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Ten percent of the world’s maternal deaths occur in Nigeria, and many approaches for saving women’s lives have been tried there. Nigeria has promoted skilled birth attendance at the community level and through the media. It has worked to improve the quality of health services. Several states have begun to provide antenatal and maternity services free of charge. Ebonyi State, in Nigeria’s southeast, has passed a law that makes it illegal to allow a woman to labor for more than 10 hours without referring her to a higher level of the health care system.
The Mother and Child Care Initiative and Related Matters Law became law in June 2008 and was amended to cover maternal morbidity in September 2009. Its aim is to reduce maternal mortality and morbidity by shortening the delays that women experience in accessing the services they need. The law mandates the reporting of all maternal deaths, and it is expected that the investigation of maternal deaths will lead to improvements in the quality of care provided to pregnant women.
The first lady of Ebonyi State, Chief Josephine N. Elechi, says that the law is necessary to ensure that women receive the care they need in places where low educational levels and cultural beliefs might otherwise discourage laboring women from going to a health facility. She has organized radio broadcasts and awareness-raising activities in communities to spread the word about the new law. In an informal survey of women recovering from fistula repair, representing remote corners of the state, nearly two-thirds of the women said they had heard about the law that might prevent other women from experiencing similar birth injuries. All said that enacting the law is important and good.
The success of the new law will depend on whether the people truly have access to maternal health services. A concurrent law was written to ensure that antenatal and maternal care are free of charge to women in the state. In principle, this subsidy of maternity services is currently available at six private mission hospitals, and the Ebonyi State health commissioner planned to expand the subsidy to all state general hospitals in 2010. In practice, many women pay higher fees than they should and are often uninformed or unable to advocate for themselves. Work remains to ensure that facilities can cover their costs and that posted fees for services are respected.
Even with the availability of free services, the costs of transportation will pose a challenge to many families that are legally required to transfer long-laboring women. The state is working to make transportation more accessible, working with partners and local government area chairmen to provide motorcycles and ambulances and encouraging people to use mobile phones to get vehicles to laboring women in need. The state plans to engage the support of members of the national union of road transport workers, and it hopes that the communities themselves will maintain, protect, and fuel the vehicles put at their disposal.
The passage of the law sends a strong message about Ebonyi State’s position on the value of women’s lives, but the law’s impact will depend on its application. The law mandates the formation of monitoring committees at the state, local government, and ward levels. These committees bring together a range of stakeholders to track local maternal mortality and morbidity and communicate with the statewide monitoring body, which will collect statistics and conduct confidential inquiries as needed. The committees were initially convened in October 2009, but whether they continue meeting may depend on the provision of sitting allowances provided by the state and local governments—an important budgeting detail not yet finalized.
Already, the law is beginning to have an impact. Dr. Sunday-Adeoye and his colleague Dr. Ebenyi Hyacinth collected data from the 19 largest medical facilities in Ebyoni State, and report that maternal deaths decreased from 49 in 2006 to 13 in 2010. The number of women receiving antenatal care increased from 22,303 in 2006 to 67,623 in 2010.