Ending maternal, child mortality in Nigeria with new intervention

• Volunteer obstetrician scheme to improve maternal, child outcomes

Professor Oluwarotimi Akinola is the president of Society of Gynaecology and Obstetrics of Nigeria (SOGON). He is a medical consultant and teacher of doctors at the Lagos State University Teaching Hospital (LASUTH). He leads a Federal Government initiative to stop maternal mortality nationwide. In this interview with ADAKU ONYENUCHEYA he highlights the challenges facing women in accessing healthcare during pregnancy and the several interventions put in place to address the maternal mortality.
aku
Nigeria still occupies its position as one of the countries with the highest indices of maternal mortality in the world, despite several interventions put in place by the Federal Government. Why are we still struggling to reduce the scourge in the country?
The issue would be from personnel, human capital. We don’t have enough midwives and doctors, unavailability of materials, insecurity in the North, like Zamfara where some projects have shut down because of security and you can’t access some villages and places at the risk of your own life. So those are some of the reasons. Of course, these are not the only ones, education is also important; when you are backward you don’t seek help.

Basically, there are three delays that can lead to maternal and child mortality. The first one is delay in seeking help; so that help seeking behaviour is lagging. The women sit at home and don’t know they have a problem or not even aware at all for one reason or the other, maybe because of sociocultural beliefs and all that. They don’t seek help and once they don’t seek help, there is nothing anybody can do.

The second delay is that they know and are determined to seek help, but the distance to the health facilities is far, they need to travel to the hospital as they lack access to transport system and communication.Security also comes in, that is, fear of being attacked. All these are delays in accessing healthcare. So they have decided to seek it, but no means of accessing it due to the above listed factors.

The third delay has to do with quality of care, delay in getting the care when they get to the hospital. That can start from the gate of the hospital, how the woman is being treated by the security personnel, either their behaviour or that the woman is being turned back, sometimes the fees can be expensive, or no blood or medical personnel to attend to the woman, or the personnel don’t have the skills.

The fourth delay is referrals. We have three levels of care, primary, secondary and tertiary. There should be a flawless referral system, ability to refer among these three levels of care, so that the higher care level wouldn’t be clogged by cases that could be handled in the lower care level. All these are the things which constitute reasons Nigeria is still battling with the high indices of maternal and infant mortality.

There have also been some state government interventions, and some states are still plagued with the maternal mortality issues. Which of the states are worst hit in the country and why?
When you talk about the states that are most experiencing the issue, there are lot a of the places in the north, where there are no facilities, the human capital is low. The states that are worst off are in the northwest, which are Sokoto, Jigawa, Zamfara, Kano, in the northeast, Yobe and of course we understand what is happening in Borno State because of the insurgency and all that, that is the epicenter of maternal mortality.

What are the current statistics of maternal and child mortality in Nigeria?
I can’t give that now and reason being that, there is a data bank, what we call National Demographic Survey, 2013, which gives us the general figures of the deaths in each state every year. When we say, for example, antenatal attendance in southwest and southeast are like 90 percent, in those northern places we have about 40 percent and so average national, we are going to be about 60 percent, which is the way it goes.

We known for example that in Nigeria, only about 38 percent of people who deliver get skilled birth attendants, which means that the rest of the women either deliver at home or in areas where there is nobody who can take care of them when complications arise and so they die.Nigeria right now has the worst maternal mortality in the whole world, in 2008 the ratio was 545:100, 000, in 2013 it was 576:100, 000 maternal mortality, so nothing has really changed, but when we talk about what has happened in the past 15 years, then you can say there is a difference, because it used to be 1500:100, 000, it became 800:100, 000 and now we are talking about 576:100, 000, it is stagnant and people are saying if we go on the way we are going, it will take us another 100 years before we can reach the target. So we are now doing what is called accelerated maternal mortality reduction programmes interventions that can mop up and let us catch up with what is happening elsewhere.

Why we are still recording more deaths despite several policies implemented by the Federal Government to reduce maternal mortality in the country?
There are different interventions. The Minister of Health talked about setting up a committee for Accelerated Maternal Mortality Reduction and they have been attacking big from various areas. Last year, one of the states in the North reported that a particular hospital in three months recorded 48 maternal deaths, and of course, we responded to that, and found that something was wrong. There were lots of factors to identify. Like I said, health seeking behaviour and advocacy play a crucial role to reduce the scourge. Lagos State did that from 2012 to 2014. We had town hall meetings where all the traditional, religious rulers and everybody was involved to sensitise the people, because sometimes you take people to the hospital to go and die when they have been mismanaged and things have gone out of hands. They need to seek healthcare early.

The minister’s intervention that we are talking about is tagged ‘Save One Million Lives (SOML)’, which we could access to do all the maternal health and then there were some indicators for performance that when you exhaust the money, they give you bonus and you refund and then they give you more money. The amount given was $1.5 million, although, not many states have completely exhausted their $1.5million because they have not done all those things that would be assessed. Some states have done and they are already assessing that. So, those are encouragements coming from the Federal Government that any state that does certain things would take $1.5 million. The project has been going on and there are several of these interventions.

The Society of Gynaecology and Obstetrics of Nigeria (SOGON) has played a part in the reduction of maternal and child mortality in Nigeria. What role are you playing now?
What we push as Society of Gynecology and Obstetrics is what we started with, whi ch is called Maternal Death Review, then it became Maternal Death Review and Response, but now it has become Maternal and Perinatal Death Surveillance and Response (MPDSR).

SOGON actually initiated it in the country, promoted it after a lot of advocacy, and we got the Federal Government at the National Council of Health to adopt of and now by the time we added the perinatal component to it, they rolled it out.

What it simply means is that it is not the figures that 10 or 20 people died that matters, but it is a qualitative kind of thing. Why did they die? Did they not seek help? Did they try to access it and they couldn’t? Is it because they don’t want the pregnancy or because family planning wasn’t available and when they got pregnant and went to the hospital, drug was not available? Is it because there was no blood or that the doctor or midwife wasn’t available there? So, it is a whole story and so when you get the story, you try and correct those things, implement them and then re-examine again so that it doesn’t happen. We call that medical audit. You identify it and then inform someone about it. Those people you inform will analyse why it happened, and when they have analysed it, they will have action plan on what can be done so that it doesn’t repeat itself.

We have implemented the MPDSR in Lagos State under serious SOGON pressure, and all those seven states in the north that we are talking about are now implementing it with different levels of performance and compliance. The Federal Capital Territory (FCT) also sponsored SOGON to push it and so it is very well established in the FCT now.Last week, a fact came out in the United States, New York to be precise, that black women die more from pregnancy related deaths. So, they chose a pilot place where it was happening at State University of New York, downstate hospital and they are doing the same MPDSR that we are talking about.

SOGON has initiated a new scheme to help drive a reduction in maternal and child mortality. How effective would this be, especially in the northern states with the highest indices?
We have what we call Volunteer Obstetrician Scheme, which has not completely enjoyed success nationwide. Just before then, we brought Maternal and Perinatal Death Surveillance and Response into the front burner and we are helping to implement it, which is still growing to deepen it so that it can become effective nationwide.

In some developed countries, we heard them talking about confidential inquiry into maternal death. The confidential inquiry, which they started about 1948 in England, is to say they are just studying what happened, why the woman died, not because they want to punish anybody, so they call it ‘No name, no blame’. Whatever finding they discovered, somebody might have made a mistake and it will never be used in the court of justice to punish that person. So, people can come out and say they tried this and that and this is what to do, and how to do it so that we can prevent it happening again.

It has been fairly difficult for people in Nigeria to even understand the concept of ‘no name, no blame’. You can check the American document that I said happened in the last one week or so. It is really emphasised there that there would be no name, no blame. The World Health Organisation is now also pushing this MPDSR thing we are talking about so that it becomes a worldwide thing and the seasoned principle of ‘no name, no blame’ is a kind of medical audit to improve the system, not to punish anybody.

Are you involving all the state government in your maternal mortality reduction programmes and interventions?
It is a national and state problem, and everybody is involved. We just recently paid an advocacy visit to Bayelsa State because we know the state as one whose indices is very poor. So we went there and met with the governor and the entire ministry of health and the Federal Medical Centres there. We identified the different areas where the problems lies and mapped out way forward and the state government has started implementing it.

Just last week, they launched their maternal perinatal mortality reduction programme in the state. The governor has invested money in the health of these women, and he is establishing all those structures that will reduce it.There was once an Abiye programme in Ondo State by former Governor Olusegun Mimiko, which was also aimed at reducing maternal mortality. These are the things we are trying to do.

Sustainability is a major problem in Nigeria. How can Nigeria drive sustainability in the health interventions for reducing maternal and child mortality?
We must make people to take ownership. Lagos State government has taken ownership of the MPDSR programme from us. What we are telling them is to go further. It is not just doing facility based, they are doing facility based recruit, but we are saying let’s go into the communities.

What they did in Ondo State was that don’t bother delivering the woman. If a woman comes to register with you and you bring the woman, we will give you certain amount of money. That was the system so that they discouraged people taking deliveries, and the governor found other political areas to engage those whose major job was to take deliveries, and they were always following him around.

So it is just from that perspective that steps can be taken and when you are talking about sustainability, the government and people should own it. If the people can own it, they can discuss among themselves, and it is not costly to do. A couple of states also have it now. So, talking about sustainability, those are the things that will make it sustainable. For our Volunteer Obstetrician Scheme, it continues.