In 2020, we shone a spotlight on RICOM3, a programme focused on helping Nigerian women take ownership of their pregnancy journey, by going the extra mile to implement a Quality of Care (QoC) model that women and health care workers can easily adopt, own and practice. A consortium consisting of Jhpiego, mDoc and Health Strategy and Delivery Foundation (HSDF) is now implementing phase two of the programme. Their aim is to reduce maternal morbidity and mortality (MMM) from indirect causes by applying the QoC model to improve prevention, early detection and management of indirect causes of MMM associated with preeclampsia and eclampsia (PE/E), along the continuum of public and private maternal health and reproductive health (MH/RH) care services, for women of reproductive age (WRA). The programme is currently being implemented in Lagos State and the Federal Capital Territory (FCT).
The Reducing Indirect Causes of Maternal Mortality and Morbidity (RICOM3) programme, funded by MSD for Mothers, is taking an innovative approach to addressing maternal deaths caused by Non-Communicable Diseases (NCDs). This approach is focused on strengthening health provider capacity through mentoring, coaching, capacity building, and establishing quality improvement teams at health facilities to reduce the risk of maternal and reproductive health complications that arise during and after pregnancy. In addition, women of reproductive age are registered on the digital CompleteHealth™ platform, where they have access to dedicated health coaches who provide round-the-clock self-care support to modify their lifestyles to prevent and manage complications during and after pregnancy.
This is critical because Nigeria remains one of the leading contributors to maternal deaths globally, contributing to around 20% of maternal deaths worldwide. In Nigeria, the current maternal mortality ratio is 512 per 100,000 live births with noncommunicable diseases (NCDs) including cardiovascular diseases, cancers, diabetes and chronic respiratory diseases accounting for 24% of total deaths during pregnancy. A lesser-known fact is that approximately 5–10% of pregnancies in Nigeria are complicated by hypertensive disorders. Still, the effects of NCDs on women of reproductive age and their risk factors have received limited attention.
Evidence for Change: The Quality-of-Care Model of Integrated Maternal Health and NCD Services
In 2019, the RICOM3 programme embarked on a baseline assessment that consisted of a prevalence assessment of risk factors leading to PE/E in 4 Local Government Areas (LGAs) in Lagos State and the FCT — Abuja Municipal Area Council (AMAC) and Bwari in the FCT, and Alimosho and Ikorodu in Lagos State. In addition, an assessment of QoC for the prevention and management of these PE/E risk factors in maternal and non-communicable disease services was carried out in 20 health facilities (10 health facilities each in the FCT and in Lagos State).
The findings from this assessment show that:
I. Women have limited awareness of risk factors that indirectly cause maternal morbidity and mortality (MMM) linked to PE/E.
II. The high prevalence of hypertension, obesity, anaemia and diabetes, to a lesser extent, is of concern to girls/women of reproductive age.
III. Less than five percent of women with identified risk factors/diagnoses were aware of their status.
IV. An assessment of health facilities demonstrated many gaps in service delivery readiness, confidence and knowledge of health care workers, and quality of antenatal care (ANC) for prevention, early detection and management of PE/E risk factors like, hypertension, diabetes, anaemia, and obesity.
Current strides in improving quality of maternal care
Following this assessment, the programme channeled its second phase to scaling up implementation, which is currently ongoing and is slated to be completed in December 2022.
This phase is driven by three primary objectives:
I. To scale up the RICOM3 QoC model in 40 public and private facilities in two Area Councils in the FCT and two LGAs in Lagos State, by strengthening woman-centered maternal and reproductive health services, across the care continuum, for improved experience of care and prevention and management of pre-eclampsia/eclampsia (PE/E) associated indirect causes of maternal morbidity and mortality.
II. To drive the demand side of QoC through the provision of virtual guidance in self-care and lifestyle modifications in the prevention of modifiable risk factors and complications from indirect causes of maternal mortality and morbidity.
III. To promote sustainability of the QoC model by engaging key stakeholders in Lagos State and the FCT to advocate for two things: the incorporation of the model into maternal health, non-communicable disease strategies and government health budgets, and into existing health insurance schemes and private health maintenance organisations.
So far, a total of 71,061 women have received antenatal care, delivery and postnatal care services in the 40 RICOM3-supported health facilities in 2021, and 51,384 women of reproductive age have onboarded onto the CompleteHealth™ digital platform. The average proportion of women screened for blood pressure, diabetes, and anemia from January-June 2021 and July-December 2021 increased from 81% to 90%, 53% to 71% and 74% to 80% respectively in the 40 health facilities. This demonstrates continued robust improvements in care in existing phase-one sites and in new phase-two sites during this scale up phase.
But it wasn’t all smooth sailing as the programme recorded some challenges, mostly attributable to human resources issues, as some health facilities had limited staff available. Furthermore, virtual coaches supporting the scale-up of the CompleteHealth™ platform reported experiencing burnout. More learning needs to be done around automation and personalisation, as well as what to do to achieve the ideal coach-member ratio based on the risk profile of each registered member. In addition, there was the unavailability of functional equipment in some health facilities to contend with.
Beyond the RICOM3 programme: Recommendations for action and sustainability
The current phase of the RICOM3 programme will end in December 2022, and its exit strategy is to ensure an established state-wide operationalisation of the QoC model in Lagos State and the FCT. A sustainability plan was therefore developed along the domains of Political Sustainability (Governance), Fiscal Sustainability (Financial), Operational Sustainability (Service Delivery) and Institutional Sustainability (Coordination). This plan focuses on ensuring that structures are in place at the government level, health facility level and among stakeholders and partnerships to safeguard the continuous application of this lifesaving QoC model.
The results highlighted are proof that the QoC model improved the quality of maternal care, and consequently outcomes of pregnant women in the project states. It could become a workable intervention in Nigeria to help improve maternal health indices, especially reducing the indirect causes of MMM and should be adopted by health facilities nationwide. In line with the strategic direction of the programme, public and private sector stakeholders should synergise to incorporate the QoC model interventions into maternal health and non-communicable diseases strategies at state and national levels.
State governments should also consider integrating the QoC model intervention package as part of existing state health insurance schemes. An investment case consisting of a costing and savings analysis is in development to support the adoption of the QoC model nationwide. Once completed, the respective Departments of Planning, Research and Statistics (DPRS) in state ministries of health should leverage the investment case for maternal health and NCD programmes and tailor it to their needs accordingly. This should inform advocacy for the reflection of any new considerations into the 2022 health sector budget allocation. In addition, private health maintenance organizations should consider incorporating the model into their plans. This then moves the model from being a service availability-centred service to a quality of care-centred package.
Subsequently, the systems strengthening, and quality improvement advantages of the Quality of Change model are too good a benefit to ignore.