Hindawi Publishing Corporation

International Journal of Population Research

Volume 2012, Article ID 464657, 5 pages
doi:10.1155/2012/464657

Research Article
Estimating Maternal Mortality Level in Rural Northern
Nigeria by the Sisterhood Method

Henry V. Doctor,1, 2 Sally E. Findley,1 and Godwin Y. Afenyadu2

1 Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Avenue,
Suite B2, New York, NY 10032, USA
2 Partnership for Reviving Routine Immunization in Northern Nigeria (PRRINN); Maternal, Newborn and

Child Health (MNCH) Program, Nassarawa GRA, Kano State, Nigeria

Correspondence should be addressed to Henry V. Doctor, [email protected]

Received 23 March 2012; Revised 26 July 2012; Accepted 10 August 2012

Academic Editor: Kristin L. Dunkle

Copyright © 2012 Henry V. Doctor et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Maternal mortality is one of the major challenges to health systems in sub Saharan Africa. This paper estimates the lifetime risk of
maternal death and maternal mortality ratio (MMR) in four states of Northern Nigeria. Data from a household survey conducted
in 2011 were utilized by applying the “sisterhood method” for estimating maternal mortality. Female respondents (15–49 years)
were interviewed thereby creating a retrospective cohort of their sisters who reached the reproductive age of 15 years. A total of
3,080 respondents reported 7,731 maternal sisters of which 593 were reported dead and 298 of those dead were maternal-related
deaths. This corresponded to a lifetime risk of maternal death of 9% (referring to a period about 10.5 years prior to the survey) and
an MMR of 1,271 maternal deaths per 100,000 live births; 95% CI was 1,152–1,445 maternal deaths per 100,000 live births. The
study calls for improvement of the health system focusing on strategies that will accelerate reduction in MMR such as availability of
skilled birth attendants, access to emergency obstetrics care, promotion of facility delivery, availability of antenatal care, and family
planning. An accelerated reduction in MMR in the region will contribute towards the attainment of the Millennium Development
Goal of maternal mortality reduction in Nigeria.

1. Introduction [1]. Despite challenges of measuring maternal mortality, the

need for monitoring of maternal mortality is a priority for
Maternal mortality is one of the major challenges to health many countries including Nigeria. Estimates of maternal
systems in the world and sub Saharan Africa in particular mortality are indispensable for planning and monitoring
[1]. In order to encourage the international community to the outcomes or impact of interventions. Recently, Nigeria
address this challenge, maternal mortality reduction was expressed reservations about accuracy and methods used to
included as one of the Millennium Development Goals, obtain figures quoted and the bases for such estimates [5].
MDG 5. The target of MDG 5 is to reduce maternal mortality A number of countries have strengthened their efforts to
ratio (MMR) by 75%, from 1990 to 2015 [2]. improve the quality of information about maternal mortality
Although several studies [3, 4] have highlighted the slow such as incorporation of sibling history modules in large-
progress in reducing maternal mortality, global reduction in scale household surveys, whether recent deaths in censuses
maternal deaths with variations across countries has been were related to pregnancies, and the use of record linkage or
reported elsewhere [1]. Global maternal deaths reduced by confidential inquiry to identify under-registration of (mater-
35% from 526,300 in 1980 to 342,900 in 2010. In Nigeria, the nal) deaths in vital registration systems [6]. Despite these
MMR in 2008 was reported to be 608 deaths per 100,000 live efforts, vital registration is virtually nonexistent in Nigeria.
births (95% confidence interval (CI): 372–946). This was an Existing efforts to study maternal mortality in sub Saha-
increase from an MMR of 473 (95% CI: 306–703) in 1990 ran Africa are often met with key challenges: large sample
2 International Journal of Population Research

sizes are required for these rare events, majority of maternal deaths per 1,000 live births and 88 deaths per 1,000 children,
deaths occur at home, and follow-up studies take time. The respectively [12].
“sisterhood method” for estimating MMR is an ideal method The program was established in 2007-2008 with cofund-
in such settings since it requires fewer respondents than vital ing from the Department for International Development
registration and cohort studies. Data collection procedures (UK) and the Norwegian Government. In each state, the
for this method are retrospective (a period of about 10– program generally focuses on increasing demand for MNCH
12 years before the survey), simple, quick, and based on services (through community mobilization and awareness
information about maternal deaths among sisters of the creation, among others) and strengthening the supply system
respondents [7]. Nevertheless, this method is not used to (through, improving health facility staffing, drug supplies,
measure progress towards safe motherhood in the short term and equipment, emergency transport scheme, among others)
nor evaluate program impact [8]. Another disadvantage is with an ultimate goal of ensuring that all women know
that it provides estimates of maternal mortality that should maternal danger signs, deliver with skilled birth attendants,
be seen as orders of magnitude rather than precise ratios and have access to emergency care. This integrated approach
since they can have wide CIs. The method does not provide complements state governments efforts towards achieving
a current estimate for the year of the survey. In general, the MDGs for child and maternal mortality reduction.
estimates from this method are fairly precise and the level of
accuracy may be low due to the retrospective nature of the
2.2. Data Collection. As part of the program’s monitoring
data and lack of verification of the information provided.
and evaluation activities, a household survey was conducted
In this paper, we estimate the lifetime risk of maternal
in 2011 to generate information on selected performance
death and the associated MMR. This method has been used
indicators. This follows a similar survey conducted in 2009.
and validated elsewhere [9, 10]. Maternal and child health
A sample of 770 women of reproductive age (15–49 years)
data were collected from women of reproductive age (15–
per state was selected and designed to represent intervention
49 years) as part of household survey conducted by the
and control communities.
Partnership for Reviving Routine Immunization in Northern
Sisterhood questions were included in this survey to help
Nigeria; Maternal Newborn and Child Health (PRRINN-
estimate MMR and to provide evidence and validate the
MNCH) Program (hereafter “the program”) in July-August
speculation that MMR in Northern Nigeria is more than a
2011 in four northern states (Jigawa, Katsina, Yobe, and
1,000 deaths per 100,000 live births. The specific questions
Zamfara) to track the progress on baseline or preintervention
were as follows: (1) how many sisters have you ever had who
levels (based on the 2009 survey) of some program processes,
reached reproductive age (15 years)? (2) how many of these
outcome, and impact indicators. The 2009 household survey
sisters are alive? (3) how many of these sisters are dead? (4)
did not include sisterhood questions.
how many of these sisters died during pregnancy, labor or
What is the level of maternal mortality in the study
within 42 days after the delivery? Interviewers checked that
area? In order to answer this question, we analyze household
the sum of questions two and three was equal to the total
survey data collected by the program in 2011 by using
in question one. Trained interviewers visited the selected
the sisterhood method. The estimated level of maternal
women at home and administered a questionnaire, which
mortality would then be used for advocacy by drawing the
included translation of key concepts and terms into the local
attention of policymakers and other stakeholders to the
languages, Hausa or Kanuri. The inclusion of the sisterhood
problem and hope that they will deploy interventions to
questions in the survey was therefore not for the purposes
address the problem.
of tracking trends or measuring the impact of the program
interventions.
The fieldwork for the survey took place between July
2. Methods and August 2011. Respondents were interviewed using a
structured questionnaire on a series of maternal and child
2.1. Setting. According to the 2006 population census,
health related questions. The inclusion criteria for reported
Jigawa, Katsina, Yobe, and Zamfara States had an esti-
sisters were that they were born to the same mother as the
mated population of 4.3, 5.8, 2.3, and 3.3 million people,
respondent and had reached reproductive age (15 years).
respectively. These four states were selected for the program
Migration of women in the study area is insignificant,
activities because they have generally poor maternal and
an important factor since migration can compromise the
child health indicators. For example, MMRs are over 1,000
completeness of the information gathered by failing to report
deaths per 100,000 live births (significantly higher than the
dead sisters who had migrated.
national average) [11]. Antenatal care services are available
in selected health facilities in these states and according
to the Nigerian Demographic and Health Survey of 2008, 2.3. Analysis. The data on sibling histories from the sister-
in the northern region, 59.1% of pregnant women in the hood questions were disaggregated into 5-year age groups.
five years preceding the survey had no antenatal care, and For each age group, the number of sisters exposed to the
among those receiving antenatal care, only 37% received such risk of maternal death and the duration of their exposure
services from a skilled provider. About nine out of 10 women (i.e., the number of reproductive years) was calculated
(88.4%) in this region delivered at home, with infant and by multiplying the number of sisters by an age-specific
child mortality rates well above the national average of 75 adjustment. The lifetime risk (LTR) of maternal death was
International Journal of Population Research 3

Table 1: Responses of 3,080 respondents about their sister’s vital status and LTR of maternal death, selected states, Northern Nigeria, 2011.

Column 1 Column 2 Column 3 Column 4 Column 5 Column 6 Column 7 Column 8

Number of Number of Number of Sisters exposed
Age group Number of Adjustment Lifetime risk
respondents sisters maternal (Col. 3 ∗ Col.
of respondent sisters factor (Col.5/Col.7)
(%) who died (%) deaths (%) 6)
15–19 217 (7.0) 375 23 (3.9) 7 (2.3) 0.107 40 0.17
20–24 713 (23.1) 1607 120 (20.2) 50 (16.8) 0.206 331 0.15
25–29 799 (25.9) 2099 169 (28.5) 75 (25.2) 0.343 720 0.10
30–34 724 (23.5) 1863 124 (20.9) 76 (25.5) 0.503 937 0.08
35–39 363 (11.8) 951 71 (12.0) 37 (12.4) 0.664 631 0.06
40–44 211 (6.9) 696 77 (13.0) 45 (15.1) 0.802 558 0.08
45–49 53 (1.7) 140 9 (1.5) 8 (2.7) 0.900 126 0.06
Total 3,080 (100.0) 7,731 593 (100.0) 298 (100.0) 3,344 0.09
MMR = 1,271 maternal deaths per 100,000 live births; 95% CI is 1,152–1,445.

calculated using the total number of maternal deaths divided deaths per 100,000 live births underscoring the fact that the
by the estimated total number of sisters exposed. An average maternal mortality situation in the rural areas of Northern
estimate of total fertility rate (TFR) was obtained from Nigeria is one of the worst worldwide, and largely due to
the 2008 Demographic and Health Survey [12]. In 2008, poor health systems, low utilization of skilled antenatal care,
the average TFR for all the states was 7.3. The formula to and preference for home deliveries [14]. The MMR reported
calculate and approximate MMR from the LTR [7] was: in this study is also much higher than the latest national
MMR = 1 – [(1 − LTR)∗(1/TFR)]. Ninety-five percent CIs estimate of 608 maternal deaths per 100,000 live births [1].
for the MMR were calculated based on [13]. This study provides very rough estimates on maternal
mortality in selected states of northern Nigeria and com-
plements some of the previous MMR figures which have
3. Results generally been speculative with reference to MMR being
“in excess of 1,000 deaths per 100,000 live births” [11].
Studies using the sisterhood technique provide reasonable
The results reported here demonstrate the grim situation
estimates if 3,000 sisters or more are studied [7]. As a result,
experienced by rural women of northern Nigeria who are
our analyses aggregated all the women from all the states. A
challenged with poor health infrastructure, poorly equipped
total of 3,080 respondents reported 7,731 maternal sisters of
health facilities, and attitudes that we think are not conducive
which 593 were reported dead and 298 of those dead were
to attaining good maternal and child health. Programs aimed
maternal-related deaths. Table 1 shows the sister’s vital status,
at improving the infrastructure and access to health services
by 5-year age groups and LTR of maternal death for all the
in rural areas will probably have a great impact in improving
states, and estimated LTR for the entire cohort. The total LTR
maternal health. Innovations such as those pioneered by
of maternal death was 9% (or about 1 in 11) and using 7.3 as
the program on emergency transport scheme for emergency
the TFR for all the states, the average MMR in the study area
obstetric cases as well as improving access to quality
was 1,271 maternal deaths per 100,000 live births, 95% CI
emergency obstetric care (EOC) services especially in rural
was 1,152–1,445 maternal deaths per 100,000 live births. The
areas will help to stem the high level of maternal mortality.
LTR refers to a period about 10.5 years prior to the survey.
Creating demand through community sensitization on the
The results in Table 1 also show a common trend of high
benefits of antenatal care, availability of emergency transport
maternal mortality in the age groups 20–24, 25–29, and 30–
system, and EOC services will increase utilization of maternal
34 in which at least 16% of the death reported by surviving
and child health services.
sisters was a maternal death. The LTR among the age groups
The high burden of maternal death in the youngest
is relatively stable and declining at least for the first four age
age groups compared with the oldest age groups may be
groups (Table 1).
associated with low age at marriage, a typical occurrence in
rural Northern Nigerian settings. Although our study could
4. Discussion not ascertain the prevalence of low age at marriage, since
age misreporting is one of the challenges experienced in the
Much has been speculated about the level of maternal study areas and the absence of indicators to capture the age
mortality in Northern Nigeria, with MMR speculated to be in at death of the deceased, early marriages in this part have
excess of 1,000 maternal deaths per 100,000 live births [11]. been documented elsewhere [15, 16]. This underscores the
Our study confirmed this speculation by documenting an fact that interventions that delay pregnancy could be effective
MMR of 1,271 maternal deaths per 100,000 live births from in minimizing LTR of maternal death.
the four states. The MMR estimate based on respondents Out-migration, which may have an effect on MMR in
aged 30 years and below was very high at 1,751 maternal settings with substantial migration rate, is not likely to affect
4 International Journal of Population Research

the MMR estimate reported here since observed migration policy of the program nor that of the donors. The authors are
patterns in the area are mostly due to marriages. Similarly, also grateful for very useful comments from an anonymous
abortion-related deaths—which may have been classified as referee. Any remaining errors are theirs.
deaths due to causes unrelated to pregnancy or childbirth
and thus led to underestimate of the MMR—may likely have
no impact in the study area as there are no or very minimal References
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Conflict of Interests [11] Centre for Reproductive Rights and Women Advocates
Research and Documentation Centre, Broken Promises:
The authors declare no conflict of interest. Human Rights, Accountability, and Maternal Death in Nige-
ria, Centre for Reproductive Rights and Women Advocates
Research and Documentation Centre, New York, NY, USA,
Acknowledgments 2008.
PRRINN-MNCH Program is funded and supported by the [12] National Population Commission [Nigeria] and ICF Macro,
Nigeria Demographic and Health Survey 2008, National Popu-
Department for International Development (UK) and the
lation Commission and ICF Macro, Abuja, Nigeria, 2009.
Norwegian Government. The authors also acknowledge the
[13] J. A. Hanley, C. A. Hagen, and T. Shiferaw, “Confidence
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teams, field supervisors, fieldworkers, data entry clerks, and D. Tukur, “Northern Nigeria Maternal, Newborn and Child
community members for their cooperation and continued Health Programme: selected analyses from population-based
support during the data collection. The views expressed in baseline survey,” The Open Demography Journal, vol. 4, pp. 11–
this paper are those of the authors and do not represent the 21, 2011.
International Journal of Population Research 5

[15] A. S. Erulkar and M. Bello, “The Experience of Married

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[16] National Population Commission [Nigeria], Nigeria Demo-
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mission, Calverton, Md, USA, 2000.
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