When Dr. Bello Olubenga started out his career as a gynaecologist at Maitama District Hospital in Abuja, helping mothers deliver healthy babies was his biggest motivation for putting in the long hours required for his job. This was not always the case, sometimes the hospital lost a mother or a baby. The common causes for women dying during childbirth, included severe eclampsia (convulsions caused by high blood pressure), excessive bleeding, infections, obstructed labour and unsafe abortions. But the risk of women dying during labour is also increased if there are delays when going to the hospital.
If a woman in Nigeria carries a healthy pregnancy to term, it is often unlikely that she will deliver with the help of a skilled birth attendant, explains Professor Dolapo Lufadeju, National Coordinator of the Rotarian Action Group for Population and Development (RFPD) in Nigeria. Only 43% of deliveries in Nigeria are assisted by a skilled provider. RFPD assists Rotary clubs and districts in the planning, implementation and co-funding of projects in maternal and child health and family planning with the aim of fostering improvements in human well-being and dignity, women’s empowerment and a sustainable balance between population and environment.
“Over 65 percent of deliveries in Nigeria happen at home or with a traditional birth attendant in the communities. The 35 percent of women who manage to make the frequently long tedious journey to the medical facility often meet hospitals in dire state with no equipment and where it is available, it is broken down. The shortage of trained doctors or midwives worsens mothers’ chance of a healthy delivery,” Lufadeju said.
All these burdens have contributed to the poor health and population indicators that put Nigeria amongst the ten worst countries to be a mother or baby. The country’s maternal mortality ratio — based on data from Nigeria’s 2018 National Demographic Health Survey (NDHS) is 512 death cases for every 100,000 women. The NDHS also showed that the neonatal mortality rate was 67 per 1,000 live births, while 132 infants per 1,000 die before their fifth birthday. “This is deeply worrying and if we don’t take calculated moves to improve the situation for our mothers and babies, women will continue to die while giving birth,” Lufadeju said.
Training to improve maternal health in Kaduna & Kano States
Twenty-five years ago, Lufadeju joined hands with a fellow Rotarian, Professor Robert Zinser from Germany and under the roof of the RFPD, they started the “Child Spacing and Family Health” project in two communities in the northern state of Kaduna. This RFPD-project gave training to nurses, doctors, midwives, and village health workers. It also supplied poor hospitals with essential medical equipment. It educated people about the benefits of family planning and made contraception more widely available. RFPD set up contraception distribution cupboards in 21 hospitals. During the five years of the project, contraception use soared from 3 to 27 percent in participating hospitals, according to findings of an independent evaluation carried out by the German Foundation for World Population, Deutsche Stiftung Weltbevoelkerung (DSW).
Building on the success of this pilot project and the lessons learned, RFPD initiated the systematic integration of “Obstetric Quality Assurance” (OQA) and “Maternal and Perinatal Death Surveillance and Response” (MPDSR) in 20 project hospitals in Kano and Kaduna States. This allowed medical and administrative staff to work together to reduce maternal and child mortality. Between 2008 and 2010 infant mortality declined by 15 percent while maternal mortality declined by 37 percent in participating hospitals, according to project records.
And here is how the RFPD-project made a difference: The clinics recorded every birth by registering and monitoring each incoming mother. They introduced standards of measure and made data collection and analysis compulsory, in order to find suitable solutions to specific problems which were killing mothers and their babies. All this was being done manually on paper.
Going digital to centralise data collection
Lufadeju and Zinser realised they needed a more accurate centralised system. In 2014 they solicited the help of Dr. Nicholas Lack, a trained medical statistician who had worked with German Institutes for Quality Assurance in the health service for three decades checking the quality of obstetrics and gynaecology care in hospitals.
“My job was to change the paper system of monitoring maternal and child deaths to a digital system which was more efficient and less time consuming. Improving quality of obstetric care requires analysis of quality of care, quality of structure and quality of outcome. It was clear that the way ahead was to design a database that was more consistent,” Dr. Lack says.
With that decision, RPFD launched the digital Obstetric Quality Assurance model in 10 hospitals. The tool measures three standards of quality: structure, process and outcome. Improvements in the outcome (the health of mothers and babies) are achieved by analysing the processes — the skills and qualifications of medical personnel handling mothers. These processes can only be improved when structures such as buildings, equipment, water supply, power supply, hygienic conditions are available to support doctors to do their work.
The tool also includes a module for tracking the supply chain for family planning on a monthly basis. It displays modern contraceptive prevalence rates for long and short term acting commodities, reflecting the degree of stock outs at facility, community, local government, state, zonal and national levels. RFPD expanded the project to include another 15 hospitals in Ondo and Enugu State as well as in the Federal Capital Territory.
Maitama District Hospital in Abuja was one of the project hospitals and Dr. Olubenga was introduced to the OQA tool. “I have an idea what is going on in all the facilities, how they use the commodities and what they need. When there is a maternal or perinatal death, we do a review and follow up immediately. If there is a facility that is not reporting, I follow-up immediately. I don’t have to wait until the end of the month to go there,” he says. He is now the Chairman of the FCT Abuja Maternal and Perinatal Death Surveillance and Response Committee.
Using data as a problem-solving tool for maternal and child health
Professor Ireti Akinola of the Society of Gynaecologists and Obstetrics of Nigeria (SOGON) explains that the OQA tool makes remote electronic data entry possible where today’s wireless telecommunication coverage is already satisfactory — even in remote rural areas.
Data can be collected via mobile phone, tablets, laptops and computers. Thus, the tool does not require specific devices and operating systems for data entry and can be applied in most geographical locations. All that is required is an email account, a user-id, a password and minimal computer literacy to enter data. The tool also includes a report generation module.
Dr Lack says entering the data is however, not the end of the solution, but the beginning. “Data entry is only the first step, maternal deaths and stock-outs will not stop just because we feed a computer with data or gaze at graphs,” he said, adding that “Maternal and child mortality requires critical analysis of the report and suggestion of action that will be taken. This is not done by a machine but by human beings.”
The project has initiated a training process which will be rolled-out in hospitals in the six geo-political zones and 37 states. It involves bringing together midwives and doctors with experts to discuss the data and find solutions that respond to the existing problems.
“Where equipment is lacking, initiative must be taken to provide it and thus improve the quality of structure” says Dr. Lack. “If we find that in certain communities or regions the number of home deliveries is too high, we seek solutions to encourage women to deliver in hospitals. People may expect that our tool can solve all issues at stake, but this is just the beginning. We must train more and more medical staff to be forward looking, raise their awareness and improve their problem-solving abilities. We need people who will follow up on the data and who will also respond to any demand for action.”
Scaling up a proven model nationwide
Nigerian state and federal authorities were impressed by the results of the intervention and asked RFPD to further scale up efforts to cover hospitals throughout the country and include family planning indicators. Nigeria is only the second country in Africa to adopt such a model after South Africa.
In 2019 RFPD and Nigeria’s Federal Ministry of Health started to roll out the project as a “Nationwide Family Planning Campaign” administered by Rotarians. The project receives additional support and financing of up to $3 million from Rotarians in Nigeria, Germany, Austria and Switzerland and the German Ministry of Economic Cooperation and Development (BMZ).
The goal of this campaign is to improve the nationwide quality of health infrastructure, including hygiene and equipment. Furthermore, maternal and perinatal death analysis are to be introduced systematically on a larger scale and public awareness of delivery and antenatal care is meant to be increased. The project will monitor the family planning supply chain for long and short acting contraceptives by looking out for stock-out rates and contraceptive usage indicators, in a bid to address the low uptake of modern contraceptives and reducing the unmet need for family planning.
By June 2018, the OQA tool covered 1,000 hospitals across the country. It will be expanded to cover 200 tertiary health centres, 4,000 secondary health centres, 35,000 primary health centres, and 8,000 wards, according to Dr. Lack. Gradual scaling up will take the first year of the project and in the next two years, focus will be on the training of staff in the usage of this tool and general issues of OQA.
Thirty-seven state statisticians, 3,500 doctors and 800 local government monitoring and evaluation officers will be trained in the use of the tool and analysis of data. In addition, 4,000 medical record officers in secondary and tertiary health institutions will also be trained. Training will be supported by Rotarians who will work alongside doctors and midwives during community dialogues and check on the delivery of contraceptives.
“We use Nigerian Rotarians as motivators to ensure that all planned project measures will in fact be implemented. Rotarians will continuously check for change; they will monitor whether reports have been reviewed and action is being taken accordingly,” Dr. Lack said.
The target is to reduce non-hospital births from 65 to 1 percent, he said. This requires building hospitals but also improving health care to ensure that the prospect of giving birth there is so attractive that people want to come to the hospitals. Lack says the vision of the project is to help raise mothers’ age at their first delivery to at least 20 years, spacing of children of two to three years and fertility dropping to three children per woman.
In addition, the project ensures that all aspects of sustainable family planning are addressed during the community dialogues which are now being conducted with the aim of dispelling myths and misconceptions concerning family planning. This will also be supported by a countrywide media campaign with partner organisations in Nigeria, such as the Population Media Center.
Dr. Olubenga says the tool has reduced the workload of his team and enabled immediate intervention. “We are happy that it now also covers maternal and child health in all primary health centres as well as within the communities. This data platform came in a few years back and we didn’t have an electronic tool. So we were doing everything manually but during the last two years, things have changed completely for the better,” he said.
He adds that the phone network sometimes fails in hospitals in remote areas. This delays reporting using the tool and work piles up because the tool works only when one has access to the internet. He also says that sometimes the interventions recommended after analysis of data are not made available because of lack of funding.
While there is an improvement in record keeping and ensuring orders are on time, the Nigerian government has cut funding for Family Planning commodities and services from NGN 2.9 billion in 2018/2019 to only NGN 300 million in 2019/2020. Other donors, including the United States Agency for International Development (USAID) withdrew their matching funding following the government’s failure to fulfil its counterpart funding obligation.
For now, RFPD hopes it can expand and improve the health systems and institutions in Nigeria to match WHO standards of maternal and perinatal death surveillance and response. The project is one step towards ensuring Universal Health Coverage (UHC) for maternal, child health and family planning by extending these benefits to cover even the remote villages in the entire country.
A health and development journalist, Shifa Mwesigye has ten years of national and international journalism experience. She has written for newspapers in Uganda, Nigeria, and USA. She is also a co-author of the book, Crossroads. An MA graduate of Journalism and Communication from Makerere University in Uganda, Shifa has extensive training experience in development journalism, maternal and reproductive, child health, and family planning from Population Reference Bureau, USA. She also trained with the Commonwealth Press Unit London UK on Journalism and Ethics and also received Data Journalism training from Africa Centre for Media Excellence.
Very good intervention. What is the role of private hospitals in this project.