Determinants of maternal mortality in south-western Nigeria: Midwives' perceptions

Background: Maternal mortality remains one of Nigeria's most significant public health challenges. In order to address this issue sustainably, it is necessary to consider the perceptions of all stakeholders involved, including midwives.Objectives: To examine the determinants of maternal mortality in south-western Nigeria from the midwife's perspective.Design: A cross-sectional study was employed using mixed methods with a semi-structured questionnaire and an in-depth interview guide.Participants: Quantitative data were obtained from 215 midwives using a convenience sampling technique. Qualitative data were obtained from 25 midwives from five government health centres, selected using a stratified sampling technique.Methods: Quantitative data were analysed using SPSS Version 20 using descriptive and inferential statistics with 95 % confidence intervals, while qualitative data were analysed using thematic analyses.Findings: The mean age and work experience of the participants were 35.2 +/- 9.3 years and 8.4 +/- 7.0 years, respectively. The midwives perceived that the main determinants of maternal mortality were postpartum haemorrhage (86.5 %), hypertensive disorder in pregnancy (80.9 %), mismanagement at mission homes/traditional birth attendant centres (MH/TBAs) (79.1 %) and sepsis (70.1 %). Some of the priority target areas to improve the well-being of pregnant women as identified by the midwives, were increased awareness of pregnancy danger signs (97 %), destigmatising caesarean section (CS) (96 %), regulation of MH/TBAs (92 %), and increased accessibility of hospitals (84 %). Findings from the qualitative data also affirmed that regulating MH/TBAs, destigmatising CS and subsidising healthcare expenses were prerequisites to curbing maternal mortality. Inferential analysis revealed that determinants such as unsafe abortion (p < 0.001), ectopic pregnancy (p = 0.001), domestic violence (p = 0.023), malaria (p = 0.029), short interbirth interval (p = 0.03), and patients' negative perceptions of CS delivery (p = 0.036) were more commonly perceived to be associated with maternal mortality by younger midwives (age 17-34 years) compared with older midwives.Key conclusion: The results indicate that resolving the maternal mortality crisis sustainably in Nigeria will require increased accessibility to basic health care and health promotion campaigns to counteract unhelpful sociocultural norms.