Stopping needless maternal deaths

The high rate of maternal deaths in Nigeria has been a major cause of public health concern at both the national and international levels. According to the Federal Ministry of Health – Integrated Reproductive Maternal Newborn and Child and Adolescent Health plus Nutrition (IRMNCAH) Strategy (2017 – 2021), 24 per cent of the Nigerian population is made up of women of reproductive age (15-49 years).

Despite existing health policies and strategies such as the National Health Policy (2016), the National Strategic Health Development Plan (2015 to 2022), the Sustainable Development Goals (SDGs), to mention a few, significant gaps still exist in the coverage of high-quality interventions and in the overall health status of women of child bearing age in Nigeria. In addition, several important national goals and targets relating to the health and wellbeing of mothers and their children have not been met to date.

As we work towards making significant progress to reduce maternal deaths in Nigeria, the focus of this article is to advocate to government and all its stakeholders to prioritize mitigating the major causes of maternal deaths. Julianna’s story is just one out of thousands of examples in all corners of Nigeria.

Nigeria is undergoing an obstetric transition in which the proportion of maternal deaths due to underlying indirect causes such as high blood pressure is increasing in proportion to the women that continue to die of direct obstetric causes such as bleeding after childbirth. Pregnant women diagnosed with hypertension (HTN), diabetes mellitus (DM) or Pre-eclampsia/Eclampsia (PE/E) face a higher risk of complications in future pregnancies, a higher risk of developing cardiovascular disease and of dying prematurely. Major risk factors for indirect causes of maternal mortality and morbidity (MMM) associated with PE/E include: Hypertension and Diabetes Mellitus (chronic and gestational), Anemia and Obesity.

The Federal Ministry of Health (FMOH) has demonstrated its commitment to addressing non-communicable diseases (NCDs) through the creation of an NCDs division, the development of a national non-communicable diseases (NCDs) multi-sectorial plan (2019 – 2025) and the inclusion of coverage for diabetes and hypertension (HTN) as part of the basic health care provision fund. However, there has been limited attention paid to the unique vulnerabilities of women of child bearing age with NCDs and associated risk factors, despite the substantial burden of NCD-related ‘indirect causes’ of maternal mortality and morbidity (MMM) among women of child bearing age.

In November 2018, MSD for Mothers funded a consortium of Jhpiego, mDoc and Health Strategy Delivery Foundation (HSDF) to develop and test a Quality of Care (QoC) model to prevent, screen and manage risk factors for indirect causes of maternal mortality and morbidity (MMM) associated with PE/E in maternal and family planning services in Lagos State and the Federal Capital Territory (FCT). Based on epidemiologic data in Nigeria, the major PE/E risk factors targeted by this initiative include hypertension (HTN), diabetes mellitus (DM), anemia and obesity.

The project conducted an initial assessment to determine the quality of MH/RH care, health care workers knowledge, and women’s awareness and self-reported behaviors related to risk factors for indirect causes of MMM. A survey of 636 women in the community showed that many women have risk factors for PE/E and are not aware of their risk factors. A little over half of 400 women tested for DM, HTN, Anemia and Obesity had three to five risk factors for cardiovascular disease (CVD) and premature mortality. One third of 400 women had stage one or two hypertension (American Heart Association classification) whilst only five-12 percent of these women were aware they had HTN. Approximately half of the women were overweight or obese based on a calculated Body Mass Index (BMI). 7.8 per cent of the women met the criteria for pre-diabetes and 2.3 per cent met the criteria for diabetes, whilst less than one third of these women were aware of their status. A little over half of the women who were tested had anemia based on low hemoglobin (blood) levels.

Assessment of health care worker knowledge and confidence in 20 health facilities demonstrated many gaps. 79 health care workers surveyed reported low confidence and had low knowledge of best practices for managing HTN, DM, anemia and obesity in women of childbearing age, including calculation of BMI. Observation and chart reviews of antenatal care (ANC) visits revealed many problems with quality of care and missed opportunities to prevent, screen and manage risk factors for indirect causes of maternal deaths in pregnant women. For example, there was a rare documentation of whether a female ANC client had a personal or family history of PE/E, HTN, DM, or anemia. Focus group discussions with women of child bearing age and in-depth interviews with stakeholders and policy makers in the two states helped shed light on client and health system factors underlying the assessment findings.

Based on the findings from the initial assessment results, the project collaborated with stakeholders in Lagos and FCT to design a woman centered quality of care (QoC) model to improve prevention, screening and management of risk factors for indirect causes of MMM in MH/RH services for women of reproductive age.

The QoC model aims to improve the quality of antenatal care (ANC), labour and delivery, post-natal care (PNC) and Family Planning (FP) services and women’s capacity for self-care applying several approaches. Including: education of health workers, support of quality improvement teams in health care facilities and education and self-care support for women via MH/RH services and a digital platform called CompleteHealth. In addition to designing and implementing the QoC model, the programme analyzed the cost implications of implementing the QoC model and explored potential sources of funding essential for sustaining and scaling QoC model.

In October 2019, the project began piloting implementation of the QoC model in 20 public and private health facilities in four LGAs in Lagos and FCT, working in close collaboration with a multi-stakeholder Technical Advisory Groups (TAG). Initial implementation focused on the ANC touch point, extending to labour and delivery and PNC in April 2020. Early results of implementing the QoC model in the first year have been encouraging, showing improved quality of screening for maternal mortality risk factors among women using MH/RH health services, increased health care workers’ knowledge, increased knowledge, confidence and self-care of women using the digital platform and increased utilization of ANC services (despite a transient decrease during the peak of COVID-19 transmission?

A total of 58,388 women have received maternal and reproductive health services in the 20 health care facilities in the first year of implementing the QoC model. (26,712 women registered for ANC, 17,887 women delivered with a skilled birth attendant and 13,789 women received PNC services).

The proportion of women screened for high blood pressure, diabetes and anemia during ANC visits in the 20 health care facilities increased from 35 per cent to 71 per cent, 11 per cent to 65 per cent and 20 per cent to 60 per cent respectively from October 2019 to September 2020. Health care workers knowledge scores after on-site in-person and off-site virtual training increased in all sites, with 90 per cent of 450 HCWs attaining a knowledge score of at least 80 per cent after on-site training. 2,590 HCWs participated in 13 virtual ECHO sessions over an 11-month period with an average knowledge gain of 15 per cent.

In June 2020, a survey of 100 randomly selected pregnant women in 10 of the 20 project-supported health facilities corroborated the program results (based on medical chart review) with most surveyed women reporting that they received screening of HTN, obesity and other risk factors for maternal deaths. The survey also highlighted the remaining quality gaps to address in the next phase of the initiative, particularly for interpersonal dimensions of care and health care worker communication of health information to women clients.

A comparison of the costs of providing MH/RH services via the QoC model versus the cost of providing M/RH services in the usual way showed that the differences in cost are nominal and that cost should not be a barrier to extending the QoC model to additional health care facilities.

A Fiscal Space analysis demonstrated significant gaps in government funding for RH, MH, and NCD services in each state relative to needs among women of childbearing age. Despite indications of tightening resource envelopes for critical priority public health issues, potential sources of financing to extend the QoC model to improve MH/RH services in additional health care facilities include the State Health Insurance and Private Health Insurance Schemes, the prioritization of MH and NCD programs in public health budget allocation and release. Some earmarked funds include the Basic Healthcare Provision Funds (BHCPF).

Several assets that this initiative advocates to be leveraged, include strong engagement of state officials and stakeholders via the Technical Advisory Groups (TAG) in each state; demonstrated commitment by the health care workers to increasing their skills and changing practice; the willingness of many experts (example, members of professional associations) to support ECHO virtual learning sessions; and engagement of many women on the virtual digital platform for self-care.

With these initial successes, we use this opportunity to advocate to the Federal Government through the Federal Ministry of Health and State Ministries of health and their Primary Health Care Development Agencies/Boards and all stakeholders to harness all available resources to start tackling all causes of maternal deaths, including preventable maternal deaths due to high blood pressure, diabetes mellitus, anemia and overweight/obesity. We need to learn from and scale successful efforts such as the one described in this piece that shows it is possible to rapidly improve timely screening and management of risk factors for preventable maternal deaths.

In conclusion most maternal deaths are preventable, as the healthcare solutions to prevent and manage complications are well known. We need to learn lessons from pilots such as the one described in this paper and scale up the successes across the country. This is one way Nigeria can make progress towards reducing maternal deaths in the country to 250 per 100,000 live births by 2030. All women need access to high quality care in pregnancy, during and after childbirth. It is important all births are attended by skilled birth attendants after women have accessed high quality antenatal care services, as timely screening and management of the risk factors leading to maternal deaths can make a difference between life and death for a mother as well as the baby.

There is a “Julianna” in every state in Nigeria needing the appropriate care to prevent her from being just another number in the rising cases of women dying while being birth. These deaths are needless and could have been prevented.
*Dr. Okoli is a Public Health expert and the Deputy Country Director at Jhpiego Nigeria.