Reducing maternal deaths via evidence-based interventions
•Nigeria Health Watch, WHO, and other stakeholders propose a roadmap for policy implementation, and better maternal health care
Recent figures indicate that Nigeria has one of the highest maternal mortality ratios, 914 per 100,000 live births, estimated to account for 19 per cent of the global maternal deaths.
According to the World Health Organisation (WHO), every day in Nigeria, about 154 women between the ages of 15 and 45 years die from preventable causes linked to pregnancy and childbirth. Northern Nigeria has one of the highest maternal mortality rates in the world, with approximately 1,012 maternal deaths per 100,000 live births.
It is estimated that 58,000 Nigerian women die yearly from complications related to pregnancy and childbirth, devastating families and communities and resulting in $1.5 billion (N903,000,000,000) in lost productivity.
As part of efforts to make sure that no woman in Nigeria dies giving birth, the Nigeria Health Watch, for the past 18 months, has been working on a maternal health advocacy and communications programme to spotlight the importance of quality of care in maternal health in Nigeria through MSD for Mothers funded projects.
Nigeria Health Watch is a non-profit organisation that uses informed advocacy and communication to seek better health and access to healthcare in Nigeria.
MSD for Mothers is MSD’s $500 million global initiative to help create a world where no woman has to die giving life.
Managing Director Nigeria Health Watch, Mrs. Vivianne Ihekweazu, at a programme titled, “Evidence for Change: Learnings and Recommendations for Quality Maternal Care”, held on Wednesday, June 1, 2022, in Abuja, said:
“Ultimately, in the end, we hope to be able to synthesise the finding and propose a roadmap for policy implementation for better maternal health care in Nigeria.
“So over the period, we have interacted with all of you to spotlight insights and evidence from MSD for Mothers collaborators programmes, which aim at spotlighting interventions that will enable Nigeria to achieve the Sustainable Development Goal (SDG) target of a global Maternal Mortality Ratio (MMR) of fewer than 70 maternal deaths per 100,000 live births by 2030.”
Ihekweazu said to spotlight the quality of care for women’s maternal health, they focused on six thematic areas for the purpose of the project: understanding quality of care gaps; quality assurance; private sector capacity; affordability; digital support/technology; and evidence for change.
She said the objective of this Evidence for Change is to: amplify MSD for Mothers-supported collaborators, as evidenced through the outcomes and impact of the initiatives and innovations in improving maternal health outcomes in Nigeria; and highlight the importance of adopting a quality-of-care approach to delivering maternal health care in Nigeria through the strategic approaches of MSD for Mothers-supported projects in Nigeria.
“We hope by the end of this event that we would have shared some of the key learnings and some of the innovative solutions from our various programmes. Understanding current challenges and gaps in delivering quality health care in Nigeria, helped by the fact that some of our key stakeholders are in the room with us,” Ihekweazu said.
Ihekweazu said some of the key stakeholders include: Kaduna State Ministry of Health; Private Health Institutions Management Agency (PHIMA); Pharmacists Council of Nigeria (PCN); Association of Nigerian Private Medical Practitioners (ANPMP); Association of General Private Nursing Practitioners of Nigeria (AGPNPN); Kaduna State Primary Health Care Development Agency; and Federal Ministry of Health.
She said MSD Collaborators include: mDOC; Village Health Worker (Girl Child Concern); WHO – Maternal and Perinatal Database for Quality, Equity and Dignity (MPD-4-QED programme); LifeBank; Smiles for Mothers; MomCare; IntegratE; Saving Mothers Giving Lives 2.0; RICOM3; and Nivi.
A representative of WHO, Dr. Bosede Ezekwe, in a paper titled, “How the World Health Organization is improving the capacities of health facilities through the MPD-4-QED Programme” said the Nigerian Maternal and Perinatal Database for Quality, Equity and Dignity (MPD4QED) seeks to address high burden of maternal and perinatal mortality (including in health facilities) at 576 per 100 000 live births and 77 per 1 000 live births in 2013, according to the National Demographic Health Survey (NDHS).
Ezekwe, whose paper was presented by the Director of Policy & Advocacy, Nigeria Health Watch, Ify Babatunde-Yusuf, said in addition, many women experience life-threatening complications with short-term or long-term impacts on quality of life.
She said among the quality standards expected to be available in every health facility, is that every mother and newborn has a complete, accurate, and standardised medical record during labour, childbirth and the early postnatal period.
Ezekwe said it is also expected that every health facility has a mechanism for data collection, analysis and feedback as part of its activities for monitoring and improving performance around the time of childbirth.
She said one of the process indicators in the QED project includes the development of facility-based routine data collection systems for maternal and perinatal mortality and near-miss necessary for quality improvement.
Ezekwe said Nigeria is one of nine first wave countries implementing Quality of Care (QoC), which aim is to halve hospital-based maternal and newborn deaths in five years.
She said the WHO Quality, Equity and Dignity (QED) project to improve QoC for mothers and newborns in health facilities is one strategy to achieve the SDG targets.
The medical doctor said ending the Preventable Maternal Mortality (EPMM) programme’s target of a reduction of MMR by all countries to at least two-thirds of their 2010 baseline levels is reliant upon the provision of available, accessible, acceptable, quality service in an enabling environment that respects human rights principles.
According to the WHO, the SDG builds on the gains of the Millennium Development Goals (MDGs) with a target for the reduction of maternal mortality ratio to less than 70 per 100,000 live births and the reduction of newborn mortality to less than 12 per 1,000 live births by 2030.
Ezekwe said the MPD-4-QED Programme, currently, is for referral-level hospitals; all women admitted for delivery or on account of complications within 42 days of delivery or termination of pregnancy and their babies; and all babies within the first seven days of life.
On the challenges faced in providing such innovative solutions for health providers, in terms of structural roadblocks, regulatory obstacles, sociocultural factors or otherwise, Ezekwe said the success of the programme requires ownership of the programme at different levels including hospital management and government and that transition to Federal Ministry of Health (FMoH) is currently underway.
She said operations’ capacity (including financial) needs to be strengthened to host the website, integrate with the national DHIS2, ensure alignment with electronic records for hospitals on electronic medical records system and provide data for Internet connection for electronic data entry in hospitals.
On human resource challenge, Ezekwe said the motivation for data collections requires new strategies and innovations, as stipends will no longer be provided under FMoH. “There has been waning motivation for data collection following stoppage of stipends as well as attrition (reposting/relocation of trained data collectors and hospital coordinators). Training required for new staff coming on board,” she said.
On institutional challenge, she said intermittent industrial action (strike) by doctors and other health workers, the COVID-19 pandemic (lockdown) reduced patronage of the hospitals.
“We are discussing ‘Evidence for Change’, what relevant data sets, information, results, and impact have been recorded so far during implementation, and how do these provide evidence to accelerate change in terms of sustainability, scale-up or adoption? This is the largest of its kind in the region,” Ezekwe said.
She said, in the first year, participating hospitals recorded 69,055 live births, 4,498 stillbirths, and 1,090 early neonatal deaths. According to her, as of May 31, there were 213,584 woman (and their babies) enrolled; and data is high quality with less than one per cent missing data on vital status.
She said the analysis was able to identify areas for quality of care improvement. For example, increased coverage of companionship in labour and the use of labour monitoring tools.
The public health physician said prospective surveillance of maternal and perinatal data, including the use of selected quality of care indicators, for periodic assessment of hospital performance and quality improvement, is critical for achieving the aims of the WHO QED initiative and for meeting the third sustainable development goal targets at the country level.
Ezekwe said a nationwide database programme for harmonising and aggregating data could be implemented in settings with similar medical record infrastructure as Nigeria, to identify interventions that could be readily implemented to drive policy change and impact. She said with the global shift towards increased facility births and the digitisation of routine national health management systems, there is a huge potential to scale up this programme to other countries.
On working with various stakeholders at public and private sector levels to provide solutions for health providers, Ezekwe said: “WHO engaged with Government through the Federal Ministry of Health at inception phase through a stakeholder engagement meeting where the Honorable Minister of Health, Professor Isaac F. Adewole, launched the programme in April 2019.
“Private hospitals were also engaged alongside the public hospitals at federal and state levels resulting in the participation of six private hospitals in the programme.
“The professional associations including the Society of Obstetricians and Gynaecologists of Nigeria (SOGON) and Association of Feto-Maternal Specialists of Nigeria (AFEMSON) were engaged with data from the programme to generate discussions around the quality of care for mothers and newborns
“A Nigerian IT firm was engaged to develop and manage the web-based platform, train collaborators to enter and upload data and build the capacity of the FMoH ICT Department to take over management of the platform for sustainability.”
On what policy recommendations have emanated from the work so far, that could create a better-suited policy environment for implementation and innovation, she said approval of the Honourable Minister of Health (HMH) for MPD-4-QED to serve as an entry point for strengthening MPDSR and facility assessment in tertiary hospitals nationwide and as the platform for integration of MPDSR and QoC in tertiary facilities.
Ezekwe said this is captured in the MPDSR Bill awaiting the President’s assent.
The MDSR is a mechanism set up to examine the circumstances surrounding every maternal death. It is the continuous process of identifying, notifying, and reviewing maternal deaths as they occur, and implementing actions to improve maternal care and prevent future deaths.
Associate Manager, Women’s Wellness, mDoc Healthcare, Chiagoziem Abiakam, in a paper titled, “Empowering Women Through Digital Technology: Providing holistic support through virtual coaching and digital nudges” said mDoc optimises the end-to-end self-care experience for people with regular and chronic health needs by harnessing quality improvement methodologies, behavioral science, data and technology.
mDoc is a digital health company, which leverages a high-tech high-touch approach to optimize the end-to-end care for people living with chronic conditions in Nigeria. They harness behavioral science, quality improvement methodologies, data and technology to provide an integrated care solution for people with chronic and regular health needs.
Abiakam said: “We oﬀer a four-pillar, high tech, high touch approach to integrated self-care- Virtual coaches and digital nudges through CompleteHealthTM; In-person community-based NudgeHubsTM and community ambassadors; Tele-education of providers and patients MQNTM
Digital patient navigation via NaviHealth.aiTM; and NaviHealth.ai™ provides information on accessible, convenient facilities, which oﬀer quality care.
We help you ﬁnd quality healthcare services you need on NaviHealth.ai our geo-coded directory.
“Patient review can be a powerful tool. They increase visibility and conﬁdence in existing and potential individuals to utilise the facility. The NaviHealth.ai patient feedback system is based on the dimensions of quality (safety, timeliness, eﬀectiveness, equity, eﬃciency, and patient-centred care) as established by the National Academy of Medicine.”
Abiakam said mDoc provides self-care support for women across the life course, for instance, women diagnosed with breast cancer, as well as ﬁnancing through the Rupe-Flexi partnership to help them pay for their drugs.
She said patients diagnosed with HER2+ breast cancer are catered to on mDoc’s CompleteHealthTM platform and provided with a sustainable means, through partners, to aﬀord the medication they need for their treatment.
Abiakam said the overall goal of providing virtual care to women of reproductive age under RICOM3 project is to reduce Maternal Mortality and Morbidity (MMM) from indirect causes by applying a QoC model to improve prevention, early detection and management of indirect causes of MMM associated with pre-eclampsia/eclampsia (PE/E) along the continuum of public and private Maternal Health (MH)/Reproductive Health (RH) care services for women of reproductive age (WRA).
She said the project’s clinical focus areas are indirect causes of MMM that increase the risk for PE/E and premature cardiovascular disease.
Abiakam said they are working in four Local Government Areas (LGAs/districts in two ‘states’ – Lagos State and Federal Capital Territory (FCT) with 40 healthcare facilities (20 each state) – public and private hospitals and clinics.
She said they are using women centered QoC model to reduce the risk of indirect MMM linked to PE/E.
On capacity building (clinical/Quality Improvement, QI, Abiakam said the project is conducting onsite skills-based training; tele-ECHO virtual sessions to re-enforce provider learning/knowledge; supportive supervision and mentoring; and access to job aids and guidelines.
To ensure QI, she said the firm identifies quality gaps, set improvement aims, develop QoC measures; establish and support QI teams to test changes (PDSA) and monitors trends in measures to track progress toward aims. Strengthen the Non-Communicable Diseases (NCD) Health Management Information System (HMIS) and use it for decision-making.
Abiakam said there is virtual support for women’s digital platforms, WhatsApp, SMS. “Virtual support of women to improve self-care; tele-ECHO sessions for women initiated when COVID transmission started,” she said.
Abiakam said there is a peer to peer learning between all selected facilities and digital platform coaches, the spread of innovations and that they share successes and also learn how peers are managing challenges.
She said they have seen positive outcomes in their capacity building endeavours: An increase from 41 per cent to 84 per cent in self-efficacy of members between baseline and follow-up; an increase from 49 per cent to 82 per cent digital literacy of members between baseline and follow-up, and an increase from 38 per cent to 81 per cent health literacy of members between baseline and follow-up.
Abiakam said early data is promising, 54 per cent average improvement in Blood Pressure (BP), 63 per cent average control in BP. “We understand our members and use multiple approaches to invest in building the digital and health literacy required to drive empowerment,” she said.
Abiakam said they have reached 67,000 women of reproductive age on CompleteHealth™ with the majority in Lagos and Abuja; 74per cent of women between the ages of 18 and 49; and 69 per cent of women who own smartphones.