No woman should die while giving life…
These words took on a whole new meaning for me when I lost my sister-in-law a few hours after she gave birth to her third child. She died from excessive bleeding after delivery (postpartum hemorrhage) and although the hospital said that they had done all they could, I’ve often wondered if there was something more that could have been done. However, my family decided to not probe further into the circumstances around her death, leaving us struggling to find closure with a ton of unanswered questions.
Before Halima’s death, maternal mortality statistics were mere numbers for me, but now they have a face and a name. My interest was therefore piqued when, at the 2019 #HealthMeetsTechNG hackathon organised by EpiAFRIC, Dr Farouk Jega, Senior Country Representative for Pathfinder International, mentioned that under the Saving Mothers Giving Life (SMGL) initiative, supported by Pathfinder and other stakeholders, Cross River State had experienced a 66% decrease in maternal mortality. I was particularly interested in the Maternal and Perinatal Death Surveillance and Response (MPDSR) part of the initiative.
Nigeria has one of the world’s highest maternal mortality ratios. The 2018 National Demographic and Health Survey data reports that the national maternal mortality ratio is 512 to every 100,000 live births while the national ratio for perinatal deaths is 49 to every 1,000 live births.
MPDSR examines the circumstances surrounding each death, including any preventable breakdown in care, whether from the household to the health facility. It is a continuous cycle that includes identifying when deaths take place, notifying the relevant authorities, and reviewing the causes of both maternal and perinatal deaths, after which actions to improve quality of care and prevent future deaths are instigated, all carried out in a no-blame environment. According to Dr Yemis Femi-Pius, Programme Manager Pathfinder International, Cross River State, “MPDSR is important but it is also very sensitive because if people know that you are auditing deaths, they might want to cover up. So, it is important to sensitise the whole hospital, even down to the cleaner because everybody has a part to play in the quality of care that the woman receives”. In Nigeria, the Federal Ministry of Health adopted the MPDSR policy in 2016.
The SMGL initiative in Cross River State started in 2014/2015 with a state-wide assessment of health facilities that provide antenatal care (ANC) services; 812 health facilities were assessed for their readiness to deliver quality basic and comprehensive emergency obstetric and new-born care. The assessment revealed low recognition of danger signs and a lack of confidence in the health system among women and community members, and low capacity of facilities and providers to provide comprehensive and basic emergency obstetric and new-born care (EmONC). It also showed irregular supply of essential medicines, poor use of registers, and infrequent performance of maternal and neonatal death audits.
Results showed that common causes of maternal deaths were obstructed labour, eclampsia, pre-eclampsia and postpartum haemorrhage (PPH) and the common causes of perinatal deaths were severe birth asphyxia, infection, and premature birth. The assessment also revealed a facility maternal mortality ratio of 876 maternal deaths per 100,000 live births.
Dr Femi-Pius revealed that the project implementation started in 2016 in 109 health facilities, which were a mixture of private health facilities, PHCs and General hospitals, across the 18 Local Government Areas in the state. The health facilities were grouped into clusters, according to the WHO recommendation which says that for every 500,000 people, there should be one facility that is providing comprehensive EmONC services. In this case it is the General Hospital and at least 4 facilities (PHCs) providing basic EmONC. Referring to the WHO recommendation which says that any woman that requires emergency obstetric services should be able to get it within 2 hours from wherever she is, Femi-Pius said, “We built a GIS map of facilities that we are supporting in the state and looking at the coverage, the GIS showed that 92% of the state is covered. Any woman within 92% of the state can access services within 2 hours”.
Addressing the three delays
The initiative adopted the whole-system approach which means engaging the individual and community in addition to the health system. The interventions addressed the 3 delays to timely care which contribute to maternal mortality: delay in deciding to seek care, delay in reaching an adequate health care facility, and delay in receiving adequate, or quality, care at the facility. This effectively tackled the gaps identified during the assessment.
In Cross River State, all the medical specialists in the state are found at the University of Calabar Teaching Hospital. General hospitals do not have consultants who can handle complicated cases. As a result of this, the Society of Gynaecology and Obstetrics of Nigeria (SOGON) and the Nigerian Society of Neonatal Medicine (NISONM) set up a Volunteer Obstetrics Scheme to enable consultants and senior registrars from the Teaching Hospital volunteer to help with complicated cases in general hospitals across the state without any extra pay. To strengthen the services they provided, Pathfinder International partnered with them to provide travel logistics, thus ensuring that they were able to visit all health facilities regularly, timing their visits to meet the monthly MPDSR meetings in those facilities. This helped improve the quality of the review because as specialists they were able to point out what was done wrong and teach them what to do the next time the same issue occurs.
The initiative equipped hospitals with needed equipment like hospital beds, resuscitation machines, solar powered blood banks, and blood pressure apparatus. They did a lot of community work, creating awareness for birth preparedness, complication readiness, and identifying danger signs. They also worked with the Ward Development Health Committee to set up a community driven emergency transport system. Each community has a pool of trained volunteer drivers that a pregnant woman can call in the case of an emergency.
Speaking on the successes of the initiative, Dr Etim Ayi, Medical Superintendent, General Hospital Calabar said that quality of care has improved at the hospital. “The neonatal unit is well used and most of the asphyxiated babies have been well managed. With MPDSR, every time we sit to review any maternal or perinatal deaths, we are able to see the loopholes and know where the gaps are. One process fits into the other”. Preliminary project results suggest that facility maternal mortality ratio decreased by 66 percent and facility neonatal mortality rate decreased by 47 percent between baseline assessment and March 2019.
At General Hospital Ugep, a town over 100 kilometers from Calabar, in southern Cross River, Mrs Mary Inah, Deputy Director In Charge of the Maternity Ward, is one of the midwives trained in Emergency Obstetric and New-born Care. “I can tell you that the trainings improved our capacity. Now there are a lot of things we can do on our own. In the past, we didn’t know the management of pre-eclampsia but with the training, we can handle pre-eclampsia comfortably before the arrival of the doctor. In the past, a woman may come with preeclampsia and we will be thinking it is malaria and we will be treating and before you know, the woman is gone,” she said.
Inah also discussed the health seeking behaviours of the women in the community. According to her, most women die in rural areas due to their cultural beliefs. It is common practice for women in this area to wait to get consent from either their husbands or their mothers-in-law before they can visit the hospital. “Some women also believe that if a woman comes to the hospital to have her baby, she is a weakling because she is causing her husband to spend too much. Most of the women we have here are cases of emergency. They stay at home until it is too late and there is nothing else they can do before they rush them here,” she said.
The MPDSR strategy is a tiny part of the initiative that fits snugly into the whole. Essentially, MPDSR reviews the deaths and reveals gaps in capacity, manpower, alongside other factors, and these gaps are plugged by the other interventions in the SMGL initiative that have helped to reduce maternal and perinatal mortality in the state. While the system appears to run seamlessly, there are some limitations, the main one being funding.
MPDSR Desk Officer in the state, Dr Itam Essien, said that although MPDSR was not in the Saving One Million Lives (SOML) budget, it has now been added to both the SOML budget and the State health budget. “Even though the release of funds will be another issue,” he added. According to Professor Friday Odey, Vice Chairman & Member of Cross River State MPDSR Steering Committee, plans are underway to introduce MPDSR to PHCs and the community. This is however dependent on the availability of funds. The initiative was funded by USAID and MSD for Mothers. MSD for Mothers is also funding a community MPDSR project in 7 states. The project is implemented by a consortium of Nigeria Health Watch, EpiAFRIC and Africare.
Now that Pathfinder has closed the project, there has been a lull in activities and of major concern is the State government’s ability to take over and maintain the momentum gained. For the sake of lives saved and lives that will be saved, it is important for the Cross River State government to continue supporting the implementation of MPDSR in the state, to prevent future avoidable maternal and perinatal deaths. I urge the Nigerian government to continue supporting the implementation of MPDSR across the country, ensuring the full implementation of the National Guidelines, empowering all levels of the health system.
Maternal and Perinatal Surveillance and Response is an important tool for strengthening health systems. Visiting the hospitals and speaking with the people directly involved has provided me with first-hand experience of how MPDSR can impact lives. Each maternal and perinatal death is heart-breaking but when carefully documented and reviewed it has the potential to tell a story about what could have been done and what can be done to save the next mother and child in distress.
Halima did not survive but thankfully, her baby did. But the loss of a wife and a mother affected the family so deeply that almost 3 years after her death, they are only just beginning to overcome the emotional, social and economic impact of their loss. The MPDSR is one system that can help protect other families from going through such heartbreak, and other states should emulate what Pathfinder has done in Cross River to prevent the loss of our mothers and babies.