Experts at the international public health organization, John Snow, Inc., have recently published a series of research articles exploring why and where women deliver with no one present (NOP)[1, 2, 3, 4]. Per these studies, the phenomenon of giving birth with NOP is concentrated in regions of the world with the worst maternal and newborn indicators, such as Nigeria, Niger, India, Tanzania, Kenya, Uganda and Ethiopia. The studies demonstrate that delivering with NOP brings untold suffering to women and children, including permanent disability and maternal and newborn deaths.
Reasons Women Continue to Deliver Alone
Leading causes of death that have been observed among women who deliver alone are postpartum hemorrhage, placenta retention, and obstetric fistula. Based on work done in Nigeria, these scholars have classified the reasons why women continue to deliver alone, despite the risk it poses to their lives and the lives of their babies, into four broad categories:
- Lack of finances to pay for services, medicines/supplies and transportation
- Poor social status, evidenced by little to no formal education among women, weak involvement in decision-making on issues affecting their own health, unsupportive partner authority, which then serves as a vehicle for perpetuating harmful community norms
- Poor quality of care marked by poor readiness of staff, equipment and/or infrastructure that are either obsolete or unavailable
- Growing gap between desired family size and actual fertility, which translates into women being less care-conscious with higher order births, leading to a greater proportion of these births delivered with NOP. A good family planning program would have helped to close this gap, prevent excess fertility, and potentially reduce the number of women delivering with NOP. But family planning programs in most developing countries where NOP is most prevalent still lag behind the dire need for contraception.
In Nigeria alone, an estimated one million women gave birth with NOP in 2013. Given the large numbers of women delivering with NOP in many developing countries, and the close association between delivering with NOP and maternal/newborn morbidity and mortality, it is imperative that actions are taken to eradicate this harmful practice. The good news is that there are interventions tailored to address giving birth with NOP. Efforts to redirect women who deliver with NOP to skilled birth attendance or delivery with at least someone present have quickly gained traction, resulting in substantial decline in the number of women delivering alone.
One example of an effective intervention took place in Sokoto State, Nigeria, where a statewide initiative for community-based distribution of the cost-effective and lifesaving drugs misoprostol and chlorhexidine—to prevent postpartum bleeding and infection of the newborn cord, respectively—paired a community-based health volunteer with every pregnant woman who delivered at home. The presence of the health volunteers significantly reduced the likelihood that a woman would deliver alone, from a high of 25% to less than 1% in Sokoto State between 2008 and 2013 [1, 3].
Additionally, there is ample evidence showing that women and children who received skilled delivery care in Nigeria were less likely to die or suffer short- or long-term disability stemming from delivery complications, compared to their peers who delivered with NOP. A few key efforts, if implemented, could go a long way in saving the lives of mothers and children in Nigeria.
Recommendations to Decrease the Number of Women Who Deliver With No One Present
Based on the research by the JSI team, the following recommendations will decrease the number of women who deliver with NOP in the short-term:
- Implement the WHO vision of quality care, and ensure that every mother receives respectful, high-quality maternity care. This will increase the attractiveness of skilled delivery to all moms.
- Create more community awareness of risks associated with giving birth alone; help mothers and community leaders advocate for better access to skilled birth attendance.
- Give women financial assistance to enable them to use skilled delivery services. Research has documented that in places where delivering with NOP is prevalent, women would choose to use skilled delivery services if they had the financial means to procure them.
For long-term effects, the following structural changes are imperative:
- Replace short-term cash subsidies with more enduring universal health insurance coverage, particularly for maternal, newborn and child health care (at least, in the initial stages) that will guarantee mothers’ financial resources to pay for skilled delivery care. This will ensure that no baby is ever born unattended.
- Improve formal education level among women and girls to unleash their inner capacity to act on life-saving health messages.
- Support existing health facilities in providing quality delivery care: update existing infrastructure, provide electricity or functional generator in HF, provide essential equipment and drugs, increase staff size and mix, and implement the WHO recommended respectful maternity care framework.
These actions will disrupt factors associated with the practice of delivering with NOP in countries around the world. The evidence suggests that women are more likely to choose skilled attendance for delivery, if such resources are available, affordable and acceptable. This ought to be a priority for governments as well as leaders, experts, and members of the maternal health community.
— Fapohunda BM, Orobaton NG (2014). 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.  Fapohunda BM, Orobaton NG (2013). When women deliver with no one present in Nigeria: who, what, where and so what? PLoS One 8(7).  Austin A, Fapohunda B, Langer A, Orobaton N (2015). Trends in delivery with no one present in Nigeria between 2003 and 2013. International Journal of Women’s Health; 7: 345-356.  Orobaton N, Austin A, Fapohunda B, Abegunde D, Omo K (2016). Mapping the Prevalence and Sociodemographic Characteristics of Women Who Deliver Alone: Evidence from Demographic and Health Surveys from 80 Countries. Global Health Science and Practice Journal. 2016; 4: 99-113.