Our principal findings are that early intensive efforts to improve family planning, accompanied by a systematic stepwise scale-up of intrapartum and emergency obstetrical care, could reduce maternal deaths by 75%. Recognizing that a model-based analysis is only as accurate as the quality of the data that are available, and that our data limitations were formidable, there are qualitative insights that appear robust.
First, reducing the unmet need for contraception is the most effective and cost-effective single intervention for reducing maternal deaths in the short term. By simply meeting the total demand for contraception, over 6,500 maternal deaths could be averted each year nationwide. Furthermore, it is cost saving in the Southwest zone (over $18 million in cost-savings), and can provide funds that could be channeled to other zones with greater health needs. This strategy would also prevent 1 in 5 deaths from unsafe abortion
Second, there is a threshold above which further reductions in mortality from sole use of contraception are not possible; integrated interventions that couple family planning with reliable access to high-quality intrapartum and emergency obstetrical care are necessary to cross this threshold. Third, even allowing for considerable variation in the pace that would be feasible to scale up maternal health services, strategies that do so by systematically making stepwise improvements in family planning, safe abortion and intrapartum care will be more effective and efficient in the long-run than solely focusing on any one of these alone. A strategy that involved phasic and concurrent improvements in the availability and standard of EmOC facilities, referral systems, access to skilled birth attendants, facility deliveries, availability and use modern contraceptives and access to safe abortion services could prevent three to four out of five maternal deaths. This strategy had cost-effectiveness ratios that were a fraction of Nigeria’s per capita GDP
While our analysis is intended to catalyze actionable steps, we recognize that decisions in Nigeria will involve a number of choices on how to proceed with investments to improve maternal health. Since specific approaches will need to be designed to be contextually appropriate for specific settings, we provide generalized results in a matrix (Table
) that allows policy makers to obtain insight into the predicted benefits expected with a variety of different approaches.
Limitations related to data quality and availability for informing the natural history parameters in addition to the assumptions used to build the underlying model structure have previously been discussed
]. Data limitations specific to Nigeria are detailed in the Additional file
. In addition, data were limited for the frequency of unsafe abortion, and estimates of unmet need were based on survey data reflecting women’s desires now, and not in the future. Additionally, data that were available and obtained from previous studies, such as many of the government-sponsored surveys
] each have their own limitations. While these data may be limited in quality, they represent the best information available now. Additionally, the cost inputs are estimates of total cost, and are agnostic about who bears the cost. However, our analysis is from a societal perspective aimed at estimating the total economic (opportunity) cost for the society. The cost outputs represent costs incurred for a cohort (which can also be expressed on a ‘per woman’ basis) over the lifetime of the cohort.
We emphasize that the purpose of this analysis was not to provide precise estimates, but to provide qualitative insight into decisions that will need to be made well before better data become available, and acknowledge the necessity for repeated studies as better data become available. We also acknowledge that other interventions, outside of those included in this analysis, are likely to have major benefits on maternal health through indirect effects (e.g. enactment of policies that improve nutrition and agriculture, education, transportation and road networks, security, and equal rights and opportunities). Albeit outside the health sector, these are critical considerations adjacent to our findings.