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. 2026 Jul 31;7(3):RAF250144. doi: 10.1530/RAF-25-0144

Commonest causes of maternal mortality in Nigeria: a situational report requiring an urgent action

Chukwuemeka Daniel Okolie 1,✉, Archie Alexander 2, Matthew Kelley 2
PMCID: PMC13452039  PMID: 42455798

Abstract

Abstract

Maternal mortality remains a critical public health challenge in Nigeria, with rates far exceeding global targets. This narrative review correlates findings from peer-reviewed studies published between 2015 and 2025 to assess the burden, causes, and contributing factors of maternal mortality across Nigeria’s six geopolitical zones. PubMed and Google Scholar were searched using predefined keywords, and studies reporting maternal mortality ratios (MMRs), causes of death, or contributing factors from Nigerian health facilities or population-based surveys were included. Hypertensive disorders of pregnancy (HDP) and obstetric hemorrhage were consistently identified as the leading direct causes of maternal death, while complications of unsafe abortion and sepsis were also prominent. Most of the non-medical contributing factors identified in this review study were poor utilization of prenatal care (PNC) services, limited access to healthcare facilities, financial constraints, and low educational attainment. Significant regional variation was observed, with facility-based MMRs ranging from 383 to 7,364 per 100,000 live births. This study emphasizes the urgent need for strengthened PNC delivery, improved emergency obstetric services, health workforce development, and targeted community health education to reduce maternal mortality in Nigeria.

Lay summary

Deaths from pregnancy-related causes remain a major public health concern, especially in less developed countries. Nigeria is one of the countries with high pregnancy-related deaths. A substantial number of women who become pregnant in Nigeria never make it through the pregnancy. Our study investigated pregnancy-related deaths and their responsible factors across Nigeria. We found out that most of these deaths are caused by pregnancy-related bleeding, high blood pressure, and their complications. Pregnant women who do not attend prenatal care and those with low socioeconomic status are affected the most. Understanding the causes and contributing factors behind pregnancy-related deaths can help create ways to reduce this serious public health problem.

Keywords: maternal mortality, causes, Nigeria, obstetric hemorrhage, hypertensive disorders of pregnancy, prenatal care, narrative review

Introduction

Nigeria operates a pluralistic healthcare system comprising public and private sectors alongside traditional medicine (Federal Ministry of Health 2018). The public healthcare sector is the concurrent obligation of the three tiers of government (federal, state, and local) (Federal Ministry of Health 2018). Despite various reform efforts, the Nigerian healthcare system remains largely underserved, with many communities lacking functional medical facilities and patients are often required to make upfront payments to access care (Osain 2011, Amedari & Ejidike 2021). Nigeria ranks poorly on the Lancet report’s health system performance index and the World Bank’s Universal Health Coverage Service Index (Amedari & Ejidike 2021). Although access to healthcare for all Nigerians through the basic minimum package of health services is backed by the National Health Act, the package has faced huge challenges in dissemination and implementation as several state governments are lagging in operationalizing it at ward levels (Amedari & Ejidike 2021). Nigeria consists of six geopolitical zones which include north-central (NC), north-east (NE), north-west (NW), south-east SE), south-south (SS), and south-west (SW) encompassing 36 states together with the federal capital territory in Abuja (Lois 2020) (Fig. 1).

Figure 1.

Figure 1

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Administrative map of Nigeria highlighting the six geopolitical zones. The color shadings represent the standard regional groupings of the 36 states and the Federal Capital Territory (FCT): north-west (cyan), north-east (light green), north-central (salmon/red), south-west (blue), south-south (dark red), and south-east (purple). Map adapted from open-source administrative templates based on National Bureau of Statistics (NBS) geopolitical demarcations. NB: this map is intended for schematic/illustrative purposes.

According to the World Health Organization (WHO), maternal mortality is defined as ‘the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from unintentional or incidental causes’ (Cresswell 2017, World Health Organization 2023). Importantly, this definition includes deaths related to ectopic pregnancies and complications of both legal and illegal abortions which are frequently underreported in low-resource settings. The maternal mortality ratio (MMR) is expressed as the number of maternal deaths per 100,000 live births and serves as a key indicator of a nation’s overall health and well-being (World Health Organization 2023, Ezeike et al. 2024). The WHO approximated the MMR as the ratio per 100,000 live births in any given population (Osunu et al. 2021).

In 2020, approximately 287,000 maternal deaths were reported globally, with most of these deaths occurring in sub-Saharan Africa (SSA). Eastern Asia, on the other hand, recorded the fewest maternal deaths (Kacmar & Mhyre 2020). Approximately 223 women die per 100,000 live births globally, meaning a girl of reproductive age has a 1 in 210-lifetime chance of dying from a pregnancy-related event. While there has been a decrease in the rate of pregnancy-related deaths in high-income countries, the MMR in low- and middle-income countries (LMICs) has remained significantly high; in 2020, over 90% of recorded maternal deaths occurred in these countries (Samuel et al. 2021). SSA accounted for the largest share, with Nigeria recording an MMR of 1,047 per 100,000 live births in 2020 (World Health Organization 2023). In response to this high MMR and experts’ recommendations, the Federal Ministry of Health in 2013 authorized all maternal health institutions in Nigeria to regularly perform maternal mortality audits, supervision, and response using the technical guidance document suggested by WHO (Achem & Agboghoroma 2014).

According to the International Classification of Diseases (ICD), the causes of obstetric deaths are divided into direct and indirect (Filippi et al. 2016). Direct causes result from pregnancy-related complications during pregnancy, childbirth, and the puerperium. They include hemorrhage, eclampsia, and other HDP, abortion, sepsis, and obstructed labor. Indirect causes include pre-existing health conditions and conditions aggravated by pregnancy, such as anemia, cardiovascular disease, hepatic disease, infectious diseases (such as human immunodeficiency virus (HIV) and malaria), pulmonary causes, and pneumonia. Global data from a study conducted between 2003 and 2009 revealed that approximately 73% of all maternal deaths were due to direct obstetric causes, while indirect causes accounted for approximately 27%. Among the direct causes, hemorrhage, hypertensive disorders, sepsis, abortion, and embolism accounted for approximately 27, 14, 11, 8, and 3% respectively (Say et al. 2014).

Problem statement

Although global health has advanced in many areas, maternal mortality in Nigeria, at an estimated rate exceeding 800 per 100,000 live births (World Health Organization 2019), represents a significant public health crisis, far surpassing the global average and the WHO Sustainable Development Goal (SDG) 3.1 target of fewer than 70 maternal deaths per 100,000 live births by 2030 (World Health Organization 2025). This persistently high rate demands urgent, evidence-based action to identify the major causes, address systemic gaps in the healthcare sector, and ensure that women of reproductive age, especially those in rural and underserved regions have access to quality maternal healthcare. Considering the public health implications, urgent action at the individual, population, and government levels is required.

The aim of this narrative review study is to synthesize the available literature on maternal mortality in Nigeria, assess its magnitude and regional variation, evaluate the major causes and contributing factors, and provide evidence-based recommendations for reducing the burden.

Methods

This study was conducted as a narrative review of the published literature on maternal mortality in Nigeria. PubMed and Google Scholar were searched for peer-reviewed articles published between 2015 and 2025 using the following search terms: ‘maternal mortality’, ‘maternal death’, ‘rate’, ‘causes’, ‘contributing factors’, ‘risk factors’, ‘Nigeria’, and names of individual Nigerian states and geopolitical zones. The 2015 cutoff was selected to capture the most recent decade of evidence, coinciding with the transition from the Millennium Development Goals to the Sustainable Development Goals era, during which maternal health policies and reporting systems in Nigeria underwent significant changes.

Studies were included if they reported MMRs, causes of maternal death, or contributing factors from Nigerian health facilities or population-based surveys. Both retrospective and prospective study designs were eligible. Studies conducted prior to 2015 but published in or after 2015 were also included. Articles that did not report original data on maternal mortality in Nigeria or that focused exclusively on non-Nigerian populations were excluded. Studies from both public (government-owned) and private health facilities were reviewed; however, only a few studies from private health facilities were identified. Although efforts were made to obtain data from all states in Nigeria, some states did not have any studies published within the review period. By perusing the abstract of each published study, those that did not meet the inclusion criteria were removed, while those that met the criteria were further reviewed to extract information such as the identified MMR, the major causes of mortality, and the contributing factors. Global studies relating to maternal mortality, as well as studies conducted within Africa, SSA, and the six geopolitical zones in Nigeria, were identified and analyzed.

No formal systematic search protocol (e.g. PRISMA) was followed, and no standardized quality assessment or risk-of-bias evaluation of included studies was performed. This review is, therefore, explicitly framed as a narrative review rather than a systematic review. The findings are synthesized descriptively, and the limitations inherent in this approach including potential selection bias and the inability to perform quantitative pooling are acknowledged.

It is important to note that the majority of included studies are facility-based, reflecting data from tertiary and secondary referral hospitals. Facility-based MMRs tend to overestimate population-level mortality because referral centers disproportionately receive complicated cases. Population-based estimates, where available, are distinguished from facility-based data throughout this review.

Literature review

Various studies conducted across Nigeria and published within the last decade revealed an alarmingly high rate of maternal mortality, with some conflicting results across several locations. Between 2005 and 2015, studies estimated that there were over 600,000 maternal deaths in Nigeria, with an estimated MMR exceeding 800 per 100,000 live births and approximately 58,000 pregnancy-related deaths in 2015 (World Health Organization 2019). A recent WHO report ranked Nigeria as the country with the second-highest number of maternal deaths (29%) globally, with a high possibility of missing the SDG target by 2030 (Nwafor 2023). Thus, health professionals and policymakers should take emergency action to improve the Nigerian public healthcare system, especially in maternal and child health.

Multi-zonal studies

A facility-based systematic review and meta-analysis of maternal mortality from 96 health facilities across the six geopolitical zones revealed MMRs of 1,769, 1,670, and 1,530 per 100,000 live births in the NC, NE, and NW zones, respectively, and 1,449, 1,825, and 1,564 in the SE, SS, and SW zones, respectively. Although the study identified a positive correlation between eclampsia, postpartum hemorrhage (PPH), and maternal mortality, no correlation was noted between maternal mortality and PNC attendance (Haruna et al. 2023). A sub-national secondary data analysis across all states estimated the MMR in 2018 to be 957, 563, 388, 806, 1,623, and 630 per 100,000 live births in the NC, NE, NW, SE, SS, and SW zones, respectively. The study also highlighted a decreased trend in maternal mortality in the NW and SE regions from 2008 to 2018 but an increased trend in the SW region (Babajide et al. 2023). A 6-month study (January to June 2014) in eight referral hospitals across eight states in four geopolitical zones showed a mean MMR of 2,085 per 100,000 live births, and although there were variations in the causes of death, the leading causes were obstetric hemorrhage, eclampsia, obstructed labor, and puerperal sepsis (Ntoimo et al. 2018).

North-central geopolitical zone

A retrospective study on maternal deaths at the University of Abuja Teaching Hospital between January 2014 and December 2018 revealed an MMR of 831 per 100,000 live births (Akaba et al. 2021). HDP, obstetric hemorrhage, and puerperal sepsis were identified as the major direct causes. Several contributing factors were noted, including delays in reaching the referred health facility, delays in commencement of necessary treatment, lack of formal education, and poor prenatal care. A six-year retrospective study conducted at Benue State University Teaching Hospital Makurdi between 2012 and 2018 revealed an MMR of 1,118 per 100,000 live births, with the leading cause being unsafe abortion, followed by HDP (Hemabh-Hilekaan et al. 2019). Unlike other studies, puerperal sepsis and obstetric hemorrhage were among the least common causes. Although most patients were literate, they did not register for PNC. A study at Jos University Teaching Hospital between January 2016 and December 2022 revealed an MMR of 773 per 100,000 live births; the most common direct causes were HDP, maternal sepsis, complications of unsafe abortion, obstetric hemorrhage, and uterine rupture (Kahansim et al. 2023). Most deaths occurred within the first 24 h of presentation in women who had no or only primary education and who had not registered for PNC.

North-eastern geopolitical zone

A study from the University of Maiduguri Teaching Hospital, Borno State, between January 2006 and December 2010 revealed an MMR of 1,074 per 100,000 live births (Bakari et al. 2015). The major direct causes were eclampsia (34.6%), hemorrhage (9.1%), HIV (17.8%), and puerperal infections (7.5%); contributing factors included older maternal age, grand-multiparity, lack of formal education, poor usage of prenatal care services, and delayed presentation to health facilities. A descriptive cross-sectional study across tertiary, specialist, general, and cottage health facilities in Gombe State in 2019 and 2020 showed MMRs of 1,092 and 993 per 100,000 live births, respectively, with eclampsia, pre-eclampsia, and PPH as the main direct causes (Mohammed et al. 2022). The average MMR in a 14-year study (2004–2017) at General Hospital Wukari, Taraba State, was 900 per 100,000 live births, with an observed lowering trend (Ebelechukwu et al. 2024). A strikingly high MMR of 7,364 per 100,000 live births was noted at Federal Medical Center Nguru, Yobe State, with eclampsia, obstetric hemorrhage, and sepsis as the major causes, and lack of PNC, grand-multiparity, and lack of formal education as contributing factors (Usman et al. 2018).

North-western geopolitical zone

A randomized retrospective cohort study conducted between December 2011 and May 2012 among sisters of women who died from pregnancy-related causes in 24 local government areas of Jigawa State showed an MMR of 1,012 per 100,000 live births using the sisterhood method (Sharma et al. 2017). A retrospective cross-sectional household survey in August 2017 in six randomly selected local government areas in Kebbi State estimated an MMR of 890 per 100,000 live births; the causes of death were not specified, but most women did not register for PNC and most of the deliveries occurred at home, unsupervised (Gulumbe et al. 2018). A one-year retrospective study in health facilities in Sokoto between July 2017 and June 2018 revealed an MMR of 705 per 100,000 live births, with the majority of deaths resulting from obstetric hemorrhage, eclampsia, and prolonged obstructed labor (Oyeniyi et al. 2020). Most deaths occurred in women under 30 years of age and in areas with poorly equipped health facilities. A study in selected health facilities in Zamfara State showed a wide gap in MMR between rural and urban areas, with rates of 5,120 and 750 per 100,000 live births, respectively (Maiwada et al. 2016). Obstetric hemorrhage was the major cause of death, followed by puerperal sepsis and eclampsia.

South-eastern geopolitical zone

A retrospective three-year study (February 2014 to January 2017) at Amachara General Hospital, Umuahia, Abia State, showed an MMR of 532 per 100,000 live births. This is lower than the national average, with previous cesarean scar, HIV positivity, and puerperal sepsis as the commonest causes (Onyemachi et al. 2023). Unlike other studies, HDP and obstetric hemorrhage were not among the major causes. A five-year retrospective study at Nnamdi Azikiwe University Teaching Hospital (NAUTH) Nnewi, Anambra State (January 2014 to December 2018), revealed an MMR of 1,896 per 100,000 live births, with 83% of cases not having registered for PNC (Adinma-Obiajulu & Adinma 2024). The major direct causes were pre-eclampsia and eclampsia, obstetric hemorrhage, and puerperal sepsis, while HIV/AIDS was the major indirect cause. Most deaths (48.5%) occurred within the first 24 h of hospital presentation, and patients’ delay in recognizing life-threatening obstetric complications was a contributing factor. A nine-year retrospective review at Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State (January 2012 to December 2020), revealed an MMR of 1,114 per 100,000 live births (Umeononihu et al. 2023). Most deaths were due to obstetric hemorrhage and HDP, and occurred in women without formal education, those who did not register for PNC (85.4%), and those who were grand multiparous (43.4%). A three-year prospective study at the University of Nigeria Teaching Hospital (UNTH) Enugu (April 2013 to March 2016) showed an MMR of 1,252 per 100,000 live births, with severe hemorrhage, anemia, and HDP as the leading causes (Ugwu et al. 2020). Most deaths occurred within 24 h of hospital presentation, in women who did not register for PNC, and who were of low- or middle-income status. A study across three tertiary health institutions in Imo State showed an MMR of nearly 2,100 per 100,000 live births, with 65% of cases having neither registered for nor attended PNC (Njoku et al. 2024). Most pregnancy-related deaths occurred after delivery and after 28 weeks’ gestation, with hemorrhage, pre-eclampsia and eclampsia, puerperal sepsis, severe anemia, hepatitis, embolism, anesthetic complications, and abortion as causes.

South-southern geopolitical zone

A 10-year retrospective study at the University of Uyo Teaching Hospital, Akwa Ibom State (2008–2017), revealed an MMR of 1,062 per 100,000 live births, with pre-eclampsia and eclampsia and obstructed labor as the most common causes (Anikpe et al. 2019). Contributing factors included age less than 30 years, first pregnancy, lack of PNC registration, and low education level. An analytical cross-sectional study assessing predictors of facility-based PNC and delivery services in a rural community in Cross River State revealed low utilization of facility-based maternal and child healthcare services during pregnancy (Etokidem et al. 2022). Educational and occupational status was positively correlated with PNC utilization, while poor attitude of healthcare providers and delays in the health facility were among reasons for poor utilization. A study assessing primary healthcare services and maternal mortality in Ugep, Cross River State, quoted an MMR of 1,200 per 100,000 live births (Arisukwu et al. 2021). Although pregnant women received skilled obstetric care during pregnancy, high patronage for unskilled birth attendants was noted. An MMR of 395 per 100,000 live births was noted at Central Hospital, Benin City, Edo State, with most deaths occurring in the immediate postpartum period (Aikpitanyi et al. 2019). PPH was the direct cause, and unlike other studies, HDP was not among the major causes. Contributing factors included delay in commencing treatment, unavailability of blood products, poor case management from referring facilities, patients’ delay in seeking healthcare, and financial constraints. A 10-year facility-based survey (2008–2017) at the University of Benin Teaching Hospital (UBTH) and Central Hospital, Edo State, revealed an MMR of 674 per 100,000 live births, with eclampsia and hemorrhage as the major direct causes and HIV/AIDS as the leading indirect cause (John-Abebe 2024). Most deaths occurred in women who did not register for PNC. A cross-sectional study at Madonna Teaching Hospital Elele, a rural private tertiary hospital in Rivers State, showed an MMR of 1,908 per 100,000 live births, with most deaths due to early pregnancy bleeding, unlike findings in other studies where PPH and pre-eclampsia/eclampsia were the commonest causes (Mbachu et al. 2017). The authors noted routine active management of the third stage of labor and judicious use of magnesium sulfate as possible factors responsible for the low rates of PPH and eclampsia, respectively. Non-medical contributing factors included administrative delays and delays in seeking healthcare. A seven-year review of maternal mortality at a tertiary hospital in Rivers State revealed an MMR fluctuating between 580 and 785 per 100,000 live births, with a sustained increase over the study period; the leading causes were HDP, obstetric bleeding, and uterine rupture (Awoyesuku et al. 2020). Delays in obtaining healthcare services due to financial challenges were noted as a possible contributory factor.

South-western geopolitical zone

The MMR at University College Hospital (UCH) Ibadan, Oyo State, was 1,265 per 100,000 live births (Bello et al. 2015). The major causes were hemorrhage (36%), sepsis (17%), and HDP (16%). Most women were critically ill at presentation, and the majority of deaths occurred within 24 h after birth, in multiparous women who had not registered for PNC. Delays in accessing healthcare and health financing were identified as major non-medical contributing factors. A five-year retrospective descriptive study at the Mother and Child Hospital Akure, Ondo State (February 2010 to December 2014), showed an overall lower MMR of 383 per 100,000 live births, with a reduction from 708 in 2010 to 208 in 2014 (Oyeneyin et al. 2017). The major direct causes were PPH (30%), eclampsia (29%), and uterine rupture (14%). The study showed a downward trend despite an increase in birth deliveries, which can be attributed to the free maternal health services offered at the institution. A 13-year cross-sectional and temporal trend analysis at Lagos University Teaching Hospital (LUTH), Lagos State (2007–2019), revealed a statistically significant increase from 2,211 per 100,000 in 2007 to 3,556 per 100,000 in 2019 (Olamijulo et al. 2022). Most women (89%) did not register for PNC, and the leading direct causes were hypertension, puerperal sepsis, and hemorrhage, while the primary indirect causes were anemia in pregnancy, HIV, and sickle cell disease. A study in three referral hospitals in Lagos State showed an MMR of 1,602 per 100,000 live births, with 88% of maternal deaths occurring in women who did not register for PNC (Okonofua et al. 2017). The study identified eclampsia, primary PPH, obstructed labor, and puerperal sepsis as the commonest direct causes, while delay in presentation, refusal of recommended treatment, delay in treatment, poor use of treatment protocols, poorly equipped health facilities, and lack of skills by health providers were contributing factors. A retrospective study at Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) Ile-Ife, Osun State (October 2012 to September 2015), revealed annual MMRs of 1,744, 1,622, and 1,512 per 100,000 live births, respectively (Awowole et al. 2017). The direct causes were infection, obstetric hemorrhage, and HDP, with financial constraints, wrong diagnosis, and delay in referral as major contributory factors. A study on causes and contributing factors of maternal mortality in Ogun State revealed that hemorrhage and pre-eclampsia/eclampsia were the leading direct causes, while inadequate human resources, delay in seeking care, inadequate equipment, delay in referral services, and lack of ambulance transportation were the leading contributory factors (Sageer et al. 2019). Most data from these studies exceed the global and national MMR at an alarmingly high rate, indicating the need for urgent action (Table 1).

Table 1.

MMRs and leading causes of death reported across the six geopolitical zones.

Zone Facilities/states (reference) Period MMR range Top direct causes Key contributing factors
NC Abuja UTH (Akaba et al. 2021); Benue SUTH (Hemabh-Hilekaan et al. 2019); Jos UTH (Kahansim et al. 2023) 2012–2022 773–1,118 HDP, hemorrhage, sepsis, unsafe abort Delays in referral/treatment, no education, poor PNC, death < 24 h
NE Maiduguri UTH (Bakari et al. 2015); Gombe fac (Mohammed et al. 2022); Wukari GH (Ebelechukwu et al. 2024); FMC Nguru (Usman et al. 2018) 2004–2020 900–7,364 Eclampsia, hemorrhage, sepsis, HIV, PPH Grand-MP, no education, no PNC, older age; ↓trend at Wukari
NW Jigawa-pop (Sharma et al. 2017); Kebbi-pop (Gulumbe et al. 2018); Sokoto fac (Oyeniyi et al. 2020); Zamfara fac (Maiwada et al. 2016) 2011–2018 705–5,120 Hemorrhage, eclampsia, obstructed labor, sepsis No PNC, home delivery, age < 30, poor facility, rural–urban gap
SE Amachara GH-Abia (Onyemachi et al. 2023); NAUTH Nnewi (Adinma-Obiajulu & Adinma 2024); AE-FUTH Ebonyi (Umeononihu et al. 2023); UNTH Enugu (Ugwu et al. 2020); 3 tertiary hospitals-imo (Njoku et al. 2024) 2012–2020 532–2,100 Hemorrhage, PE/eclampsia, sepsis, HDP, anemia, abort 65–85% no PNC, no education, grand-MP, death < 24 h, low income
SS Uyo UTH (Anikpe et al. 2019); cross river rural (Etokidem et al. 2022); Ugep (Arisukwu et al. 2021); central hosp benin (Aikpitanyi et al. 2019); UBTH+ central edo (John-Abebe 2024); Madonna TH rivers (Mbachu et al. 2017); tertiary hospital rivers (Awoyesuku et al. 2020) 2008–2017 395–1,908 PE/eclampsia, PPH, hemorrhage, obstructed labor, HDP, early pregnancy bleed No PNC, low education, age < 30, unskilled attendants, financial, admin delays
SW UCH Ibadan (Bello et al. 2015); MCH Ondo (Oyeneyin et al. 2017); LUTH Lagos (Olamijulo et al. 2022); 3 referral hospital Lagos (Okonofua et al. 2017); OAUTHC Ile-Ife (Awowole et al. 2017); Ogun fac (Sageer et al. 2019) 2007–2019 383–3,556 Hemorrhage, eclampsia, PPH, sepsis, HTN, HDP, obstructed labor 88–89% no PNC, death < 24 h, financial, delays, poor protocols, no ambulance; free services → ↓trend (Ondo); ↑trend (LUTH)
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PE, pre-eclampsia; HDP, hypertensive disorders of pregnancy; PPH, postpartum hemorrhage; HTN, hypertension; abort, abortion complications; PNC, prenatal care; grand-MP, grand-multiparity; pop, population-based; ↓, decreasing; ↑, increasing; UTH, University Teaching Hospital; SUTH, State University Teaching Hospital; GH, General Hospital; TH, Teaching Hospital; MCH, Mother & Child Hospital; FMC, Federal Medical Center; FUTH, Federal University Teaching Hospital; fac, health facility; NC, north-central; NE, north-east; NW, north-west; SE, south-east; SS, south-south; SW, south-west; MMR, maternal mortality ratio per 100,000 live births. All studies are facility-based unless marked ‘pop’ (population-based/sisterhood method).

Discussion

From the reviewed literature, maternal mortality in Nigeria can be noted to exceed the 2020 global rate of 223 per 100,000 live births and is far above the WHO-targeted MMR of less than 70 per 100,000 live births by 2030 (World Health Organization 2025). Most of the data were also above the MMR for the African region, which in 2020 was 531 per 100,000 live births (World Health Organization 2023). A study on maternal mortality trends in Africa showed that although the MMR has decreased across the continent, the rate remains high in SSA (Onambele et al. 2022). The commonest direct causes of maternal mortality (HDP and obstetric hemorrhage), identified in this review, are consistent with findings from systematic analyses of maternal mortality in SSA (Musarandega et al. 2021, Lawrence et al. 2022) and globally (Say et al. 2014, Cresswell et al. 2025) (Table 2). A WHO systematic analysis of global and regional causes of maternal mortality confirmed hemorrhage, HDP, and sepsis as the three most common direct causes globally (Cresswell et al. 2025). Furthermore, an institutional review of LMICs in Asian, Caribbean, Latin American, and SSA regions revealed HDP and obstetric hemorrhage as the most common direct causes of death (Bailey et al. 2017).

Table 2.

Frequency with which each direct cause of maternal mortality was reported as a leading contributor across the reviewed studies

Direct cause Frequency as leading cause Zones most affected References
Hypertensive disorders of pregnancy (pre-eclampsia/eclampsia) Most frequently reported All zones Bakari et al. (2015), Bello et al. (2015), Awowole et al. (2017), Okonofua et al. (2017), Usman et al. (2018), Anikpe et al. (2019), Sageer et al. (2019), Awoyesuku et al. (2020), Oyeniyi et al. (2020), Ugwu et al. (2020), Akaba et al. (2021), Mohammed et al. (2022), Olamijulo et al. (2022), Haruna et al. (2023), Kahansim et al. (2023), Umeononihu et al. (2023), Adinma-Obiajulu & Adinma (2024), Njoku et al. (2024)
Obstetric hemorrhage (antepartum and postpartum) Second most frequently reported All zones, especially South Bakari et al. (2015), Bello et al. (2015), Maiwada et al. (2016), Awowole et al. (2017), Mbachu et al. (2017) , Takai et al. (2017), Oyeneyin et al. (2017), Usman et al. (2018), Sageer et al. (2019), Oyeniyi et al. (2020), Ugwu et al. (2020), Akaba et al. (2021), Haruna et al. (2023), Umeononihu et al. (2023), Adinma-Obiajulu & Adinma (2024), John-Abebe (2024), Njoku et al. (2024);
Puerperal sepsis Third most common All zones Bello et al. (2015), Maiwada et al. (2016), Awowole et al. (2017), Okonofua et al. (2017), Akaba et al. (2021), Olamijulo et al. (2022), Kahansim et al. (2023), Adinma-Obiajulu & Adinma (2024), Njoku et al. (2024);
Complications of unsafe abortion Significant but underreported NC, SE Hemabh-Hilekaan et al. (2019), Kahansim et al. (2023), Njoku et al. (2024)
Obstructed labor Reported in multiple studies North, SW Bakari et al. (2015), Okonofua et al. (2017), Oyeniyi et al. (2020)
Ectopic pregnancy/early pregnancy bleeding Rarely reported separately SS Mbachu et al. (2017)
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Similar patterns have been reported in neighboring West African countries. Although the MMR in the Republic of Benin is lower than that of Nigeria, the leading direct causes were also obstetric hemorrhage and pre-eclampsia/eclampsia (Konnon et al. 2020). Another study in two maternity hospitals in Cotonou, Republic of Benin, showed an MMR of 2,028 per 100,000 with obstetric hemorrhage, HDP, and puerperal infection as the leading direct causes (Dangbemey et al. 2023). These high MMRs and leading causes were also similar to findings from a Gambian tertiary health center (Idoko et al. 2017). Although the study in the Kara region of Togo showed a lower MMR, the leading direct causes (obstetric hemorrhage, pre-eclampsia, and complications of abortion) were also similar to those in Nigeria (Ajavon et al. 2022). The review of maternal mortality in a hospital in Cameroon showed the leading direct causes to be similar to those in Nigeria (Ekane et al. 2015). A study at the Maradi Maternal and Child Health Center in the Republic of Niger showed an MMR of 2,646 per 100,000 live births, with direct causes (obstetric hemorrhage and HDP) accounting for 57 versus 43% for indirect causes (Abdou et al. 2024). Furthermore, a study on factors associated with maternal deaths in Bongor Provincial Hospital, Chad, showed an MMR of 1,005 per 100,000 live births, with obstetric hemorrhage as the major direct cause, followed by pre-eclampsia/eclampsia, sepsis, and abortion (Madoue et al. 2023) (Table 3).

Table 3.

Maternal mortality data from Nigeria compared with neighboring and regional countries.

Country/region MMR (per 100,000) Leading direct causes Key similarities with Nigeria References
Nigeria (national estimate, 2020) 1,047 HDP, hemorrhage, sepsis, abortion — World Health Organization (2023)
Global average (2020) 223 Hemorrhage, HDP, sepsis Nigeria exceeds global rate by ∼five-fold World Health Organization (2025)
Africa regional average (2020) 531 Hemorrhage, HDP, sepsis Nigeria exceeds regional rate by ∼two-fold World Health Organization (2023)
Republic of Benin (Cotonou) 2,028 Hemorrhage, HDP, puerperal infection Same leading direct causes Dangbemey et al. (2023)
Republic of Benin (national) Lower than Nigeria Hemorrhage, pre-eclampsia/eclampsia Same leading direct causes Konnon et al. (2020)
The Gambia (tertiary center) High Similar to Nigeria Similar causes and contributing factors Idoko et al. (2017)
Togo (Kara region) Lower than Nigeria Hemorrhage, pre-eclampsia, abortion complications Same leading causes; abortion prominent Ajavon et al. (2022)
Cameroon (Douala) High Similar to Nigeria Same leading direct causes Ekane et al. (2015)
Republic of Niger (Maradi) 2,646 Hemorrhage, HDP Direct causes higher than indirect (57 vs 43%) Abdou et al. (2024)
Chad (Bongor) 1,005 Hemorrhage, pre-eclampsia/eclampsia, sepsis, abortion Same leading causes; low PNC attendance Madoue et al. (2023)
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HDP, hypertensive disorders of pregnancy; PNC, prenatal care.

Hypertensive disorders of pregnancy: classification, risk factors, and management

Hypertensive diseases in pregnancy (HDP) warrant particular attention given their role as one of the major causes of maternal mortality not only in Nigeria but also globally. They affect both the pregnant mother and the fetus, correlating with higher rates of maternal, fetal, and infant mortality and severe morbidity, particularly in cases of severe pre-eclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. Studies have identified HDP as among the leading causes of maternal morbidity and mortality, including in high-income countries such as the United States and the United Kingdom (Kuklina et al. 2009, Hutcheon et al. 2011, Barbosa et al. 2015, Nair et al. 2015, Nyfløt et al. 2018, Ford 2022, Jones 2022, Centers for Disease Control & Prevention 2023). HDP are defined as chronic hypertension, pregnancy-associated hypertension (including gestational hypertension, pre-eclampsia, eclampsia, and chronic hypertension with superimposed pre-eclampsia), and unspecified maternal hypertension (Shah 2019).

Classification of hypertensive disorders in pregnancy

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    Chronic hypertension: systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg before pregnancy or before 20 weeks of gestation, or use of antihypertensive drugs prior to pregnancy, or when blood pressure remains elevated beyond 12 weeks postpartum.

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    Chronic hypertension with superimposed pre-eclampsia: chronic hypertension together with organ dysfunction characterized by proteinuria, thrombocytopenia, pulmonary edema, elevated transaminase levels, renal insufficiency, or new-onset headache.

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    Gestational hypertension: systolic and/or diastolic blood pressure ≥140/90 mmHg after 20 weeks of gestation in a previously normotensive woman.

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    Pre-eclampsia: gestational hypertension with features of organ dysfunction such as proteinuria, thrombocytopenia, elevated transaminase levels, pulmonary edema, renal insufficiency, or new-onset headache or visual disturbance not attributable to another condition.

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    Pre-eclampsia without severe features: as defined above.

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    Pre-eclampsia with severe features: systolic and/or diastolic blood pressure ≥160/110 mmHg measured twice at an interval of four or more hours; generally, occurs in the third trimester and is associated with higher rates of maternal morbidity and mortality; characterized by hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome).

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    Eclampsia: new-onset seizures in a pregnant woman with pre-eclampsia.

Risk factors for hypertensive disorders in pregnancy

According to Umesawa & Kobashi (2017), risk factors for HDP can be modifiable or non-modifiable.

Modifiable risk factors include smoking, alcohol intake, elevated body mass index (BMI), anemia (which increases risk up to four-fold), and low educational attainment. Non-modifiable risk factors include maternal age greater than 35 years (with higher risk of pre-eclampsia in Black women and some other races younger than 20 years), gestational diabetes, primiparity, multiple gestations, prior pregnancy complications (history of pre-eclampsia), family history of type 2 diabetes, hypertension, or pre-eclampsia, pre-existing diseases (diabetes mellitus, renal diseases, autoimmune diseases, chronic hypertension, urinary tract infection, and pyelonephritis), and certain genetic variations.

Management approaches for hypertensive disorders in pregnancy (Umesawa & Kobashi 2017, Khedagi & Bello 2021)

Prevention and early detection: early PNC registration and attendance; screening for chronic HTN and diabetes; increased surveillance for non-modifiable risk factors; prompt diagnosis and early referral; close monitoring in health facility; good nutrition and DASH diet; BMI control.

Pharmacological:

First-line: beta-blockers (e.g. labetalol), calcium channel blockers (e.g. nifedipine), and alpha-methyldopa.

Second-line: hydralazine and hydrochlorothiazide.

Contraindicated medications: ACE inhibitors (e.g. lisinopril) and angiotensin receptor blockers (e.g. losartan) – teratogenic.

Prophylaxis: low-dose aspirin, calcium supplementation, vitamin C, vitamin E, vitamin D, fish oil, and folic acid.

Eclampsia prevention: magnesium sulfate – effective in preventing eclampsia in patients with pre-eclampsia (Khedagi & Bello 2021).

Systemic measures: women’s education and empowerment; increasing health-seeking behaviors; and collaborative efforts at individual, public, and government levels.

Obstetric hemorrhage: classification, risk factors, and management

Obstetric hemorrhage is excessive or significant pregnancy-related blood loss that occurs before, during, or after childbirth. As a major cause of maternal and perinatal morbidity and mortality, obstetric hemorrhage requires prompt intervention (Walfish et al. 2009, Drew & Carvalho 2022).

Risk factors for obstetric hemorrhage (Muluye et al. 2023, Wormer et al. 2024)

Maternal risk factors: advanced maternal age, short inter-pregnancy interval, history of maternal hemorrhage in previous pregnancy, maternal smoking and other substance use, multiparity and grand-multiparity, history of uterine surgeries, history of early pregnancy bleeding, chronic maternal hypertension and pre-eclampsia, uterine tumors (e.g. fibroids), maternal obesity, prolonged or precipitate labor, anemia, and multiple pregnancies.

Sociodemographic risk factors: lack of PNC registration or attendance, low socioeconomic status, inability to access or afford healthcare services, late presentation to health facilities, lack of education, poorly equipped healthcare facilities and inadequate manpower, delays in treatment and referral, and emergency admissions or referrals.

Classification of obstetric hemorrhage (Dibaba et al. 2021, Willacy 2022)

Antepartum hemorrhage: occurs after 24 weeks’ gestation, before onset of labor. Common causes include placental abruption, placenta previa, uterine rupture, vasa previa, cervical laceration, genital trauma, tumors, chorioamnionitis, and coagulation defects.

Intrapartum hemorrhage: occurs during labor and delivery. Common causes include uterine atony, genital laceration/trauma, placental abruption, placenta accreta, and uterine rupture.

Primary postpartum hemorrhage: occurs within 24 h after childbirth. Common causes include uterine atony, retained placenta/products of conception, uterine rupture, genital tract laceration, coagulation disorders, placenta accreta/increta/percreta, and uterine inversion.

Secondary postpartum hemorrhage: occurs after 24 h to 12 weeks postpartum. Common causes include retained products of conception, infection, subinvolution of placental site, and coagulation disorders.

Management approaches for obstetric hemorrhage (Walfish et al. 2009, Bazirete et al. 2020, Drew & Carvalho 2022, Okonofua et al. 2022, Oguejiofor et al. 2023)

Prevention and risk reduction: education on the importance of PNC, contraceptive use, and child-spacing; health awareness campaigns; early hospital presentation; women’s empowerment; training healthcare professionals on detection and management; and adequate maternal nutrition.

Policy-level interventions: government implementation of policies such as providing free maternal and child health services and free PNC, building and equipping health facilities, and employing more health workers.

Medical management (facility-based): prompt recognition and treatment of underlying cause(s); IV access and fluid resuscitation; assessment of blood loss and transfusion with blood/blood products; active management of the third stage of labor (Okonofua et al. 2022, Oguejiofor et al. 2023); uterotonics (oxytocin, misoprostol); uterine packing and intrauterine tamponade; surgical/radiologic interventions (arterial embolization, uterine curettage); close feto-maternal monitoring; and immediate referral to higher-level facility when indicated.

Causal pathways and contextual drivers

The persistently high maternal mortality in Nigeria reflects the convergence of multiple interconnected causal pathways rather than isolated risk factors.

The healthcare system pathway involves chronic underfunding of the health sector, poor distribution of health facilities and personnel (with concentration in urban areas), inadequate emergency obstetric care capacity, and the ongoing emigration of healthcare professionals (Olonade et al. 2019, Akinwale & George 2022, Kamarulzaman et al. 2022, Ajoseh et al. 2024, Chidinma 2024, Lucas 2024). These systemic deficiencies mean that even when women reach a health facility, the quality of care may not be sufficient to prevent death from treatable complications, such as PPH or eclampsia.

The socioeconomic pathway links poverty, low educational attainment, and gender inequality to reduced healthcare utilization. Women with limited education are less likely to recognize obstetric danger signs, less empowered to make autonomous healthcare decisions, and more likely to rely on traditional birth attendants (Anikpe et al. 2019, Etokidem et al. 2022). Financial barriers such as direct costs of care, transportation, and opportunity costs create a vicious cycle in which the poorest women have the highest risk of complications but the least access to life-saving interventions (Table 4).

Table 4.

Contributing factors to maternal mortality by geopolitical zone

Contributing factor NC NE NW SE SS SW References
Poor PNC utilization* ✓ ✓ ✓ ✓ ✓ ✓ Bello et al. (2015), Okonofua et al. (2017), Gulumbe et al. (2018), Usman et al. (2018), Anikpe et al. (2019), Hemabh-Hilekaan et al. (2019), Ugwu et al. (2020), Akaba et al. (2021), Olamijulo et al. (2022), Kahansim et al. (2023), Umeononihu et al. (2023), Adinma-Obiajulu & Adinma (2024), Njoku et al. (2024)
Financial constraints / poverty† ✓ — — ✓ ✓ ✓ Bello et al. (2015), Awowole et al. (2017), Awoyesuku et al. (2020), Ugwu et al. (2020), John-Abebe (2024)
Delays in care (three-delays model)† ✓ — — ✓ ✓ ✓ Bello et al. (2015), Awowole et al. (2017), Mbachu et al. (2017), Okonofua et al. (2017), Akaba et al. (2021), Adinma-Obiajulu & Adinma (2024), John-Abebe (2024)
Lack of formal education† ✓ ✓ — ✓ ✓ — Bakari et al. (2015), Usman et al. (2018), Anikpe et al. (2019), Akaba et al. (2021), Kahansim et al. (2023), Umeononihu et al. (2023)
Grand-multiparity — ✓ — ✓ — — Bakari et al. (2015), Usman et al. (2018), Umeononihu et al. (2023)
Poorly equipped / staffed facilities — ✓ ✓ — — ✓ Maiwada et al. (2016), Okonofua et al. (2017), Usman et al. (2018), Sageer et al. (2019), Oyeniyi et al. (2020)
Young maternal age (<30 years) — — ✓ — ✓ — Anikpe et al. (2019), Oyeniyi et al. (2020);
Home delivery / unskilled attendants‡ — ✓ ✓ — ✓ — Gulumbe et al. (2018), Arisukwu et al. (2021)
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✓, documented in reviewed studies from that zone; —, not prominently reported.

NC = north-central; NE = north-east; NW = north-west; SE = south-east; SS = south-south; SW = south-west; PNC = prenatal care.

*

The only contributing factor reported across all six geopolitical zones.

†

Reported in four of six zones.

‡

Prominent in NE, NW, and SS zones.

The cultural and behavioral pathway encompasses deeply rooted beliefs and practices that influence care-seeking behavior. Preference for home delivery, reliance on traditional birth attendants, and distrust of formal healthcare systems contribute to the first and second delays. In northern Nigeria, cultural norms restricting women’s autonomy and mobility further compound these barriers (Maiwada et al. 2016, Sharma et al. 2017, Gulumbe et al. 2018) (Table 5).

Table 5.

Illustrates the three-delays model as documented across the reviewed Nigerian studies

Delay type Description Examples from reviewed studies References
First delay Delay in deciding to seek care Failure to recognize danger signs; reliance on traditional birth attendants; cultural/religious barriers; refusal of recommended treatment Mbachu et al. (2017), Okonofua et al. (2017), Arisukwu et al. (2021), Adinma-Obiajulu & Adinma (2024)
Second delay Delay in reaching a health facility Poor road infrastructure; lack of ambulance services; long distances to referral centers; financial inability to afford transportation Awowole et al. (2017), Sageer et al. (2019), Awoyesuku et al. (2020), Akaba et al. (2021), John-Abebe (2024)
Third delay Delay in receiving adequate care at the facility Poorly equipped facilities; inadequate staffing; unavailability of blood products; poor case management; lack of treatment protocols Maiwada et al. (2016), Awowole et al. (2017), Okonofua et al. (2017), Usman et al. (2018), Oyeniyi et al. (2020), John-Abebe (2024)
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The role of unsafe abortion and ectopic pregnancy

The role of unsafe abortion as a driver of maternal mortality is worth mentioning. Nigeria’s restrictive abortion laws push women toward clandestine procedures performed by unskilled personnel under unsafe conditions. The resulting complications such as hemorrhage, sepsis, and organ damage are major contributors to maternal death, particularly among young, unmarried women (Hemabh-Hilekaan et al. 2019, Kahansim et al. 2023). The true burden is likely substantially higher than reported, as abortion-related deaths are frequently misclassified or concealed due to stigma and legal consequences.

Similarly, ectopic pregnancy, a potentially fatal early pregnancy complication included within the WHO definition of maternal death, was rarely reported as a distinct cause of death in the reviewed studies. The study from Madonna Teaching Hospital in Rivers State noted that most deaths were from ‘early pregnancy bleeding’ (Mbachu et al. 2017), which may include complications of ectopic pregnancy and early pregnancy loss. The relative absence of ectopic pregnancy from most facility-based reports likely suggests classification practices rather than true absence, as ectopic pregnancy remains a significant cause of first-trimester maternal death in LMICs.

Facility-based versus population-based evidence

A critical limitation of the available evidence is the predominance of facility-based studies, which are subject to referral bias. Tertiary hospitals disproportionately receive complicated cases transferred from lower-level facilities, inflating the apparent MMR. The extremely high MMR of 7,364 per 100,000 reported from Federal Medical Center Nguru (Usman et al. 2018) likely reflects this phenomenon, as the facility serves as a referral center for a large catchment area with limited alternative services. Population-based estimates using the sisterhood method, such as those from Jigawa (1,012 per 100,000) (Sharma et al. 2017) and Kebbi (890 per 100,000) (Gulumbe et al. 2018), give more representative estimates but are prone to recall bias and may underestimate recent trends. National-level claims should, therefore, be interpreted cautiously, recognizing that the true population-level MMR likely falls between the lower population-based estimates and the higher facility-based figures.

Reviewed studies also showed several contributory factors to maternal mortality in Nigeria, such as not registering for or attending PNC, financial constraints, poorly equipped or poorly staffed healthcare facilities, lack of formal education, and high parity, among others. Berhan & Berhan (2014) in their systematic review noted the importance of PNC in reducing maternal mortality, and a pooled multi-country analysis on the correlation between PNC and maternal mortality showed a reduction in maternal mortality among women who attended PNC (Chilot et al. 2023). Madoue et al. (2023) also reported low prenatal care attendance in their study. This shows the necessity of PNC in the prevention of maternal mortality and the need to improve access to PNC service delivery and improve the healthcare system of Nigeria with high emphasis on maternal and child health. In Chad, Acquah et al. (2022) identified various factors such as poor PNC attendance and low education level as contributory to maternal mortality. Although the study conducted in south-east Chad revealed PNC attendance to be over 50%, the study reported several barriers such as socioeconomic factors, illiteracy, limited access to health facilities, and cultural beliefs as having a negative impact on maternal health services (Marquis et al. 2022). In the Republic of Niger, Kante et al. (2024) identified that despite several advances in maternal and child health, barriers in accessing emergency obstetric care, unequal distribution of health workforce and infrastructure, and high fertility rate remained challenges.

Recommendations

From the reviewed literature, it is evident that several factors such as poor PNC attendance, lack of formal maternal education, and poorly equipped and staffed health facilities are responsible for the alarmingly high MMR in Nigeria. Although there have been some efforts to decrease this rate, more remains to be done, especially to address the underlying contributory factors. To ensure that the issue of maternal mortality in Nigeria is mitigated and that the country meets the SDG 3 targets by 2030, the following recommendations are proposed, organized by feasibility and implementation priority.

Strengthening prenatal care access and utilization

Since poor PNC utilization is the most frequently cited contributing factor, there is a need for the government to make PNC services completely free for pregnant women. This has been shown to be effective where implemented; the declining MMR observed in Ondo State was attributed to the free maternal health services offered at the institution (Oyeneyin et al. 2017). Rather than mandating PNC attendance, which raises ethical concerns regarding autonomy and human rights and would be difficult to enforce, a more feasible approach can be introduced. This can be achieved by removing financial barriers (such as user fees, transportation costs), integrating PNC with existing community health programs, deploying community health workers to promote PNC uptake, and utilization of mobile health technologies for appointment reminders and health education. A minimum of eight PNC contacts, as recommended by WHO, should be promoted.

Optimizing emergency obstetric care

Prioritizing the upgrading of existing health facilities to provide basic and comprehensive emergency obstetric and newborn care is more realistic than constructing new facilities de novo. This includes making sure there is an availability of essential commodities (oxytocin, magnesium sulfate, blood products), training healthcare workers in evidence-based management of obstetric emergencies and establishing functional referral networks with ambulance services. The cost of upgrading existing facilities is significantly lower than constructing new ones and can be implemented incrementally. Emergency ambulance services should be expanded across all locations in Nigeria, including rural areas.

Addressing unsafe abortion and early pregnancy complications

Minimizing abortion-related maternal deaths requires a multifaceted approach including expanded access to family planning and contraception, provision of post-abortion care at all levels of the health system, and community education to reduce stigma around seeking care for abortion complications. Improved surveillance and classification of early pregnancy deaths, including ectopic pregnancy, is also needed to better quantify the burden.

Retention and development of health workforce

The emigration of healthcare professionals from Nigeria has reached critical levels (Olonade et al. 2019, Akinwale & George 2022, Ajoseh et al. 2024, Chidinma 2024, Lucas 2024). Addressing this requires improved remuneration and working conditions, career development opportunities, and creation of enabling practice environments. The government should discourage the current medical brain drain by providing incentives for healthcare workers, increasing their wages, and providing an adequate, enabling, and functional environment. Task-shifting strategies such as training midwives and community health extension workers to manage uncomplicated deliveries and recognize danger signs can partially mitigate workforce shortages in the short term. Specialized training of health professionals to effectively handle high-risk obstetric cases should also be prioritized.

Women’s education and empowerment

Investing in girls’ education, especially in northern Nigeria where educational attainment is lowest, has downstream effects on maternal health through enhanced health literacy, delayed marriage and childbearing, improved economic independence, and greater healthcare decision-making autonomy. Basic education should be made completely free for the girl child, and cultural beliefs and practices that discourage education and empowerment of women should be addressed via community engagement.

Health awareness and promotion

Increased health awareness and health promotion should target the vulnerable population, particularly women of reproductive age. The awareness should focus on the importance of regular medical checkups, disease screening and prevention, and recognition of obstetric danger signs. Family planning and use of reliable methods of contraception should be encouraged, and family planning counseling should be part of every visit of a reproductive-age woman to a health facility.

Strengthening vital statistics and maternal death surveillance

The Nigerian Ministry of Health should develop evidence-based guidelines for managing common obstetric and gynecological conditions and ensure that all health facilities adopt such guidelines. The government should put policies in place to ensure appropriate and adequate documentation of vital statistics by all health facilities, both government-owned and private. Health facilities should adopt regular audit meetings to review morbidity and mortality rate trends. The health ministry should ensure that all healthcare providers are appropriately licensed, and their licenses are up to date. Minimum standards should be established for all health facilities, especially private-owned ones, including requirements for a particular number of healthcare professionals, blood bank services, and ability to handle health emergencies. Facilities not meeting such standards should face penalties.

Use of telemedicine

Telemedicine should be developed and utilized in PNC services to foster communication between pregnant women and their healthcare providers, particularly in rural and underserved areas.

Increased health funding

The yearly budgetary allocation for health, especially for maternal and child health, should be increased, and the usage of funds should be monitored to ensure compliance and prevent misappropriation.

Limitations

This narrative review has several limitations. The absence of a systematic search protocol, formal study selection criteria, and quality assessment means that the findings may be subject to selection bias. The predominance of facility-based studies limits the generalizability of reported MMRs to the broader population. Several Nigerian states had no published studies within the review period, creating geographic gaps in the evidence. The heterogeneity of study designs, time periods, and outcome definitions precluded quantitative synthesis. The exclusion of studies published before 2015 may have omitted relevant earlier data; this cutoff was chosen to focus on the most recent evidence coinciding with the SDG era but may limit historical trend analysis.

Conclusion

The current poor maternal health system and the alarmingly high MMR in Nigeria are matters of grave concern. There is a need to ensure that the expectation of a healthy pregnancy does not turn into a tragic reality, especially in a developing country, such as Nigeria. Maternal mortality is driven by a combination of direct obstetric causes, predominantly HDP and hemorrhage, with significant contributions from unsafe abortion and sepsis; and systemic factors including poor PNC utilization, healthcare system deficiencies, poverty, and low educational attainment. Achieving the SDG 3.1 target will require coordinated, sustained investment in maternal healthcare infrastructure, workforce development, community engagement, and policy reform. This calls for a collaborative effort at the individual level and all levels of the Nigerian government to ensure that the country meets the SDG 3 targets on or before the next five years.

Declaration of interest

The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the work reported.

Funding

This research did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.

Author contribution statement

CDO developed the topic and performed the primary search, drafted the original paper, and reviewed and incorporated edits. AA provided research support, reviewed and edited this manuscript, and supplied financial support. MK reviewed and edited this manuscript.

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