Success stories contributing to NMR and MMR reduction in Niger

Niger’s history of innovative public health interventions and health care reforms led to a 49% reduction in the maternal mortality ratio (MMR) from 2000 to 2020, and a 23% reduction in the neonatal mortality rate (NMR) from 2000 to 2022.

^, Expansion of health coverage and reduction of mortality in Niger over this period is notable, given the high baseline levels of NMR and MMR and the context of political instability.^, These accomplishments are a testament to the dedication of leadership in the health sector, the resilience of its health system, and a sustained national will to improve maternal and newborn health that spans crises and changes in government. Niger’s successes offer lessons for future maternal and neonatal health interventions in other high-mortality and lower-income settings. This narrative provides three success stories of key policies and programs that contributed to NMR and MMR reduction in Niger.

Background

The Exemplars in Neonatal and Maternal Mortality study identified seven countries that achieved exceptional progress in reducing neonatal and maternal mortality between 2000 and 2017, beyond what could be attributable to their economic progress alone. These countries were then studied to evaluate factors associated with rapid reductions in neonatal and maternal mortality. A mixed-methods approach was used to assess key drivers of progress, leveraging literature reviews, qualitative analyses, policy and program reviews, and quantitative analyses of country-level data.

In selecting NMR/MMR Exemplar countries, the research team intentionally selected countries with a range of baseline mortality levels, in hope of identifying success factors for a wide variety of country contexts. Despite political setbacks during and since the study period in Niger, as well as periods where some maternal and newborn health indicators experienced stagnation, in-country research identified specific aspects of maternal and newborn health (MNH) programming that can provide valuable lessons—especially for other settings with high mortality levels.

The reforms of the 2000s

Niger made extensive efforts in the 2000s to make health care more accessible through a series of ambitious programs that expanded the number of health care facilities and health workers, reached remote and previously underserved communities, and waived healthcare fees for pregnant women and for children under five. According to UN IGME (Inter-agency Group for Child Mortality Estimation) estimates, the neonatal mortality rate (NMR) was reduced by 23%, from 44 to 34 deaths per 1,000 births between 2000 and 2022.

UN MMEIG (Maternal Mortality Estimation Inter-agency Group) estimates suggest the maternal mortality ratio (MMR) was reduced by 49% from 2000 to 2020, decreasing from 867 to 441 deaths per 100,000 live births.

A presidential declaration kicks off a period of reform to scale up health infrastructure

In 2000, a Presidential Declaration for Rural Development was launched to ensure access to basic services across the country, including healthcare services. This declaration spurred a major scale-up and localization of its health care facilities at the community level.

The number of integrated health centers (IHCs) increased rapidly over time to reach previously underserved rural communities, from 400 in 2000 to 856 in 2012, and 1,194 in 2020. IHCs are midlevel health facilities in the Nigerien health care system, providing basic primary health care services. Most IHCs (75% as of 2020) are categorized as type 1, meaning they have more basic infrastructure, such as a delivery room but not a dedicated delivery ward. Type 1 IHCs tend to be staffed by one or two nurses. The remaining 25% of IHCs are type 2, each equipped with a delivery ward, laboratory, and staffed with additional trained personnel such as two nurses, a midwife, and a lab assistant.^, From 1998 to 2021, institutional delivery increased from 18% to 45% of all deliveries, with the growth of the IHC network, especially type 1 IHCs, supporting increased access to delivery care services.^, The 1998 Demographic and Health Survey (DHS) found that only 16% of institutional deliveries took place in IHCs, with 81% taking place in public hospitals. By the 2021 Enquête Nationale sur la Fécondité et la Mortalité des Enfants de Moins de Cinq Ans (ENAFEME), 70% of institutional deliveries took place in IHCs, and 8% took place in public hospitals.^,

Niger also scaled up the number of health care workers in the 2000s. Starting with only 296 medical doctors in 2004, or only 0.22 medical doctors per 10,000 people, Niger increased the number of doctors to 952 by 2012, more than doubling density to 0.53 doctors per 10,000 people.

Similarly, in 2004, Niger had 2,818 nurse/midwives or 2.11 nurse/midwives per 10,000 people. This figure rose to a 2014 peak of 5,899 nurse/midwives, a 45% increase in density at 3.05 nurse/midwives per 10,000 people.

Waived fees contributed to increases in uptake of maternal and neonatal health services

The surge in use of maternal and neonatal health services has followed a set of policies enacted in the late 1990s and early 2000s. The Health Development Plan (1994-2000), National Primary Health Care Support Program (1995-2002), and Health Development Strategy (2002-2011) were important high-level strategies and action plans that demonstrated concerted efforts to improve healthcare in Niger.

In 2006, fees for health services were waived for pregnant women and for children under five years, including for family planning, ANC, intrapartum care, and emergency obstetric care. This fee exemption was paid for with a combination of national budget funds and support from the French Development Agency, the Global Fund, UNICEF (United Nations Children’s Fund), and local NGOs, with reimbursements to health facilities paid out monthly.

Coverage of many MNCH services increased in the 2000s following these health policy reforms. From 1998 to 2012,  demand for family planning satisfied by modern contraceptive methods substantially increased from 17.8%  to  40.8%.

^, The percentage of pregnant women receiving at least one antenatal care (ANC) visit more than doubled from 40.3% in 1998 to 87.8% in 2012, while those with at least four visits over the same period nearly tripled from 11.3% to 33.1% (Figure 1).^, In this 14-year span, the rate of institutional delivery also grew, from 18.1% to 34.1%.^,,

These numbers are suggestive of a health care system focused on expanding service delivery while ensuring rural areas and other underserved communities are not left behind. The fee waiving policy experienced a number of challenges in its implementation, including timely and efficient disbursement processes that affected the availability of essential commodities in facilities.

Although these obstacles in the rollout and administration raise questions about the program’s long-term sustainability, overall these policies still contributed to a period of improvements in key MNCH coverage indicators. Collectively, this evidence suggests a successful example of how policy reform and the removal of financial barriers can propel improved uptake of essential primary health care services. Moving forward, further progress will be needed to ensure all women and newborns can access necessary health care services at the time of birth.

Progress slowed with political instability in the 2010s

Although health reforms showed success in the first decade of the 2000s, a military coup in 2010 interrupted Niger’s progress in expanding access to health care. Some MNCH indicators stagnated or regressed in this period. For example, though some efforts to improve availability of human resources for health showed growth, they were not sustained in the 2010s.

The density of nurses/midwives declined to 2.03 nurse/midwives per 10,000 population by 2015—a lower level than Niger began with in 2004.

Political instability negatively impacted Niger’s health system in the early 2010s because of government changes in priorities and closure of health facilities.

One physician shared their thoughts about this time: “In the areas where displaced persons [were] staying, the available health structures and services [did] not fully cover the enormous needs of the displaced and host populations.”

Health systems resilience and recovery is a notable achievement, considering Niger’s context during these years. Recent survey data from 2021 suggest that in some aspects of MNH, Niger is beginning to overcome setbacks from this difficult period.

Although some indicators such as C-section rates and maternal postnatal care (PNC) coverage are still stagnating, progress is visible on several MNH indicators in ANC, institutional delivery, and neonatal PNC.^, The percentage of women receiving four or more ANC visits remained fairly stable from 32.8% in 2012 to 37.3% in 2021 (Figure 1).^, Institutional delivery rose from 34.1% in 2012 to 44.6% in 2021 (Figure 2).^, Coverage of neonatal PNC within two days also increased, from 12.9% to 34.0% over the same period.^, In terms of facility readiness, analysis of the 2015 and the 2019 Service availability and readiness assessment (SARA) surveys found that facilities were relatively well-equipped to provide ANC and BEmONC services. This evidence also suggests Niger was able to maintain facility readiness for ANC and BEmONC across facility types, including IHCs where many ANC visits and institutional births take place. Progress in these key indicators, in tandem with other successful programs described below, highlight the overall resilience of the Nigerien health system and the commitment of health care leadership through a period of instability.

Husband schools

During the study period, several unique programs were piloted in Niger and scaled up across the country to improve maternal and newborn health – including the husband schools initiative. Challenges related to gender inequality and access to health care still exist across multiple population characteristics. In 2012, about 20% of women in Niger had attended at least some primary education.

Women are typically married young, with 60.9% of women ages 15 to 19 married according to data in 2012. Median age at first birth was 18.5 years of age for women ages 20 to 49, and the total fertility rate in 2012 was estimated at 7.6 births per woman. At this time, 3.5% of wives reported that they were the primary decision-maker for their own health care, and 10% of wives reported they had the freedom to decide to visit their own relatives. In addition, indicators of women’s empowerment have generally stagnated since 2012. Engaging men in maternal and neonatal health topics is therefore a critical step in driving progress on women’s health and well-being in Niger.

Twice a month, in common areas of villages across the country, Nigerien men gather to learn about reproductive, maternal, and child health, and discuss how to support their families and communities in healthy practices. These gatherings, known as “husband schools” (Écoles de Maris), are an example of how Niger has delivered a culturally and contextually relevant health care program that improves the lives of women and families. Strong results from husband schools programs have led to their broad expansion in Niger and the introduction of similar initiatives in neighboring countries.

Figure 3 below presents a conceptual framework for how activities at husband schools ultimately can help to shift gender roles, improve knowledge and attitudes about healthcare, and promote uptake of health care services.

Husband schools engage men and educate them about women’s health

Launched by UNFPA (United Nations Population Fund) in 2008, the first 11 husband schools were set up in the Zinder region as a response to a survey about obstacles to reproductive health in Niger.

Following this example, more husband schools were established by NGOs such as Hellen Keller International, AGRANDIS Nut, and SongES Niger, which expanded the program to 50 villages. According to a UNFPA report, 1,284 husband schools had been established as of 2018, spanning nearly half of the country’s health districts. Information from SongES Niger suggests that these schools have engaged more than 10,000 model husbands since 2007.

The strategy of the husband schools is to focus on a core group of husbands in the village, encouraging them to understand the benefits of using reproductive, maternal, newborn, and child health (RMNCH) services, including family planning, antenatal care, and institutional delivery. To qualify for the group, a man must be married, at least 25 years of age, support his wife’s use of RMNCH services, and be generally considered by the community to be a good person.

These men, called model husbands (Maris modèles), then serve as agents of change in the wider community. Each husband school consists of eight to 12 members and is supervised by the project field officer and the head of the village health center. All members are also trained on essential practices related to nutrition and hygiene. Every member is considered equal, with no one husband designated as leader. The husband school model has proven to be adaptable based on the values and needs of each community.

Husband schools conduct a variety of activities to improve men’s knowledge, shift attitudes and behaviors, and increase community knowledge of MNCH practices.

The husband schools develop sketches to illustrate healthy behaviors and perform them in public settings, organize public health days in villages, and assist with water and sanitation construction projects. Members are also encouraged to share their experiences through peer learning, which allows for community concerns to be heard. In this way, the group can identify nonmember men in the community who might be receptive to a home visit from a health official, especially those not utilizing health services or preventing their wives’ access. The programs also promote men’s involvement in household responsibilities, which helps give women more time to be involved in their children’s health. According to an interview conducted by Mercy Corps, one father of four said of the husband school experience, “I’ve learned a lot of things. I’ve learned how to give my wife advice about exclusive breastfeeding practices. I help her with housework. I take the children when she’s cooking.” This is one example of how husband schools’ activities can lead to better communication in households and support shifts in gender roles.

Results seen in data and testimonials

Evidence suggests that husband schools have had an impact on increasing RMNCH knowledge and health service uptake in Niger. In 2019, the Institute for Reproductive Health at Georgetown University, in partnership with USAID (US Agency for International Development), conducted a qualitative evaluation of husband schools in three regions of Niger (Dosso, Tahoua, and Zinder), with 36 interview subjects and 117 focus group respondents.

Both wives of model husbands and wives of husbands who received information from model husbands reported that their husbands had become more informed and involved in their family's reproductive, maternal, and child health. Wives reported that they also learned more about reproductive health from their husbands and gained more independence in health-related decision-making processes. Husbands in the community reported that they viewed model husbands as sources of information when they had any health-related questions. Further, the perception of husband schools was found to have shifted over time: communities developed a sense of admiration for model husbands.

Subnational evaluations from UNFPA also speak to the impacts of husband schools increasing usage of RMNCH services.

^, In areas with husband schools, assessments found rapid progress in MNH indicators. For example, in the years since four husband schools were established in 2007, the family planning utilization rate in the Bandé district increased from 2% to 20%.^, Other key MNH services also showed higher uptake: the percentage of women who attended at least one ANC visit at the Bandé district IHC rose from 28.6% in 2006 to 87.3% in 2010, with higher skilled birth attendance rates in communities that have husband schools across the Zinder region.

Implications and insights

Although evidence from these evaluation of husband schools shows positive results, this approach alone does not necessarily promote women’s autonomy in health care decision-making.

The husband schools are an important channel of disseminating crucial women’s health information to men who are often the primary decision-makers in the household in Niger, but ultimately the goal remains for women to be able to make their own health care decisions. Still, evidence suggests that involving men in conversations about reproductive, maternal and newborn health is an effective strategy for effecting behavior change and cultural shifts.

The success of husband school programs in Niger has led to their initiation and expansion in other neighboring countries. Knowledge and implementation practices about husband schools were disseminated in the region more broadly starting in the late 2010s.

^, In 2023, the Sahel Women’s Empowerment and Demographic Dividend initiative developed a guide to help other Francophone Central and West African countries develop husband schools and future husband clubs, leveraging experts from Niger as well as Burkina Faso, Mali, and Mauritania.^,

A transformative postpartum hemorrhage program

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality, causing an estimated 27% of maternal deaths globally, with resource-constrained countries having the highest PPH burden. Niger's large-scale five-year PPH program decreased the incidence of PPH-related deaths by 53%, making the country's proportion of maternal deaths caused by PPH in health facilities (9.53%) comparable to that of high-income countries.

These remarkable results demonstrate that the treatment protocol used in the study has the potential to lead to further declines in PPH-related mortality in similar settings.

A powerful idea based on highly effective, low-cost interventions

The program began with the idea to make three highly effective and low-cost interventions to treat PPH available to all pregnant women. These three interventions are the drug misoprostol, an intrauterine condom tamponade, and a noninflatable antishock garment (NASG).

Misoprostol increases uterine tone, and the tamponade applies direct pressure to the uterine lining to decrease bleeding. An NASG applies pressure to the lower body to push blood upward away from the uterus and helps to treat hypovolemic shock. This initiative originated as a 2008 pilot project in the Tillaberi region in western Niger that succeeded in reducing PPH by 75% within three years.^, It was also influenced by the 2012 FIGO World Congress in Rome, where compelling evidence was presented on the efficacy of the three interventions. Funding for the pilot project came from the government of Norway, the government of Niger, the Kavli Trust (Kavlifondet), the InFiL Foundation, and individual donors from Norway, the UK, and the US. The program assessment was conducted by Health and Development International in collaboration with Niger’s Ministry of Health.

After the successful 2008 pilot, the program of interventions was rolled out nationally to all health care facilities in 2015. As of 2020, these facilities were composed of one national maternity hospital, eight regional maternity hospitals, 35 district hospitals, and 1,217 peripheral health centers. There was one round of training to train teams of trainers, who were taught about the causes of PPH, related supply systems, data management and reporting for the program, and how to deliver the three interventions. These teams were then deployed to every facility in the country that provided maternal health services to train the workers who would be implementing the program.

Figure 4 below shows the protocol for PPH prevention, monitoring, and treatment in Niger developed for this program. The program called for a PPH prevention dose of 600 µg of misoprostol to be distributed to every pregnant woman at her late third-trimester ANC visit. Women were given instructions about PPH warning signs, how to administer the misoprostol, and advised to bring the medication with them when they returned to give birth at a health facility.

Women would take the misoprostol immediately following delivery, with a traditional wraparound garment placed under her body. A study in Niger showed that this garment absorbs about 500 ml of blood—the threshold of bleeding that defines PPH. During institutional delivery, saturation of the wrap triggered the three-step intervention protocol listed below.

• Administering an additional treatment of 800 µg misoprostol and monitoring the bleeding.
• If misoprostol fails to stop the bleeding within 20 minutes, a condom tamponade is inserted and inflated with a saline solution so that it presses against the bleeding area.
• If bleeding persists for 6 to 12 minutes, an NASG is applied, and the mother is transported to a hospital. If a woman goes into shock or preshock, step three is implemented immediately, followed by steps one and two.

In the case of home delivery, this same protocol would take place after a woman was transferred to a health facility for treatment. Counselling at ANC and preventative misoprostol provision helped to mitigate risks before arriving a health facility in case of blood loss that saturated the wraparound garment.

Strong program execution yields reductions in mortality from PPH

A pre-intervention survey was conducted in 2012 to 2013 at every hospital in the country and at a representative sample of 150 health centers.

During the program’s implementation from January 2015 to December 2020, data on 1.4 million institutional deliveries were collected from 9 referral hospitals, 35 district hospitals, and 1,217 health centers. Data were reported monthly, with reporting becoming more complete as the program continued, from 26% at the start to 94% of all institutional deliveries by 2018.

Comparing data from the pre-intervention survey, the program was found to have reduced the percentage of maternal deaths caused by PPH in facilities from 32% to 10% (Figure 5).

The percentage of maternal deaths from PPH remained fairly consistent for every year of the program, from 2015 to 2020. Although maternal PPH case fatality rates before the program’s initiation are not available, the program survey found case fatality rates from maternal PPH were 5.05% in 2015, the first year of the program (Figure 5). This number declined each year over the five-year evaluation, and by 2020 stood at 2.58%, demonstrating reductions in mortality from PPH over time. PPH incidence rates measured during the program’s period were relatively stable over time – future programming may be able to reduce incidence through preventative strategies.

Maternal death rates from causes other than PPH were stable from 2015 to 2020—evidence that PPH declined since the implementation of this program. There is also no evidence that PPH has similarly declined in neighboring countries, providing further evidence that Niger’s unique PPH program is linked to this progress. Estimates from the research team also suggest that the implementation of this program resulted in 122,577 fewer cases of PPH and 1,417 fewer deaths from PPH from 2015 to 2020. The financial benefits of this program have been roughly estimated to be 5.7 times the annual budget for the program, costing about $37.94 per disability-adjusted life-year prevented.

Success through implementation of a systematic protocol

Niger is the first country to attempt to so rapidly reduce maternal mortality from PPH using such a systematic combination of three low-cost technologies.

Structuring the provision of these technologies in a protocol with defined checkpoints between steps may be just as fundamental to the program's success as the technologies themselves.

The impact of this program contains lessons for other countries with high PPH burden. Niger’s protocol and implementation have been leveraged in the development of a WHO PPH roadmap, published in 2023.

Additionally, all three elements in the treatment protocol are inexpensive and can be stored, transported, and administered without electricity, so making it standard procedure at birthing facilities around the world is highly feasible. Rolling out this program in every facility nationwide demonstrates strong political will: Niger was intent on ensuring all women in the country had access to these interventions, no matter what facility they delivered in. Niger’s success shows that under-resourced health facilities can achieve substantial reductions in maternal PPH mortality with implementation of this protocol. As Dr. Alassoum said in an interview with BBC News, “This method . . . can prevent millions more women around the world from bleeding to death after they give birth. Niger has done it, and other countries can too.”

Future directions for maternal and newborn health in Niger

Niger has shown how maternal and neonatal mortality can be reduced in high-mortality, resource-constrained settings, through actions such as political reforms and removing financial barriers to key health services. Initiatives in Niger, such as the ongoing PPH protocol, have proven influential by contributing to global guidance such as WHO’s roadmap to combat PPH between 2023 and 2030.

The broader relevance of husband schools is also evident in their expansion from Niger to other West and Central African countries, including Burkina Faso, Mali, Mauritania, and beyond.

Increasing coverage of key MNH interventions in Niger during pregnancy, in the intrapartum period, and after birth will be crucial. However, coverage alone is not enough -- improvements in the quality of care will also be needed to make progress on mortality.

Moving forward, Niger may also be able to harness lessons from other Exemplar countries farther ahead in the integrated mortality transition framework to increase health service coverage, improve quality, and ultimately propel further reductions in maternal and neonatal mortality.

Strengthening the MNH program and broader health system in Niger, while also adopting relevant lessons and strategies, will be critical for accelerated success as Niger seeks to build on successes and overcome the last decade’s challenges.