Challenges in reducing maternal and neonatal mortality in Niger: an in-depth case study

Abstract

Introduction: Recent modelled estimates suggest that Niger made progress in maternal mortality since 2000. However, neonatal mortality has not declined since 2012 and maternal mortality estimates were based on limited data. We researched the drivers of progress and challenges.

Methods: We reviewed two decades of health policies, analysed mortality trends from United Nations data and six national household surveys between 1998 and 2021 and assessed coverage and inequalities of maternal and newborn health indicators. Quality of care was evaluated from health facility surveys in 2015 and 2019 and emergency obstetric assessments in 2011 and 2017. We determined the impact of intervention coverage on maternal and neonatal lives saved between 2000 and 2020. We interviewed 31 key informants to understand the factors underpinning policy implementation.

Results: Empirical maternal mortality ratio declined from 709 to 520 per 100 000 live births during 2000-2011, while neonatal mortality rate declined from 46 to 23 per 1000 live births during 2000-2012 then increased to 43 in 2018. Inequalities in neonatal mortality were reduced across socioeconomic and demographic strata. Key maternal and newborn health indicators improved over 2000-2012, except for caesarean sections, although the overall levels were low. Interventions delivered during childbirth saved most maternal and newborn lives. Progress came from health centre expansion, emergency care and the 2006 fee exemptions policy. During the past decade, challenges included expansion of emergency care, continued high fertility, security issues, financing and health workforce. Social determinants saw minimal change.

Conclusions: Niger reduced maternal and neonatal mortality during 2000-2012, but progress has stalled. Further reductions require strategies targeting comprehensive care, referrals, quality of care, fertility reduction, social determinants and improved security nationwide.

Keywords: Child health; Health policies and all other topics; Health systems; Maternal health; Public Health.

Figure 1. Trends in neonatal mortality rate (NMR) (A) and maternal (pregnancy-related) mortality ratio (MMR) (B) in Niger, estimates from national household surveys. DHS, Demographic and Health Survey; ENISED, Etude Nationale d’Evaluation d’Indicateurs Socioeconomiques et Demographiques.

Figure 2. Inequality trends in neonatal mortality rate in Niger, 2000–2017 (5-year period).

Figure 3. Coverage trends in maternal (A) and newborn (B) health (MNH) indicators; Demographic and Health Survey (DHS) 1998, 2012 and ENAFEME 2021 surveys. mDFPS: Demand for family planning satisfied by modern contraceptive methods (modem methods indude pills, condoms (male and female), intrauterine deviœe, sterilization (male andfemale), injectables, implant, diaphragm, spermicidal agents, patch and emergency contraception); ANC1+: One or more visits of antenatal care; ANC4+: Four or more visits of antenatal care; ideliv: Birthoccurred at a health institution/health facility; PNC-mom: women received a postnatal check-up within two days post-delivery; SBA: skilled birth attendant; csection: œsarean section; EBF: Infants less thanone month of age reœived only breastmilk in the previous 24 hours; TT: baby was born protected from tetanus toxoid infection; Early BF: Baby was breastfed in the first hour after delivery; PNC-baby: Babyreceived a postnatal check-up within two days post-delivery

Figure 4. Neonatal lives saved by interventions, groups of interventions by the continuum of care and facility types. Estimations obtained using the Lives Saved Tool (LiST) model. BEmOC, basic emergency obstetric care; CEmOC, comprehensive emergency obstetric care. PROM, Premature rupture of membranes.

Figure 5. Maternal lives saved by interventions, groups of interventions by the continuum of care and facility types. Estimations obtained using the Lives Saved Tool (LiST) model. BEmOC, basic emergency obstetric care; CEmOC, comprehensive emergency obstetric care. PROM, Premature rupture of membranes.

Figure 6. Key maternal and newborn policies and programmes timeline in Niger. C-IMCI, community-based integrated management of childhood illness; C-section, caesarean section; HRH, human resources for health; MDG, Millennium Development Goals; SDG, Sustainable Development Goals; UHC, universal health coverage. CARMMA, Accelerated Campaign to Reduce Maternal Mortality