In 2010, some 40,000 Nigerian women died in childbirth — 14% of the world’s total maternal deaths. In many rural areas, women and girls marry young and put in long hours of gruelling domestic labour — grinding meal, fetching firewood and water, tilling and selling crops — well into late stages of pregnancy.
In the 1980s, with advice from international organizations, most African countries adopted direct payment for health services as the primary means to finance their health systems. Patients had to pay for health services out-of-pocket, severely hindering access to services for the most vulnerable. New recommendations in the 2000s called for African countries to offer subsidies or abolish payments for certain health services and groups. Until now, the impacts of these reforms in francophone West Africa have not been documented.