This is a guest post provided by John Snow, Inc. and written by Bolaji Fapohunda, PhD[1]; Nosakhare Orobaton, MBBS, DrPh

Did you know that more than one in ten Nigerian women gives birth at home without a doctor, a skilled birth attendant (SBA), or even an unskilled relative? Indeed, more than one million children are born annually in Nigeria with “no one present” (NOP).

Women who deliver with no one present are more likely to die from childbirth and their newborns are more likely to die in the first days, weeks, or months of life; making children less likely to reach their 5th birthday.

Today, Nigeria contributes 14 percent to the global burden of maternal mortality, second only to India. Unlike India, however, Nigeria constitutes only two percent of the world’s population, making the maternal mortality levels in the country a veritable public health emergency.

Barira Aminu who delivered at the facility, was referred by a CBHV, and her newborn received CHX and was immunized at Tirwun, Bauchi State.

At the heart of this public health emergency are the women who deliver with NOP. Skilled birth attendants have been shown to be a key ingredient in saving maternal and newborn lives. Thus, we must focus on women who give birth with NOP if we are to stem the tide of maternal and newborn deaths and accelerate safer deliveries (which should be the right of every woman in Nigeria).

Over the last three years, JSI Research & Training Institute, Inc. (JSI) has been conducting a series of studies to better understand why women deliver with NOP in Nigeria. JSI has published three peer-reviewed journal articles on this issue and two more are forthcoming. The studies have served as a national call to eradicate the practice of no one present.

These JSI studies show that age, parity, poor female education, low-to-no personal income, living in a rural area, being Muslim, weak personal autonomy, and geography contribute to women delivering with no one present.

Northern Nigeria accounts for roughly 96 percent of all such deliveries nationwide. Seventy-three percent of deliveries with no one present occur in the North West zone alone. A JSI study found seven contributing factors for such extremely high levels of delivering with no one present:

  1. Financial insecurity, coupled with an obstructive pay-before-service payment policy
  2. Husbands’ lack of support for skilled attendance
  3. Perceptions that delivering with NOP in the past would result in similar successes in future NOP deliveries
  4. Diminishing social and economic value of children
  5. Diminishing emotional value of children
  6. Persistence of harmful community norms, including beliefs that NOP is good, fashionable, and a sign of delivery-made-easy by God
  7. Poor quality of delivery care, particularly the inability of the formal health care system to deliver WHO recommended respectful maternity care

The study concluded that addressing the above factors will increase the number of births attended by a SBA and, ultimately, reduce maternal mortality and morbidity in Nigeria. So how do we begin to address these issues? There are several promising interventions.

The study concluded that addressing the above factors will increase the number of births attended by a SBA and, ultimately, reduce maternal mortality and morbidity in Nigeria. So how do we begin to address these issues? There are several promising interventions.

Recent evidence shows that good programs with strong governance can make a difference. A statewide community-based intervention in Sokoto distributed the cost-effective and lifesaving drugs misoprostol and chlorhexidine to prevent postpartum bleeding and infection of the newborn cord, respectively, while placing a community-based health volunteer with every pregnant woman who delivered at home. The presence of a health volunteer significantly reduced the likelihood that a woman would deliver alone. In fact, the incidence of giving birth with NOP dropped from a high of 25% to less than 1% in Sokoto State between 2008 and 2013.

Improving household finances can also make a difference. JSI found that high user fees and the high cost of medicine, supplies, and transportation are the largest obstacles to women using SBA in Northern Nigeria. The prevailing pay-before-service model is described by communities as harsh, painful, and obstructive. A recent evaluation of a financial assistance program being piloted in several communities in Nigeria demonstrates that the use of SBA increases when women have access to income they control.[2]

On Tuesday, May 26 in Abuja, JSI will hold a “no one present” call to action and policy discussion with high-level Nigerian stakeholders, including government officials. This meeting will inform stakeholders about the issues surrounding the “no one present” phenomenon, disseminate the JSI-led studies, and raise a call to action for eradicating the practice.

To read more on this phenomenon, see the references below:

Fapohunda BM, Orobaton NG (2013) When women delivery with no one present in Nigeria: Who, what, where and so what? PLoS ONE 8(7):

Fapohunda BM, Orobaton NG. Factors influencing the selection of delivery with no one present in northern Nigeria: implications for policy and programs. International Journal of Women’s Health 6:171-183. Available:

Austin A, Fapohunda B, Langer A, Orobaton N. Trends in delivery with no one present in Nigeria between 2003 and 2013. International Journal of Women’s Health. 2015; 7: 345-356. Available:

Fapohunda B, Orobaton N, Shoretire K, Abdulazeez J, Maishanu A, Sadauki H et al (2015).  Community Perspectives on Why Women Deliver with No One Present in Northwestern Nigeria: Summary of Key Findings. Abuja, Nigeria: USAID-Targeted States High Impact Project (TSHIP), 2015

Bolaji Fapohunda1, Nosakhare Orobaton2, Kamil Shoretire3 and Goli (2015). Are Women Who Deliver with No One Present also Likely to take other Health Care Risks? Clues from Nigeria Demographic and Health Surveys [Forthcoming].  Abuja, Nigeria: USAID-Targeted States High Impact Project (TSHIP).



[1] Correspondence: Bolaji Fapohunda, JSI R&T, 44 Farnsworth Street, Boston, MA. Email:

[2] Okoli U, Morris L, Oshin A, Pate MA, Aigbe C, Muhammad A (2015). Conditional cash transfer schemes in Nigeria: potential gains for maternal and child health service uptake in a national programme. BMC Pregnancy Childbirth. 2014; 14: 408-413.