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Despite having the largest economy in Africa, Nigeria also loses more women to death in childbirth than most other countries in the world. In 2020, about 82,000 Nigerian women died due to pregnancy-related complications, a slight improvement on the previous year, but an increase on previous decades.

The causes of death included severe haemorrhage, high blood pressure (pre-eclampsia and eclampsia), unsafe abortion and obstructed labour. Doctors and activists say high maternal mortality rates reflect a lack of trust in a broken public healthcare system and little political will to fix it.

The World Health Organization recommendation for a functioning healthcare system is one doctor for every 600 people; in Nigeria, the ratio is one for every 4,000-5,000 patients. The federal budget for healthcare in 2024 is 5% , a record high, but far short of the 15% suggested by the UN.

Most Nigerians live in areas without well-equipped medical centres or have to pay upfront for treatment. During pregnancy, women skip prenatal check-ups, choose traditional healers and often don’t resort to seeking professional medical help until it is too late. Nigeria’s rate of 1,047 deaths per 100,000 births in 2020 is the third-highest maternal mortality in Africa and far from the UN goal of 70 deaths per 100,000 to be reached globally by 2030.

The patient

Lawal Arinola, 31, arrived at the Lagos Island maternity hospital early in the morning. Her uterus was not contracting after a caesarean section at a private health centre the previous day. She was losing blood and had acute renal failure. The hospital lifts had been broken for months and ground-floor theatres were unavailable, so as she went into cardiac arrest she was carried on a stretcher to a second-floor operating room. An anaesthesiologist started heart massage, shouting for adrenaline to be delivered as the machine monitoring Arinola’s heart bleeped out a flat line.

It was five minutes before she was resuscitated and Dr Olusola Togunde and his team could perform an emergency hysterectomy. The room was hot and several times a nurse wiped sweat from Togunde’s forehead. He was checking for remaining sources of bleeding when the lights went out for the third time that day. In theory, every theatre in the hospital has a constant supply of energy from a generator, but this time the connection failed. The machines monitoring Arinola’s vital signs fell silent and the lights went off. Togunde made the post-operative stitches using the torch from a phone held by one of his assistants.

Despite all efforts of hospital staff, Arinola did not wake up from the surgery. The septic shock that she arrived with turned into multiple organ disfunction. She died in the hospital’s ICU eight days later.

The doctors

“The road to maternal mortality is filled with delays,” says Togunde, obstetrician and gynaecologist, and the head resident of the Lagos Island maternity hospital. In his 17 years of working he has seen tragedy after tragedy. He describes women being brought to the hospital unconscious after waiting for hours or even days before seeking medical help, because they fear the costs, or have to wait for husbands or male family members to take action.

Accessing healthcare is a problem around the country. In densely populated Lagos, with its unreliable public transport, even ambulance sirens don’t make the heavy traffic move.

There are delays too in the hospital itself. Togunde deals with patients shifted from one facility to another due to lack of space. The Lagos Island hospital has rigorous protocols. It has reduced the number of maternal deaths in the past 10 years from 93 in 2013 to 38 in 2023.

Where an emergency caesarean is required, the patient has to reach surgery within 30 minutes. Posters outlining the hospital rules and its efforts to fight maternal mortality adorn the walls of the hospital. Medicines are kept ready in the emergency room, so relatives do not need to go to a pharmacy to buy them, as often happens in other hospitals; and there is an emergency fund for the poorest, paid for by donors and sometimes doctors too. Yet, still the hospital struggles.

The dire state of healthcare prompts many medical professionals to emigrate, exacerbating the problems.

“Manpower is a problem,” says Togunde. “We have space, but sometimes we don’t have people to operate. The hospital does not employ staff [they are employed by the government], it is beyond our competence, and doctors emigrate. The young ones don’t even stay. Sometimes people just leave without notice, so you cannot guarantee the number of staff you will have the next day.”

“I understand that people are dying from lethal diseases, but pregnancy is not a disease,” says Dr Moses Olusanjo, a senior consultant at the maternity ward of Lagos State University teaching hospital, the principal referral centre for patients in Lagos with complications. Olusanjo has worked there and at Lagos Island hospital for more than 11 years, but is now planning to continue his education – and possibly his career – abroad.

“When you go to countries like the UK, women don’t die like here,” he says. “The problem of maternal mortality is a reflection of how our society works. Until the standard of life increases, this will not go away. The reduction of maternal mortality is solely within the power of our leaders. The problem is too vast for doctors alone to handle. It takes political will to say that our women will not die.”

The activist

Abiola Akiyode-Afolabi runs the Women Advocates Research and Documentation Center (WardC), an organisation aimed at combatting maternal mortality and gender-based violence. She had two very different experiences giving birth to her own children, one in the US and one having an emergency caesarean in a public hospital in Lagos.

“After the surgery in Lagos, I was left on a bed in a corridor while I was still bleeding,” she says. “For two hours, I was screaming for help.”

When Akiyode was finally taken by her brother to a post-delivery room, she was forced to switch beds and bathe alone just hours after the surgery. There were no sanitary products. Some of the women she shared a ward with were taken for emergencies at night, and never returned.

“I believe that they died,” she says. “This was the first time that I realised how often women were dying in this country. I saw it firsthand. It was like a mortality centre, this ward called Ward C.” Later, she named her organisation after the place of her traumatic experience.

Akiyode believes much greater political commitment is required. In 2014, her organisation and several others filed a petition to the African Commission on Human and Peoples’ Rights, charged with ensuring that African states comply with human rights obligations, to reaffirm Nigeria’s duty to end preventable maternal mortality. “We hope it will help to increase budgets, establish a national plan and take the matter seriously on a national scale,” she says.

The survivor

In the post-delivery unit of Lagos State University teaching hospital, Torkwase Umoru, 26, was discharged in time for her daughter’s first birthday. A month earlier, she started having abdominal pains and went for a scan at a private hospital in Lagos where she learned she was pregnant and that the foetus had died.

She underwent an evacuation, but over the next few days the pain became unbearable. By the time she was brought to the emergency unit, she had sepsis, a perforated bowel, and her life was in danger.

Umoru is still not sure what lead to the development of such a severe condition, whether it was uterine fibroids already present before the first pregnancy, or the way her stomach was sewn after an emergency caesarean when her daughter was born; was it a poorly performed evacuation of the dead foetus days earlier, or a lack of a proper diagnosis?

Even after surgery she did not feel better. She could not eat or drink, a colostomy bag had been attached to the side of her stomach and was burning her skin. Her husband stopped going to work and visited her every day to clean her wound.

“I felt depressed, ashamed, worthless,” she says. “But I was not afraid of dying. In fact, at that point I wanted to die. My husband told me later that he was hiding all sharp objects from my sight. He knew that I could try to hurt myself, that I was thinking about that.

“Now, after all I went through, I don’t think that I want more kids. We will maybe try to adopt,” she adds.

The foster mother

In a chemist shop in rural Ota on Lagos’ outskirts, Damilola Ayomide, an auxiliary nurse and mother of three, sells basic medicines such as painkillers, as well as children’s clothes and bread. Otherwise, the shelves in her store are almost empty.

She keeps an eye on the baby asleep in a basket on the ground. It is her younger brother’s son, Oluwaremilekun, which means “God wipe my tears” in Yoruba.

His mother, Seun Fadipe, 27, died three days after his birth at a local hospital. During pregnancy she was often sick, her legs were swollen and she fainted several times. Ayomide says the family would take her to a hospital each time, but she was always discharged within a few hours after being put on a drip and medication.

When the time came, Fadipe was so weak that the family raised money for a caesarean section. It went well, they were told, and Ayomide visited her in a hospital the day before she died.

“The hospital just called my brother to tell him that his wife was dead,” says Ayomide. “We don’t have any documents; we don’t know what exactly happened. They said that she was complaining of a headache and abdominal pain, but died before the nurses came to check.

“We could not believe it. It was so painful for my brother, I’ve never seen him like that. We all cried so much, but what could be done? It was God’s will to take her.”

Afterwards, the family decided it was best for Ayomide, with her nursing experience, to look after the baby. “I now go everywhere with the baby. I put him in a chair or in a bed and attend to my patients. Sometimes, I have to stop the visit if he cries. Last time, when I left him with a friend for a few days, he got a fever. He does not like being anywhere else. I’m his mama now. But it affects me a lot, I have my own children to take care of,” she says.

In Nigeria people depend on their extended families, especially the women who hold communities together. Every time Togunde loses a patient, he wonders about her family. He sees the pain of her parents or partner but thinks of the consequences that go further.

“Each time with a death of a mother, a household, a community, is destroyed,” he says. “The children she had don’t have their primary carer – some drop out of school, most are sent to distant relatives; siblings are separated. Once the mother is gone, her family is scattered. Their home no longer exists.”

Additional reporting by Olaoluwa Olowu