This document summarizes the key points from an analysis of accelerating progress on MDG 5 in Nigeria using the MDGs Acceleration Framework. It provides justifications for selecting MDG 5, including its importance to the government's agenda and addressing disparities across zones. Key data on Nigeria's maternal mortality ratio, causes of maternal death, and coverage of interventions is presented. The analysis identified five priority interventions within MDG 5: family planning, skilled birth attendants, emergency obstetric and newborn care, universal antenatal and postnatal care coverage, and an improved referral system. Bottlenecks within these areas were also identified.

1. APPENDIX 3
1
Acceleration Analysis for MDG 5:
Justifications for Priority& Key Points from
the MDGs Acceleration Framework Analysis
Office of the Senior Special Assistant to the President on Millennium
Development Goals
March 2013

2. APPENDIX 3
2
Introduction
In March a national stakeholder technical reviewwas held to assessthe efficiency of
current maternal health care policy. This was part of the implementation of the MDGs
Acceleration Framework (MAF) for MDG 5. The stakeholder review identified and
costed a number of key acceleration solutions across a five-year period. Stakeholders
were drawn from all levels of society relevant to the execution of policy relating to
maternal healthcare. This summary note highlights key motivating factors in the
selection of MDG 5 as the first of the MDGs to fed through the MAF process, and
also summarizes the key outcomes of the technical review process.
Wider Importance of MDG 5: Maternal Health Care
USAID estimates that maternal and newborn deaths cost the world $15 billion in lost
productivity.Evidence demonstrates that healthy women and girls can help their
families endure the global financial crisis. For example, the World Bank found that
during the economic crisis, poor families who sent women to work were less likely to
take on sustained debt. In Bangladesh, research shows that poor households with
maternal health complications spend 30% - 40% of their savings to cover expenses,
compared to only 8% for the richest quintile.
“When families incur this crushing debt, they sometimes sell off their daughters, and
the social consequences of this cannot be left out of the equation.”
– Mary Stanton (Senior Maternal Health Advisor USAID)
The Saving One Million Lives Initiative (2012) estimates 33,000 women are
estimated to die from pregnancy-related causes.Using estimates developed by the
WHO in an econometric analysis (2006) of the impact of MMR on per capita GDP in
Africa, one can loosely estimate that achieving the target for MDG 5 would add
$3,394.11 to per capita GDP in Nigeria across certain time horizons. It should be
noted that there are potential issues with the specification of the econometric model.
However, the overarching point is that the achievement of this target is likely to have
considerable economic effects, both directly through the channel of preventing

3. APPENDIX 3
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maternal death and increasing infrastructure and technical capacity which will have
supplementary positive effects.
Snapshot of Performance of the Maternal Mortality Ratio
Good progress has been made in this area. 2012 data shows that Nigeria is now 28%
away from this MDG target with Maternal Mortality down from the 1990 base of
1,000 deaths per 100,000 live births, to 350.
However 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. Similarly, skilled birth attendance improved
from 38.9% in 2008 to 53.6% in 2012, still far short of the target of 100% by
2015. The proportion of pregnant mothers attending antenatal care at least four
times has improved from 44.8% in 2008 to 57.6% in 2012, but still short of the
target of 100% by 2015. There is however lack of progress regarding ‘unmet need
for family planning’, as the indicator has barely improved from 20.6% in 2008 to
21.5% in 2012. Moreover, more than two-thirds of maternal deaths occur during
childbirth, and are closely linked to intrapartum stillbirths and early neonatal
deaths.
800
545
350
250
2004 2008 2012 2015
EstimateofDeathsper100,000Live
Births
Maternal Mortality Rate (per 100,000 live births)

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4
There are sharp disparities in maternal health between subnational units
(geopolitical zones and states) and there is a significant rural urban divide. For
example (data from the 2008 NDHS) urban maternal mortality estimates are
351/100,000 live births, where as rural estimates are 828/100,000. Maternal
mortality estimates in the North East zone are 1549/100,000 live births, compared
with 165/100,000 in the South West zone. In order for Nigeria to succeed in
achieving Goal 5 by 2015 a concerted effort is required to mitigate this growing in
country divergence. A related dimension of the inequality of access to maternal
healthcare services between the wealthiest quintile and poorest quintile; for
example, the difference in access to skilled birth attendance at delivery between
wealthiest quintile and poorest quintile is almost eight fold. Similarly, the
difference in full immunization coverage between the wealthiest and poorest
quintiles is almost 10-fold. Coverage of key interventions is low, quality of care is
inadequate, and most basic services do not reach the poorest segments.
Maternal health is strongly linked to other MDGs like child health, gender
equality, to poverty reduction and partially to education. Whilst maternal deaths
are rare statistical phenomena, the family impact is devastating and this has wider
community effects. The very fact that maternal deaths are rare makes impacting
them more difficult. Therefore the virtue of targeting this Goal is that there will be
knock on effects through the other health goals, for instance increasing the number
of skilled birth attendants present at birth requires that there are a greater numbers
of health personnel in rural areas.
Figure 1, using UNICEF 2008 data, demonstrates that compared to the next five
largest economies by GDP in Sub-Saharan Africa, Nigeria is doing worst with
regard to Maternal Mortality Ratios.

5. APPENDIX 3
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Figure 1
Figure 2 demonstrates the comparison of progress across Maternal, Infant and
Child Mortality. This shows that since 2003 the trend in both MDG 5 and 4 has
been positive. Figure 3 shows that the rate of progress in the reduction of Maternal
Mortality and Child Mortality is on track to meet the 2015 deadline, whilst the rate
of progress for Infant Mortality has slowed and is not on track to meet the target.
0
100
200
300
400
500
600
700
800
900
Ghana Ethiopia Kenya Sudan Nigeria
Comparative UNICEF 2008 Maternal
Mortality Ratios

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Figure 2
Figure 3
Maternal Infant Child
1,000
91
191
800
100
201
545
75
157
350
61
94
250
30
64
Rates, Maternal per 100,000 Live Births, Infant &
Child per 1,000 Live Births
1990 2003 2008 2012 Target 2015
20.00%
-9.89% -5.24%
31.88%
25.00%
21.89%
35.78%
18.67%
40.13%
28.57%
50.82%
31.91%
% Change From Previous Survey
2003 2008 2012 Target 2015

7. APPENDIX 3
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As illustrated in Figure 4, the major causes of maternal deaths are: haemorrhage;
infection; malaria; toxemia/eclampsia; obstructed labour; anaemia; and unsafe
abortion.
Figure 4
Skilled attendance at birth (see Figure 5 for aggregate 2012 data; disaggregated
data will be available in April 2013) continues to have considerable disparities
within country, 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 delivery 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

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performed under unsafe conditions, with an estimated 40% performed in privately
owned health facilities.
Figure 5
There has continued to be an increase in access to safe, affordable and effective
methods of contraception, which is providing individuals with greater choice and
opportunities for responsible decision-making in reproductive matters.
Contraceptive use contributes to improvements in maternal and infant health by
serving to prevent unintended or closely spaced pregnancies. Figure 6
demonstrates the trend. There is need for improvement given that various unmet
family planning needs have progressively risen since 2004 – particularly in the
rural areas where awareness is relatively low.
0
10
20
30
40
50
60
70
80
90
100
2004 2008 2012 2015
36.3 38.9
53.6
100
Proportion of birth attended by skilled health personnel (%)

9. APPENDIX 3
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Figure 6
Antenatal care coverage is among the health interventions capable of reducing
maternal morbidity. Coverage (at least one visit) with a skilled health worker
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 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 7). However, this 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 56.5 per cent for at least one visit and 47.7 per cent for four visits (2008 data,
2012 disaggregation to be released in April 2013.
0
2
4
6
8
10
12
14
16
18
2004 2008 2012
8.2
14.6
17.3
Contraceptive prevalence rate (%)

10. APPENDIX 3
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Figure 7
The unmet need for family planning remains persistently high. In 2004, the figure was
17 per cent, while the 2008 figure was 20.2 per cent, the rate of progress fell further
with the increase to 21.5 per cent in 2012 (Figure 9).
Figure 9
0
10
20
30
40
50
60
70
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)

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Summary of Justifications
There are a number of key justifications for the selection of MDG 5 for acceleration
analysis. These justifications have been extracted verbatim from the proposals:
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.
0
5
10
15
20
25
2004 2008 2012
17
20.2
21.5
Unmet need for family planning (%)

12. APPENDIX 3
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b) The choice of MDG 5 for MDGs Acceleration Framework 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 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

13. APPENDIX 3
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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.
Key Points from the MAF Document
Prioritization of Key Interventions Within MDG 5

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Through the consultation process, five key priority areas have been identified from a
list of twenty-plus major interventions:
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
Bottleneck Analysis and Prioritization
Within these areas policy bottlenecks were identified. Sector-specific bottlenecks are
contained within the particular Federal, State Ministry or relevant Local Government
Department. Cross-cutting bottlenecks are inter-sectoral and economy-wide problems
that affect the implementation of the MDG 5 interventions.
Acceleration Solutions
From this analysis acceleration solutions were proposed for each of the five
prioritized intervention areas.These range from public education, retraining of birth
attendants (in particular traditional birth attendants), decentralizing ambulance usage,
maintenance of equipment, and engagement with civil society. See the MAF
document for further details.
The Budget
It is estimated that the acceleration solutions and constituent activities would cost N65
billion across a five-year period (see Table 1 for an outline, and the MAF document
for details, costed by OSSAP-MDGs procurement staff and health personnel). By far
the most costly intervention is the provision of skilled birth attendants.

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In 2013 OSSAP-MDGsshall spend N29.5 billion oninterventions that will have some
impact on maternal health care. This plan represents a 46% increase in maternal
health related expenditure within the 2013 budget.
Table 1
2013 2014 2015 2016 2017
Family Planning 2.63 0.49 0.47 0.47 0.21 4.28
Skilled Birth Attendants 6.35 9.22 11.10 12.40 10.23 49.32
Emergency Obstetric and New-
Born Care
1.71 0.89 1.06 0.24 0.05 3.97
Universal Coverage of Ante-Natal
and Post-Natal Care
2.34 1.02 1.89 1.35 0.39 6.30
Improved Referral System 0.37 0.19 0.19 0.20 0.02 0.99
Grand Total 13.54 11.96 14.16 14.81 11.04 65.52
Acceleration Solutions
Timeline and Annual Cost
Total Cost
N.B. Units in billions of Naira