Niger, a poor landlocked country in sub-Saharan Africa, has ranked a total of nine times at the bottom of Save the Children's annual Mothers' Index since the launch of the survey in 2000.
This year is a bit different, though there's still not much to celebrate.
Out of 178 countries, Niger placed 175th in this year's list published on Tuesday, not the last but still part of the bottom five. And it's not so hard to understand why: 1 in 23 mothers there continue to be at risk of dying from giving birth, they often don't reach secondary school, and they have one of the lowest gross national income per capita and least participation in national government rate in the world.
Niger has made some progress over the years. In fact, the current maternal risk rate shows a decline of 35 percent from 2000, when the proportion of mothers dying from birth complications was as high as 1 in 15. The country also bested Nigeria in the percentage of women holding parliamentary seats, 13 percent versus the latter’s 6.6 percent.
Nevertheless, "progress hasn't been enough to pull Niger ahead of many countries in the overall Mothers' Index,” Michael Kiernan, communications specialist at Save the Children, told Devex.
The report partly attributes Niger's consistent poor rankings to the internal conflict it suffered since the early 1990s. The bottom 10 are all considered fragile states: Ivory Coast, Chad, Nigeria, Sierra Leone, Central African Republic, Guinea-Bissau, Mali, Niger, the Democratic Republic of Congo and Somalia.
Six of these nations also suffer from recurring natural disasters, as in the case of Niger, where over a million people are chronically food insecure due to droughts and desertification.
A 2012 Department of Health survey seems to support this view: Access to family planning methods is much higher in urban than rural areas (of the small percentage of females aged 15-49 with access to modern contraceptives, only 10 percent come from rural areas), and 68 infants per every 1,000 live births die in the countryside compared with 42 in towns.
Communities in remote areas are often more than 15 kilometers away from a health center, and many are not well-equipped to address various health needs.
"In urban settings, if a health center is ill-equipped, [people can] take a taxi or bus to go to a well-equipped center, but in rural areas, this would be very difficult," Issoufou said.
Early child marriage, high in Niger like in most sub-Saharan countries, communities' lack of awareness and cultural beliefs also play a role.
Some 33 percent of adolescents aged 14-19 in Niger have already given birth at least once, according to the same survey. Many women refuse to use contraceptives, or are not even aware these methods exist.
Issoufou argued: "Some communities refuse to accept — and therefore don't know the benefits of having access to family planning — but some are not aware at all. So if you go to behavior change communication, that could have good results in communities.”
In some areas in Niger, like for instance 19 communities in Tillaberi, health coverage is pretty good. There are schools, health centers and water supply.
But the picture for the remaining 14 communities in that district is different.
Issoufou said that while there have been attempts by donors and aid partners to set up basic infrastructure like health centers, this is not enough. For instance, without a decent water source, all other efforts are futile.
In 2010, the Niger government only spent 9.5 percent of its annual budget on health. This is expected to increase to 13.4 percent in 2015, with $160 million allocated for reproductive health.
It's unclear how much donors contribute toward this issue, but significant health interventions are needed.
The health expert argues that in any case, most of the interventions these days are focused on addressing the food crisis. And when they do reach out to donors on health, many of them just won't "listen."
"We share concept notes with partners, few among them are accepted or have good answers. This is our problem, if we could only have donors saying, 'OK, listen to this expert,' but some donors are not totally on board," he said.
Issoufou added: “They want to do what they want to do. [They’ll say] ‘I have money, I can say I want to build a school.’ [But] that school needs health centers too. You could build a school but you need to build a health center and potable water sources near it.”
Jenny Lei Ravelo is a Devex senior reporter based in Manila. Since 2011, she has covered a wide range of development and humanitarian aid issues, from leadership and policy changes at DfID to the logistical and security impediments faced by international and local aid responders in disaster-prone and conflict-affected countries in Africa and Asia. Her interests include global health and the analysis of aid challenges and trends in sub-Saharan Africa.