Tutors from thirty seven Schools of Midwifery nationwide on the
use of Misoprostol. The TOT was followed by the training of Midwives from 1,000 MSS
facilities to enhance the effective management of postpartum haemorrhage at the
Community and PHC levels using Misoprostol.
j) provided TOT on Quality improvement for One Hundred and Sixty One Midwife
Tutors from the 37 schools of Midwifery with the following outcomes; establishment of
critical mass of Quality Improvement Trainers nationwide, strengthen institutions on QI
with its multiplying effect, QI champions were established nationwide and facilitation
skills of participants were sharpened.
k) trained one thousand officer‘s in-charge and four thousand Midwives from the 1000 MSS
facilities on Quality Improvement to improve quality of service delivery at the facility
level. Each facility currently has a functional Quality improvement team in place.

43. APPENDIX 4
43
l) introduced routine Maternal Death Review or Audit (MDR) in MSS
facilities/communities. The exercise was designed to determine the root causes of
maternal mortality in a supportive environment, provide evidence for local decision-
making on the appropriate interventions needed to reduce maternal mortality
67. MSS Outcomes: Availableinformation from MSS facilities by December 2012, when
compared to the baseline data (December 2009) before the scheme started, provides
evidence on progress towards achieving the objectives of the Midwives Service Scheme. The
outcomes confirm significant improvements in the core indicators as compared to baseline
data.
Fig. 13: Overview of MSS Progress
* Maternal deaths is
compared for 2011
and 2012
Summary of the progress Midwives Service Scheme has delivered
within three years of implementation
+150%
+104%
ANC attendance
Deliveries
Family Planning
attendance
Maternal Deaths
Neonatal Deaths
-19%
-5%
+234%
20122009
240489
489834
27877 69641
316 257
281 267
24816 72995
68. The MSS remains a strategic intervention because of the recognition that improving the skills
of birth-attendants in areas with the greatest need is achievable within a short period.The
strategic redistribution of these health workers potentially serves as a model??? effective,
realistic and efficient response. It can be adopted to suit the local situation to ensure
successful implementation. Some of these include the signing of a Memorandum of
Understanding (MoU) with all State Governors detailing their responsibilities and the setting
up of Ward Development Committees where each of the 1000 MSS facilities is located.
Benefits of the scheme also include raising awareness on the utilization of skilled birth
attendants at delivery, as a human resource intervention. It has created platform for effective
implementation of other health interventions particularly at the rural areas. In addition, the
scheme adopted the approach of task shifting in areas where there are issues of retention of
the midwives by engaging Community Health Workers (CHW) resident in these areas to
overcome these challenges. The scheme has also fostered partnership, working with states
and local governments as well as Development Partners to ensure synergy in
implementation.
Emergency Obstetric and New-born care (EmONC)
69. Globally, 15% of all pregnant women develop obstetric complications, most of which are
unpredictable. Services for emergency care must therefore be available in order to prevent

44. APPENDIX 4
44
maternal and/or neonatal death and disability. Certain critical services, or signal functions,
have been identified as essential for the treatment of obstetric complications to reduce
maternal deaths. These signal functions provide a basis for assessing, training, equipping, and
monitoring obstetric services.
70. A Basic EmOC (BEmOC) facility can administer parenteral antibiotics, oxytocics and
anticonvulsants. It can perform manual removal of the placenta and retained products and
perform assisted childbirth. A Comprehensive EmOC (CEmOC) facility, in contrast, can
perform all BEmOC functions in addition to performing surgery (e.g., caesarean section) and
safe blood transfusions. The Nigerian BEmOC standard includes two additional signal
functions in the guideline: 24-hour service coverage and a minimum of four midwives per
facility. Neonatal resuscitation has been incorporated as a signal function to save newborn
lives for basic and comprehensive care at the global level as an additional signal function
which explains the renaming as basic and comprehensive EmONC.
71. WHO recommends that for every 500,000 population, the minimum acceptable level is five
EmOC facilities, at least one of which provides comprehensive care. According to the
FMOH/UNFPA EmOC survey in 2003, only Lagos state met the standard of four BEmOC
facilities per 500,000 people, combining both public and private healthcare providers. Just
seven states met the standard of one CEmOC facility per 500,000 people, considering public
facilities alone. In all states surveyed, a higher proportion of private facilities met the EmOC
standard compared with public health facilities, but both fell below the recommended
EmOC levels.Many facilities in Nigeria do not meet the national staffing standard for
BEmOC. While all tertiary facilities in 12 surveyed states provide 24-hour coverage, only
90% of secondary facilities provide the same service. Not only is there almost no 24-hour
coverage in primary healthcare (PHC) facilities, which are often the closest facilities for
pregnant women, but many do not have a qualified midwife present. One survey found that
in all of Nigeria, only one PHC facility (in Lagos state) met the national BEmOC standard of
a minimum of four midwives per facility with 24-hour service coverage. Many health facilities
generally lack adequate material resources, as well as basic infrastructure such as water and
electricity. This has a significant impact on health facilities‘ ability to offer quality obstetric
care. As one primary healthcare worker in the EmOC survey stated, ―There is a lack of drugs
and equipment, no suction machine, no water, no power supply. We deliver babies using
light from lanterns and candles, and also do vaginal exams with them as well. The same
EmOC survey shows that 21% of secondary health facilities and most primary healthcare
centres have no functional equipment to take blood pressure measurement in their labour
wards. The preceding situation obtained before the launching of the MSS programme in
2009.
72. The estimated proportion of women who will experience complications requiring a caesarean
section is between 5% and 15%. The prevalence of women who give birth by caesarean
section can serve as an indicator of whether EmOC facilities meet women‘s needs when they
present with obstetric emergencies. While a high caesarean section rate can also reflect poor
services, Nigeria does not meet even the low threshold, as just about 2% of babies are
delivered using this procedure and some zones recording coverage as low as 0.4%.
Universal Coverage of Ante-Natal and Post-Natal care
73. Women are advised to attend at least four antenatal visits, during which they should receive
evidence-based examinations and screenings. These services are offered through a package
referred to as focused ANC. The purpose of focused ANC is to provide better care for