Reducing maternal deaths due to post partum haemorrhage

DESPITE efforts by successive governments to reduce maternal deaths in the country, the figures continue to rise. Indeed, in recent years, the Federal Government of Nigeria has taken critical steps to improve maternal health outcomes.

According to the National Demographic Health Survey (NDHS 2018), Nigeria continues to bear the highest burden of maternal deaths worldwide, with 19 per cent (58,000) of global maternal deaths occurring in the country every year, and 512 maternal deaths with every 100,000 live births. Within the country, regional disparities exist and reveal high maternal mortality ratios (MMRs) of up to 1,625 and 1,463 deaths per 100,000 live births in northern states such as Kano and Niger respectively; and a MMR of 555 in southern states such as Lagos.

In 2017, the Minister of Health inaugurated a 34-person task force on “Accelerated reduction on maternal mortality in Nigeria,” which acknowledged that postpartum hemorrhage (PPH) is the leading cause of maternal mortality, accounting for 22 per cent of maternal deaths. In Nigeria, more than one in five maternal deaths are PPH-related.

It is believed that more efforts are required to address key drivers of mortality due to PPH if Nigeria intends to contribute to the global Sustainable Development Goals (SDG) 3.1 to reduce maternal mortality ratio to less than 70 deaths per 100,000 live births by 2030.

Indeed, oxytocin is the gold standard for the management of PPH in Nigeria. Yet, recent studies point to inconsistent clinical administration of oxytocin in hospitals and a preponderance of low-quality or degraded oxytocin in pharmacies and retail outlets, and health facilities. These challenging service delivery and supply chain realities increase the risk of sub-optimal dosing to patients, product wastage, and ultimately, inefficient use of limited healthcare funds.

Compounding these issues are health system challenges identified in the National roadmap for the accelerated reduction of maternal mortality in Nigeria that must be addressed to effectively tackle PPH. These include human resource capacity and skills of health care workers; lack of conviction among pregnant women and their families on the importance of ante-natal care and institutional delivery; poor perceptions of health care workers resulting in low patronage of facilities; and unreliable referral services that hamper life-saving care.

The most recent World Health Organisation (WHO) recommendations on uterotonics for the prevention of postpartum haemorrhage include seven uterotonics, including new options, notably, carbetocin (heat-stable formulation) and misoprostol plus oxytocin combination.

An uterotonic, also known as ecbolic, are pharmacological agents used to induce contraction or greater tonicity of the uterus. Uterotonics are used both to induce labour and to reduce postpartum haemorrhage.

The 2018 document also provides recommendations on uterotonics and for developing formal protocols in health facilities for the prevention of PPH and referral of women to higher levels of care.

Additionally, the existing coordination mechanisms and training platforms for maternal health at the federal and state levels in Nigeria present an opportunity to provide an enabling environment for the adoption of the most relevant recommendations. Human-centered design equally provides an opportunity to understand the root causes and to design and implement prototypes of innovations for lasting social change.

To ensure a user-driven approach to designing long-term solutions for tackling PPH, the Smiles for Mothers consortium has concluded plans to partner with government at federal level and in three states: Kano, Niger, and Lagos, to incorporate human-centered design in their response to PPH prevention and management.

The Smiles for Mothers programme aims to support the Federal Ministry of Health (FMoH) and State governments of Kano, Lagos, and Niger to reduce deaths due to PPH in each state by 20 per cent by 2022.

The programme, championed by Solina Center for International Development and Research (SCIDaR), the Clinton Health Access Initiative (CHAI), Co-Creation Hub (CcHUB) and McKinsey and Company will explore technology and innovation to improve services, products, and processes, and to build partnerships and relationships to collaboratively solve significant social problems.

Programme Director, SCIDaR, Uchenna Igbokwe, said: “Our monitoring and evaluation indicators will be aligned with the Nigerian government’s priorities for maternal health indicators and will draw from global indicators including those of the WHO Network for Improvement Quality of Care for Maternal, Newborn and Child Health.”

Project Manager, CHAI, Olajumoke Adekeye, said: “In addition to working directly with Federal and State ministries of health and their agencies, the program will also collaborate closely with professional associations in the medical field in Nigeria.”

SCIDaR, an indigenous Nigerian organisation, brings extensive cold chain logistics, health systems design, and implementation experience in Nigeria, as well as the capability to manage large grants from various donor organisations.

CHAI is a global health organisation with presence in more than 36 countries. CHAI’s solution-oriented approach focuses on improving market dynamics for medicines and diagnostics; accelerating access to lifesaving technologies; and helping governments build the capacity required for high-quality care and treatment programme.

Human-Centered Design Lead, CcHUB, Temi Adaramewa, said the company is a Nigerian social impact organisation, bringing deep expertise and successes using the human-centered design approach to co-create solutions and services to address pressing social challenges in Africa. CcHUB is an innovation centre dedicated to accelerating the application of social capital and technology for economic prosperity.
Adaramewa said funding from MSD, through MSD for Mothers, the company’s $500 million initiative to help create a world where no woman dies giving life, supports this programme. MSD for Mothers is an initiative of Merck & Co., Inc. Kenilworth, N.J. USA.

McKinsey and Company, a global consulting firm will serve as the lead design partner for the first innovation in the program, seeking to implement the WHO recommendations.

The #GivingBirthInNigeria project is focused on creating advocacy and communications content for MSD for Mothers-funded projects in Nigeria through channels such as online editorial, newspaper pieces, radio shows, documentaries, animated videos and social media, among others.

Communications is primarily focused on advocating for better quality of maternal health care in Nigeria. This will be done by producing solutions-centered stories on MSD for Mothers-funded projects that talk about how the projects and initiatives are working towards the ultimate goal of providing better quality maternal health care for mothers in Nigeria and contributing to finally ending maternal mortality.

More specifically, the 2018 WHO document recommends the use of the following uterotonics: Oxytocin, Misoprostol, Ergometrine/Methylergometrine, Oxytocin and Ergometrine fixed-dose combination, and a new entrant, Carbetocin (heat-stable formulation) for the prevention of PPH in women undergoing either a vaginal birth or cesarean section. A Cochrane systematic review comparing different uterotonic options to placebo or no treatment showed that these five options, including the new entrant, effectively prevent PPH compared to no uterotonic treatment. Based on this result, in 2019, WHO listed Carbetocin (heat-stable formulation) on its Essential Medicine List (EML) as an uterotonic option for PPH prevention. This is in addition to the other four uterotonic options.

These uterotonic options have various side effects, ranging from minor to significant. For instance, Ergometrine and a fixed combination of Oxytocin and Ergometrine are not recommended for women with a history of hypertension or any cardiovascular disease because of some associated side effects including increased blood pressure. Misoprostol can be used for PPH prevention for most women but some women are likely to develop side effects such as fever with chills, or diarrhoea. Oxytocin and heat-stable Carbetocin alone have fewer side effects and are suitable for women with no history of allergies.

Although Oxytocin remains the first line uterotonic for PPH prevention in Nigeria, evidence shows that the quality of oxytocin is often compromised due to improper cold chain storage from erratic power supply, weak refrigeration infrastructure, and general knowledge gaps of health workers on the appropriate storage condition for the drug. Also, in remote hard-to-reach areas, a large number of deliveries occur at the community level in the absence of a skilled health worker. While attempting to fix the cold chain and knowledge gap issues with Oxytocin, and access to delivery services in remote areas, the use of Carbetocin (heat-stable formulation) at the facility level and misoprostol, for community distribution, provide viable options to reduce PPH-related deaths.

While misoprostol is already approved and in use in Nigeria, the Federal Ministry of Health in 2020 updated its National EML to include Carbetocin (heat-stable formulation) in line with the updated WHO essential medicine list and commenced a review of its national PPH protocols and guidelines to include the use of Carbetocin (heat-stable formulation) for PPH prevention. The National EML update paves the way for alignment at the state level for Carbetocin inclusion in the State EML and, subsequently, inclusion of Carbetocin in the state’s maternal health commodities procurement plan.

The Federal Ministry of Health has taken a commendable first step in adopting the 2018 WHO recommendations. Now, there is a need for all states in Nigeria to do the same, as this will contribute to Nigeria’s efforts towards SDG 3.1 to reduce the maternal mortality ratio to less than 70 deaths per 100,000 live births by 2030. Some of the policy documents that need to be updated in light of the national EML update include the State EML, the Life-Saving Skills manual, and all relevant treatment guidelines on the use of uterotonics for PPH prevention.

Igbokwe said: “Public health challenges can be complex. However, viewing them through a human-centered design lens helps identify new and impactful ways to address them. On the Smiles for Mothers programme, we seek to apply human-centered design to understand the perspectives of all relevant stakeholders on the causes of maternal deaths due to PPH and jointly develop suitable solutions to address the challenges.

“Human-centered design (HCD) is a creative and iterative approach to participatory problem-solving. This approach places people at the center of the product, service, and program development; to design new tailor-made solutions to suit their needs. The HCD approach ensures all major stakeholders play a role in developing the potential solutions, leading to a higher likelihood of finding the right solution for a long-lasting impact. HCD offers a wide range of benefits such as better outcomes, improved processes, expanded capabilities, and increased equity.

The human-centered design process comprises three phases, namely, Co-research, Co-design, and Co-refinement phases.
Igbokwe said: “The Smiles for Mothers program aims to support the State governments of Kano, Lagos, and Niger to apply HCD to develop innovations to reduce maternal deaths due to PPH by at least 20 per cent by 2022. Besides supporting the states to apply HCD, the program also seeks to train key stakeholders in the program states on how to apply HCD, ultimately facilitating the use of HCD for subsequent public health interventions in each State.

“In April 2021, the Smiles for Mothers program trained selected stakeholders in the three program states on the value of HCD and its role in improving public health outcomes. The training involved a combination of field activities and in-class training sessions. The training participants now referred to as HCD champions, included representatives from the Directorate of Public Health, Pharmaceutical Services, Nursing Services, Maternal and Child Health Departments across the State Ministry of Health and its parastatals.

“The Smiles for Mothers team will continue to work with the HCD Champions throughout the program to ensure that all champions fully understand how to apply HCD in designing public health interventions.”