Health in Action
The Midwives Service Scheme in Nigeria
Seye Abimbola1*, Ugo Okoli1, Olalekan Olubajo1, Mohammed J. Abdullahi1, Muhammad A. Pate2,3
1 National Primary Health Care Development Agency, Abuja, Nigeria, 2 Federal Ministry of Health, Abuja, Nigeria, 3 Duke Global Health Institute, Durham, North Carolina,
United States of America
Introduction
Nigeria, with more than 140 million
people, including 31 million women of
childbearing age and 28 million children
under the age of five, is by far the most
populous African country. However, the
maternal mortality ratio (MMR) in Nigeria is 545/100,000 live births, as only
one in three births in Nigeria is attended
by skilled personnel, less than 20% of
children are fully immunised at age one,
and 36% of pregnant women do not
receive antenatal care (ANC) [1]. Thus,
strengthening these services is an urgent
imperative.
Midwives Service Scheme: The
Rationale
The slow rate of progress in Nigeria
makes the Millennium Development
Goals (MDGs) targets unachievable using
current strategies alone [2]. Health indices
in Nigeria vary widely across geopolitical
zones (See Box 1) and socioeconomic
groups [3]. The northeast (NE) zone has
the highest MMR: 1,549/100,000 live
births compared to 165/100,000 live
births in the southwest (SW). There are
also urban and rural variations with MMR
of 351/100,000 live births in urban areas
compared to 828/100,000 in rural areas.
The under-5 mortality rate of 171/1,000
live births also varies between the lowest
(219/1,000 live births) and highest (87/
1,000 live births) wealth quintiles. This
pattern is replicated in other indices of
childhood mortality. Maternal, neonatal,
and child mortality rates in Nigeria are
highest in the NE and northwest (NW)
zones and lowest in the southeast (SE) and
SW [1]. However, although the rates are
lower in the SE and SW, indices in these
regions still fall short of global development targets.
These variations in health indices are
influenced by the presence of tertiary
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hospitals, social amenities, and a population that can afford to pay for health
services that in turn attract highly skilled
health workers [4]. Therefore, in much of
rural Nigeria, beyond issues of access,
there are inadequate human resources for
providing 24-hour health services in primary health care (PHC) facilities [5].
Nigeria faces a crisis in human resources
for health (HRH) in the form of health
worker shortages, requiring an immediate
and significant increase in the number of
health workers [6], or in the meantime a
strategic redistribution of health workers
to grossly underserved rural areas (See Box
2).
Efforts to better reach underserved
communities have been on task shifting
to community health workers (CHWs) [7].
While task shifting has offered a costeffective expansion of the overall HRH
pool, skilled attendance at birth is essential to reducing the burden of maternal
mortality [8]. The shortage of skilled birth
attendants in rural Nigeria impacts negatively on utilisation of services by women
in these areas [5]. Launched in December
2009 , the Midwives Service Scheme
(MSS) was set up to address the HRH
needs in rural primary care, based on the
evidence that when the number of midwives increases, utilisation of services
increases, women’s satisfaction with care
improves, and maternal and newborn
mortality decrease [8,9]. To do this, three
categories of midwives were recruited as
part of the MSS: the newly graduated, the
unemployed, and the retired. They are
posted for 1 year (renewable subject to
satisfactory performance) to selected PHCs
in rural communities.
Midwives Service Scheme: The
Structure
The facilities selected for the MSS were
linked in an effective two-way referral
system through a cluster model in which
four PHC facilities with the capacity to
provide basic essential obstetric care were
clustered around a general hospital with
the capacity to provide comprehensive
emergency obstetric care. There were 815
participating health facilities: 652 PHC
facilities and 163 general hospitals. Each
PHC facility has four midwives to ensure
24-hour provision of skilled birth attendance at all times, as well as other
maternal and child health services.
MSS Geographical Distribution
The number of facilities in each of the
six geopolitical zones was selected on the
basis of maternal mortality burden. Nigeria was divided into three zones
(Figure 1) according to MMR: very high
MMR (NE and NW), high MMR (north
central [NC] and south south [SS]), and
moderate MMR (SE and SW). NE and
NW have six clusters per state, SS and NC
have four clusters per state, and SW and
SE have three clusters per state. The
project currently serves an estimated
aggregate of 15 million people in Nigeria.
Citation: Abimbola S, Okoli U, Olubajo O, Abdullahi MJ, Pate MA (2012) The Midwives Service Scheme in
Nigeria. PLoS Med 9(5): e1001211. doi:10.1371/journal.pmed.1001211
Published May 1, 2012
Copyright: ß 2012 Abimbola et al. This is an open-access article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original author and source are credited.
Funding: No specific funding was received for writing this manuscript.
Competing Interests: The authors have declared that no competing interests exist.
Abbreviations: ANC, antenatal care; LGA, local government area; MMR, maternal mortality ratio; MNCH,
maternal, newborn and child health; MSS, Midwives Service Scheme; NC, north central; NE, northeast; NMR,
neonatal mortality ratio; NW, northwest; PHC, primary health care; SE, southeast; SS, south south; SW,
southwest; WDC, Ward Development Committee
* E-mail: seyeabimbola@hotmail.com
Provenance: Not commissioned; externally peer reviewed.
1
May 2012 | Volume 9 | Issue 5 | e1001211
Summary Points
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Maternal, newborn, and child health indices in Nigeria vary widely across
geopolitical zones and between urban and rural areas, mostly due to variations
in the availability of skilled attendance at birth.
To improve these indices, the Midwives Service Scheme (MSS) in Nigeria
engaged newly graduated, unemployed, and retired midwives to work
temporarily in rural areas.
The midwives are posted for 1 year to selected primary care facilities linked
through a cluster model in which four such facilities with the capacity to
provide basic essential obstetric care are clustered around a secondary care
facility with the capacity to provide comprehensive emergency obstetric care.
The outcome of the MSS 1 year on has been an uneven improvement in
maternal, newborn, and child health indices in the six geopolitical zones of
Nigeria.
Major challenges include retention, availability and training of midwives, and
varying levels of commitment from state and local governments across the
country, and despite the availability of skilled birth attendants at MSS facilities,
women still deliver at home in some parts of the country.
Selection of MSS Facilities
Participating PHC facilities and general
hospitals were selected based on rigorous
criteria. Selected PHC facilities are in
hard-to-reach areas or among underserved
populations with a population of 10,000 to
30,000 people. The PHC facilities have
potable water supply and offer 24-hour
basic health services with minimum equipment including blood pressure apparatus,
weighing scale, and basic laboratory
diagnostic facilities for malaria and anaemia. Selected general hospitals provide
basic services including ANC, child delivery, postnatal care, and family planning;
comprehensive emergency obstetrics care
and prevention of mother-to-child transmission of HIV (PMTCT) services; administration of antibiotics and intravenous
fluids; and treatment of pre-eclampsia.
The general hospitals have at least 12
maternity bed spaces, a functioning operating room, blood bank, and stand-by
alternative power supply.
Midwives Service Scheme: The
Process
Recruitment
The midwives under the scheme are
selected with adherence to the International
Confederation of Midwives (ICM) global
standards for midwifery education [10].
The minimum entry level of students for
midwifery education is completion of secondary education, and the minimum duration of A-Level-entry midwifery education
is 3 years and 18 months for post-nursing
midwifery education. The maximum age
limit for recruitment is 60 years. Following
an initial nationwide recruitment exercise,
2,488 (instead of the expected 2,608)
successful midwives were deployed to 652
designated PHCs in the 36 states and
Federal Capital Territory (FCT) on the
scheme—45% of them are unemployed
midwives recruited to the scheme, 44% are
basic midwives during their mandatory preregistration community service year, and
11% of them are retired midwives.
Continuing Medical Education (CME)
To enhance the quality of their services,
midwives are trained quarterly in life
saving skills (LSS) and integrated management of childhood illness (IMCI). The
competency-based training sessions are
conducted at schools of midwifery in each
state. The trainings run for 6 consecutive
days and the class size varies from 24 to 32
people. The training programme involves
interactive theoretical and illustrative lectures with skills demonstration and practical sessions. There are initial practical
sessions on dummies, then on consenting
patients in the wards towards the end of
the course. Participants partake in a course
Box 1. The Political Organisation of Nigeria
Nigeria is divided into 36 states and one Federal Capital Territory (FCT), which are
further sub-divided into 774 local government areas (LGAs). There are six
geopolitical zones in Nigeria: north central (six states and the FCT), northeast (six
states), northwest (seven states), southeast (five states), south south (six states),
and southwest (six states).
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2
review and tests to assess the effectiveness
of the training.
There are no defined entry criteria for
the CME, as recruitment into MSS is an
ongoing process to cope with the challenge
of attrition. Thus, all recruited midwives
are eligible for participation in both
training programmes.
Political, Financial, and Community
Commitment
Given the high level of fragmentation
in the governance of the Nigerian health
system (see Box 2), a crucial initiative of
the MSS programme was for state and
local governments to sign a memorandum
of understanding with the federal government agency responsible for PHC in
Nigeria, the National Primary Health
Care Development Agency (NPHCDA),
which is also the implementing agency for
MSS. The state governments are expected
to match with N20,000, the N30,000
monthly remuneration paid to the midwives by the federal government through
NPHCDA.
In addition to the monthly stipend, the
federal government provided basic health
insurance coverage for all the midwives,
provided midwifery kits for each of the
participating PHC facilities and each
midwife, and supplied a personal health
record booklet, basic maternal and child
health equipment, drugs, registers, and
monitoring tools. The federal government
funds the CME and provides technical
support to the states and local government
areas (LGAs) on the implementation,
supervision, monitoring, and evaluation
of MSS.
The state governments support the use
of general hospitals as referral facilities for
the MSS by upgrading the hospitals to
provide comprehensive emergency obstetric and newborn care, including basic
equipment and supplies such as drugs and
other consumables, ambulance services,
steady electricity and potable water supply, stationery, and security for health
workers and equipment. The state governments also monitor and supervise the
programme within their jurisdiction and
coordinate the provision by LGAs of free
decent accommodation in the host communities and at least N10,000 supplementary allowances for the midwives.
For each PHC facility, a ward development committee (WDC) made up of influential people in the community is
established to enhance community participation and ownership and to promote
demand for services. The WDCs meet
monthly to discuss health and other developmental issues in the community under
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Box 2. The Political Economy of Health Care in Nigeria
Health services in Nigeria mirror political organisation. The federal government is
responsible for tertiary care, state governments for secondary care, and the local
governments (LGs) run primary care. Health financing is tied to the flow of funds
from the federation account, which are shared between levels of government
according to an allocation formula that keeps about half of funds at the federal
level, the 36 states share a quarter, and the other quarter is distributed to the LGs.
These resources are not sectorally earmarked and the states and LGs are not
constitutionally required to provide budget and expenditure reports to the
federal government. This results in poor coordination and integration between
levels of care, giving rise to a weak and disorganised health system with widely
varying patterns of outcomes. The MSS is an unprecedented emergency stop gap
collaborative effort among the three tiers of government to improve maternal
and child health indices in rural Nigeria.
the supportive supervision of the LGAs.
During the monthly WDC meetings, the
midwives address any concerns of the community and brief the community on their
work within the month, including their
challenges. The WDCs in turn provide
support to the midwives by ensuring their
security and accommodation. While they do
not routinely provide direct financial support
for women seeking care, the WDCs support
the transportation of pregnant women and
neonates in cases of emergency. In addition
to their clinical duties, the midwives serve as
change agents in the target communities by
working with WDCs to mobilise the people
for health action and promoting women and
child health care and home visits. Training
for these roles is part of the basic midwifery
training, and the midwives are involved in
the creation of the WDCs.
Midwives Service Scheme: The
Outcome
Monitoring and Evaluation Platform
MSS implementation was preceded by
establishing key baseline maternal, newborn, and child health (MNCH) indicators to define goals and provide a clear
framework for future evaluation. There
was a nationwide survey conducted at all
the facilities (primary and secondary) and
communities where the intervention was
located. Table 1 shows the seven core
indicators of progress in the MSS, nationwide data from the Nigeria Demographic
and Health Survey (NDHS) 2008, baseline
data from the MSS primary care facilities,
and the gains that the scheme hopes to
achieve by 2015. Even though facilitybased data are expected to reflect better
indices, the baseline survey shows that
MSS target areas are worse off compared
to the national average (data from Nigerian Demographic and Health Survey
2008) even though the national data is
population based.
Impact of the MSS
Figures 2–5 show MNCH indicators for
the six zones comparing data from mid to
the end of 2009 and mid to the end of
2010. The gains of MSS have not been
even across geopolitical zones, although it
shows an overall improvement in the
MNCH indices.
The facility-based MMR in the same
period in 2010 was 572 compared to 789
per 100,000 live births for the same period
in 2009. However, facilities in the NE and
SE did not show a decrease in MMR
Figure 1. The states of Nigeria and their MMR categories. Red (northeast and northwest), very high MMR; yellow (north central and south
south), high MMR; green (southeast and southwest), moderately high MMR.
doi:10.1371/journal.pmed.1001211.g001
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Table 1. MSS core indicators and projected outcome, with data comparing 2008
NDHS with MSS facility baseline data.
MSS Core Indicators
2008 NDHS Data
MSS Baseline
5-Year Projection
PHCs with 24-h maternal health services
Not available
0%
Increase by 80%
Pregnant women with $4 ANC Visits
45%
39%
Increase to 80%
Deliveries by skilled birth attendants
39%
12%
Increase to 72.6%
Maternal mortality ratio (MMR)
545 / 100,000
789 / 100,000
Reduce by 60%
Neonatal mortality ratio (NMR)
46 / 1,000
11 / 1,000
Reduce by 60%
Family planning (FP) attendance
10.5%
1.02%
Increase to 50%
Children immunised in infancy
19.2%
20%
Increase by 60%
MSS, Midwives Service Scheme; NDHS, Nigeria Demographic and Health Survey.
doi:10.1371/journal.pmed.1001211.t001
The lack of improvement in MMR
and/or NMR in specific zones may be due
to an increase in the proportion of high
risk deliveries in the MSS PHC facilities.
As shown in Figure 4, the majority of the
women who attend facilities ANC still
deliver at home. The additional deliveries
in MSS facilities are likely to be among
women with high risk pregnancy who
present too late for life saving interventions
in pregnancy or the neonatal period. We
hope that the continued presence of skilled
birth attendants in the communities will
ensure positive behaviour change, especially in seeking early and routine interventions from the PHC facilities.
These data provide useful information on
the progress of MSS 1 year from establishment. There have been overall improvements in the provision of MNCH services in
rural areas that usually lack skilled birth
attendants such as midwives. The data also
provide a powerful tool for advocacy to
support the scheme particularly in the NE
zone where the gains have been limited.
Midwives Service Scheme: The
Challenges
N
Figure 2. MSS facility-based maternal mortality ratios comparing July–December
2009 with July–December 2010. NE, northeast; NW, northwest; NC, north central; SS, south
south; SE, southeast; SW, southwest; MSS, Midwives Service Scheme.
doi:10.1371/journal.pmed.1001211.g002
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Figure 3. MSS facility-based neonatal mortality ratio comparing July–December 2009
with July–December 2010. NE, northeast; NW, northwest; NC, north central; SS, south south;
SE, southeast; SW, southwest; MSS, Midwives Service Scheme.
doi:10.1371/journal.pmed.1001211.g003
when compared to 2009. The facilitybased neonatal mortality ratio (NMR) in
the same period in 2010 was 9.3 per 1,000
compared to 10.97 per 1,000 live births for
the same period in 2009. Facilities in the
NE, NW, and SW did not show a decrease
in NMR when compared to 2009. The
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maternal health indicators show a general
overall improvement over baseline: family
planning visits, pregnant women with new
ANC visits and those with at least four
ANC visits, facility-based deliveries, and
the number of women receiving two or
more doses of tetanus vaccine.
4
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N
The project is currently funded from the
debt relief granted to the Nigerian
government by the Paris Club. The
greatest threat to MSS is the uncertainty
about continued funding beyond the 3yearcommitment from the grant. However, the National Health Bill passed in
2011 promises to further provide secure
funds for the administration of PHC in
Nigeria [11]. The state governments are
encouraged to be fully involved in MSS
programmes, as the plan is for them to
gradually take over the scheme in their
respective states.
Implementation of the memorandum of
understanding signed with state and local
governments is a persisting problem. This
mainly involves provision of accommodation for the MSS midwives and irregular or delayed salary payment by state
and local governments. Regular monitoring of the PHC facilities and midwives
by field agents from the NPHCDA
serves to coerce the state and local governments into fulfilling their roles.
Availability of qualified midwives poses
a challenge to the success of the scheme
particularly in the areas of most need:
the NE and NW. Ongoing recruitment
and deployment of midwives to these
areas are strategies employed to overcome this problem.
Retention of midwives in the scheme is
one of the major challenges. Most of the
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Figure 4. MSS facility-based maternal health indicators comparing July–December
2009 with July–December 2010. ANC, antenatal care; TT, tetanus toxoid; FP, family planning.
doi:10.1371/journal.pmed.1001211.g004
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they provide support and complement the work of the midwives. They
are also encouraged to spend time
within the community to identify
women and children who need care
and refer appropriately. There is a
long-term plan to identify and train
locals to become midwives who will
then work within their own communities. There are also ongoing discussions around providing supervised
home delivery as part of the MSS
in order to better reach women,
especially in northern Nigeria, who
present for ANC, but choose to
deliver at home for sociocultural
reasons.
Current training of the midwives focuses mainly on LSS and IMCI. However,
there is a need to also train them on
other various critical aspects of health
care such as PMTCT, family planning,
and information and communications
technology (ICT) skills. There is also a
need for capacity building of the PHC
team beyond just midwives.
Conclusion
Figure 5. MSS facility-based maternal health indicators percentage increase from
July–December 2009 to July–December 2010. ANC, antenatal care; TT, tetanus toxoid; FP,
family planning.
doi:10.1371/journal.pmed.1001211.g005
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newly graduated midwives (44% of
MSS midwives) are young, single, or
newly married; a particularly mobile
cohort who tend to return to their home
zones (usually southern zones) after the
completion of their 1-year mandatory
pre-registration participation in the
MSS. However, another set of newly
graduated midwives replace the ones
who leave at the end of the 1-year mandatory pre-registration programme.
Inadequate social amenities, language barriers between the midwives
and the local community, and working in hard-to-reach rural areas are
some of the factors responsible for
attrition. Strategies and incentives
used to overcome this include attractive pay package and provision of
ambulances, accommodations, and
health insurance coverage for the
midwives. Some hard-to-reach areas
in the northern zones (NC, NE, and
NW) were further provided with an
additional 1,000 CHWs. Two CHWs
were deployed to each facility and
The MSS strategy of the Nigerian
government recognises that strategically
redistributing and improving the skill set
of existing cadres of health workers is
achievable on a large scale. The initiative
potentially serves as a model for other
developing countries within and outside
sub-Saharan Africa who may need to
redistribute their health workforce to
reduce the inequities that exist among
geographical zones and between urban
and rural areas.
Author Contributions
Wrote the first draft of the manuscript: SA UO.
Contributed to the writing of the manuscript:
SA UO OO MJA MAP. ICMJE criteria for
authorship read and met: SA UO OO MJA
MAP. Agree with manuscript results and
conclusions: SA UO OO MJA MAP.
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