A few years ago, we were dismayed to learn that one in five mothers in Nigeria, the world’s seventh largest country in terms of population size, gave birth completely alone, with no one present. As parents and public-health researchers, we know that even in the best of circumstances, labor and delivery are fraught with anxiety and uncertainty. Skilled care at delivery is a basic human right that still eludes too many women and newborns in sub-Saharan Africa and south Asia. It is often the difference between life and death.
The phenomenon of women delivering alone, with its devastating consequences for mothers, newborns and families, has simply not made it on to the radar of researchers or policymakers. For example, a senior government official responsible for the health of 5 million people in one state in Nigeria was genuinely shocked to learn that one in three deliveries in his own state occurred with no one present. He was not the only one out of touch with his community.
When women deliver alone, preventable conditions such as postpartum bleeding, obstruction of labor and a newborn’s failure to breathe because his or her nostrils are blocked by mucus, rapidly become life-threatening to the mother, child or both. It means that a large proportion of mothers and babies likely die needlessly or suffer long-term complications that were preventable.
Furthermore, the impact of delivering alone does not end at birth. These mothers are also less likely to initiate exclusive breastfeeding, to seek skilled care for sick children and to utilize family planning to space out future births. Delivering alone adversely impacts women’s – and their families’ – health throughout their lifetimes.
Since we found no published accounts of this predicament anywhere, we explored the situation in Nigeria as a test casethrough the United States Agency for International Development (USAID)-funded Targeted States High Impact Project, implemented by JSI Research & Training Institute, Inc. We found that women who were poor, uneducated, who lived in rural areas, were older, and had two or more children were more likely to give birth alone.
After we published the first paper, countervoices emerged and argued that the practice was driven simply by culture. This is a worrisome narrative. Framing delivery with no one present as a cultural phenomenon removes governmental responsibility for public health and well-being. It places an unfair and unrealistic burden on communities. This is neither tenable for women nor is it effective public policy. Stepping back, our assessment of the Nigeria situation lent credence to the fact that poverty is the real “cultural” issue. Families don’t have the money; governments’ policies do not translate to quality services; and women bear the immediate physical and emotional costs.
We expanded our study to 80 countries to determine the extent of the prevalence of delivering alone and the profile of women who did so. Using publicly available data from Demographic and Health Surveys, we found that 2.2 million births a year occur with no one present. This is a profoundly distressing figure. In country after country, the profile of women who deliver alone is identical: they are poor, have low levels of education, live in rural areas and are older. Such consistency in profile across 80 countries is further affirmation that extreme poverty is the main explanation for the phenomenon. Given such disparity, we were not surprised that the countries with the highest prevalence of women who delivered alone are also the ones with the highest maternal mortality rates in the world.
It is time for national governments and the global community to lead, to act on this data. Communities can begin now: awareness campaigns in areas where women deliver alone will interrupt this vicious cycle by having someone present during labor and delivery, preferably at a health facility. Governments must also scale up and deliver misoprostol, a labor medication deemed essential by the World Health Organization, to mothers to prevent postpartum bleeding in all births that still occur at home. This is a drug that costs less than one dollar – and does not require cold storage, so can be easily distributed even in the most rudimentary of health systems. But it can prevent one of the most common causes of death of mothers during and after childbirth.
Our research with women, husbands, mothers-in-law and traditional midwives in Nigeria also points to three longer-term actions governments must take to protect mothers-to-be. We must remove financial barriers to getting care and delivery services in a health facility that is staffed with skilled care providers. We must improve the quality of care available in health facilities, including providing respectful maternity care. And we must not neglect to invest in girls’ and women’s education to increase their capacity to care for themselves and pursue their human rights.
Now is time to eradicate delivering alone with no one present. Now is the time to eliminate preventable maternal and newborn deaths. It’s a human right and a moral imperative.