Setting up facility‐based maternal death reviews in N igeria

Maternal mortality has remained an intractable public health concern in most developing countries. Over time four main strategies—family planning, antenatal care, skilled delivery care and emergency obstetric care—have been identified as key in reducing the burden of maternal deaths.1 However, these services are not universally available or used in most developing countries. Efforts to improve this have led to the introduction of audits of service and care. Audits of maternity services and maternal deaths have been associated with improvement in quality of service and better client outcome. The World Health Organization (WHO) has recommended maternal death audit to identify factors that need to be addressed for the prevention of avoidable maternal deaths.2 The accepted approaches to maternal death audit include facility-based death review; verbal autopsy (community-based death review); near-miss review; criterion-based clinical audit and confidential enquiry into maternal deaths.2 Maternal Death Surveillance and Response was recently introduced as a means of ensuring that all deaths are accounted for.3 Successful introduction and continuation of an effective maternal mortality audit programme requires political commitment, an organised health system, legal and administrative back-up, financial support and capacity development. The adoption of the practice of maternal death audit in developing countries has been limited.4 Recent reports indicate that only a few developing countries including South Africa, Malaysia, Egypt and Jamaica have achieved a comprehensive programme or system of maternal death audit in the form of confidential enquiry into maternal deaths.5, 6 Nigeria is the most populous country in Africa. The population was estimated to be about 171 million in 2012. Nigeria has a low contraceptive prevalence rate of 15%, a high total fertility rate of 5.7% and an annual population growth rate of 3.2%.7 The land mass covers an area of 923 768 km2. The civil registration and vital statistics system in Nigeria is poorly developed. Statistics on births and deaths are currently estimated from surveys. The maternal mortality ratio was estimated to be 545/100 000 live births and infant mortality rate was 75 deaths per 1000 live births in 2008.8 A recent WHO estimate showed that in 2010 Nigeria had the second highest number of annual maternal deaths in the world after India. Maternal deaths in Nigeria account for 14% of all maternal deaths globally despite contributing >2% of the global population. Nigeria is also one of the few countries that are unlikely to achieve Millennium Development Goal 5 targeted at reducing maternal mortality by 75% by the year 2015.9, 10 The life expectancy at birth for women and men in Nigeria is estimated at 47.1 years and 46 years, respectively.7 Healthcare provision in Nigeria is a concurrent responsibility of the three tiers of government. The Federal, State and Local governments have broad responsibilities for tertiary, secondary and primary health care, respectively. The Federal government through the Federal Ministry of Health provides policy guidance and technical assistance to the 36 states and Federal Capital Territory (Abuja), and they also implement, monitor and evaluate national health programmes and policies. Each of the state governments has the responsibility to legislate, make policy and provide health care for people residing in their states. Local governments are responsible for health care at the primary healthcare level. The private sector also plays a significant role in healthcare provision in Nigeria. A recent census of available health facilities in Nigeria showed a total of 34 173, of which 30 098 (88.1%) are primary healthcare facilities, 3992 (11.7%) are secondary, and 83 (0.2%) are tertiary.11 Although the private sector owns about 38% of these facilities, they provide over 60% of essential healthcare services in some states in Nigeria.12 The national health system is not well coordinated. Infrastructure and health facilities, especially at the secondary and primary healthcare levels, are inadequate and not well maintained. Most of the healthcare facilities lacked appropriately trained healthcare professionals.13 Many of the citizens lack access to standard basic and emergency health care for both prevention and treatment. The 2008 National Demographic and Health Survey revealed that 36% of pregnant women do not receive any form of antenatal care, only 35% deliveries occur in health facilities and 56% of mothers did not receive any postnatal care within 6 weeks of delivery.8 Many studies on maternal mortality in Nigeria have been reported.5, 14-16 Most of these studies, however, are limited in coverage and focus. The majority of studies were undertaken in tertiary hospitals located in urban areas and are confined to individual hospitals. These studies have identified the leading medical causes of maternal death as hypertensive disease, haemorrhage, obstructed labour, infection and unsafe termination of pregnancy. Contributory factors including sociocultural factors, poverty, lack of essential amenities and deficient healthcare services have also been highlighted. These individual studies, however, failed to identify and aggregate specific circumstances surrounding maternal deaths to identify where action is most needed for preventing similar deaths. The need to reduce maternal mortality is currently one of Nigeria's most pressing public health challenges. The Nigerian government has indicated its commitment to address this through an increase in resource allocation and development of favourable maternal health policies and effective programmes.13 In 2013, a maternal death review (MDR) was approved as part of the national strategy for improvement of maternal health care in Nigeria. This paper highlights the process, challenges and opportunities Nigeria has faced in the establishment of facility-based MDR. Facility-based MDR involves a qualitative, in-depth investigation of the causes of and circumstances surrounding maternal deaths occurring at health facilities, determining avoidable factors at the facility and where possible supplemented with information from the community. An MDR cycle involves five essential steps—identification of maternal deaths in the facility; data collection; analysis of findings; recommendations and action to prevent future avoidable deaths; and monitoring, evaluation and refinement of the process. Previous efforts to introduce MDR into the Nigerian healthcare system in 2003 were unsuccessful.4 The current effort to re-establish a national system and process of MDR was initiated in 2012 by the Society of Gynaecology and Obstetrics of Nigeria (SOGON) as part of its activities under the International Federation of Gynaecology and Obstetrics (FIGO)—Leadership in Obstetrics & Gynaecology for Impact and Change (LOGIC) Project. The FIGO-LOGIC initiative aimed at ‘improving policy and practice by strengthening FIGO member associations and using their position and knowledge to facilitate and contribute to these improvements, leading to better maternal and newborn health for under-served populations in low- and middle-income countries’.17 A comparison by SOGON of the Nigerian healthcare system with that of South Africa, which has successfully introduced a maternal audit system, identified some factors that contributed to the initial failed attempt, and that need to be surmounted before a national MDR programme can be successfully established. The factors include ensuring ownership of the programme by the Federal Ministry of Health and the State Ministries of Health, identifying and mobilising resources for implementation, ensuring a favourable policy and legal environment for implementation, training and re-training of staff, dissemination of findings and response and action based on the findings.6 It also became pertinent that other stakeholders in maternal health should be mobilised and engaged in efforts to institutionalise MDR in the Nigerian healthcare system. SOGON identified the following as key stakeholders in the development of an MDR programme in the country: Office of the President/First Lady; State Governors and their wives, Federal and State Ministries of Health; National and State Assemblies; Ministry of Women's Affairs; Directorate of Planning, Research and Statistics; National Primary Healthcare Development Agency; National Council of Women Society; Professional Associations—SOGON, Paediatrics, Anaesthesia, Pathologists, Public health physicians, nurses and midwives; civil society groups and development partners including WHO and the United Nations Population Fund. A series of advocacy visits and representations to government and its agencies and departments was undertaken to elicit support and encourage government ownership of the MDR programme, but with SOGON and other stakeholders as drivers. Two sensitisation and training workshops on MDR were organised for selected obstetricians and gynaecologists, and representatives of the following professional associations—nurses and midwives, paediatrics, pathologists, anaesthetists and public health physicians; staff of the Federal Ministry of Health and National Primary Healthcare Development Agency; WHO and the United Nations Population Fund. The lead facilitators for the workshops were experts who were invited to provide technical assistance from the UK and South Africa, countries with established maternal death audit systems. A technical workshop with participation of the representatives of major stakeholders was also organised to develop national MDR guidelines, implementation tools and an implementation plan. The outcome of the technical workshop was circulated for further input and comments and subsequently submitted to the Federal Ministry of Health as draft national guidelines, implementation tools and implementation plan for MDR in Nigeria. In September 2013, the National Council on Health, comprising the Minister of Health and Health Commissioners from all the states in the country, formally approved MDR in the Nigerian health system. It also approved and directed that all maternal deaths should be reported to the health authority. The National Council on Health is statutorily empowered to consider and approve national health policies and programmes. The draft MDR guidelines and implementation tools were subsequently finalised by an enlarged stakeholder group including representation from all the states. The printed guidelines and tools have been made available for use in all the states in the country.18 To develop a critical base of trained health workers on MDR, SOGON organised a training of trainers workshop on MDR for 25 obstetricians and gynaecologists spread across the country, who are to serve as master trainers on MDR in the country. The following are essential components of the strategy for implementation of the Nigerian MDR programme: 1. Hon. Minister of Health appointee—Chairman 2. SOGON Council nominee—Secretary Representatives of: 3. Office of the First Lady 4. Department of Family Health FMoH 5. Department Hospital Services FMoH 6. Department of Planning, Research & Statistics FMoH 7. Legal unit FMoH 8. Ministry of Women's Affairs 9. National Population Commission 10. Bureau of Statistics, Presidency 11. National Council of Women's Societies 12. National Primary Healthcare Development Agency 13. Development Partners Representatives of National Professional Associations of: 14. Paediatrics 15. Anaesthesia 16. Pathology (Morbid Anatomy) 17. Haematology 18. Nursing and Midwifery Council of Nigeria 19. Representative of Action Network for Maternal Survival 20. MDR Desk Officer (Department of Family Health, FMoH) 1. Chair appointed by Permanent Secretary 2. Office of the First Lady 3. Executive Secretary/Director Medical Services Hospital Management Board 4. Director Primary Health Care 5. Department of Planning Research and Statistics 6. Director Nursing Service 7. RH Coordinator Ministry of Health 8. State Primary Healthcare Development Board 9. Local Government Service Commission 10. Chief Pharmacist 11. Chief Pathologist 12. Obstetricians—SOGON MDR committee representative (in the same state) 13. Representative of State Chapter of National Council of Women Society 14. Representative of State Chapter Nigeria Bar Association 15. Representative of State Action Network for Maternal Survival 16. MDR Desk Officer 1. Chairman, Medical Advisory Committee (or Director of Clinical Services)—Chairman 2. Head, Obstetrics Department—Secretary Head/Representative of Department of: 3. Nursing/Midwifery 4. Paediatrics 5. Pathology 6. Anaesthesia 7. Haematology 8. Medical Records 9. Medical Social Welfare 10. Pharmacy 11. Legal unit 12. Member of a local Women's Group 13. (Invited staff directly involved in the case management) 14. MDR Desk Officer 1. The Officer-in-charge of the facility 2. Ward focal person 3. Pharmacy technician 4. Medical Record officer 5. Chairman ward development committee 6. Supervisory Councilor for Health National Level: Office of Director, Department of Family Health Facility Level: Office of Chief Medical Director (CMD) State Level: Director Medical Services, Hospital Management Board Facility Level: Office of Medical Director, PHC Facility Managers Local Government Level: Office of Councillor for Health and Health Committees The current leadership in Government is amenable to the MDR programme. SOGON's membership strength of 1050 in 2013, spread across the country, and their willingness to implement MDR are major strengths. Challenges exist in ensuring adequate allocation of resources to execute identified gaps in the health and social sectors and ensuring healthcare workers are properly trained in MDR. National health systems and infrastructure need to be strengthened. Low prioritisation and poor budgetary allocation to health have been major obstacles to ensuring that health care is available to all in Nigeria. There is also the challenge of eliciting the support and co-operation of all health workers. There would be explicit policy and legislation for the protection of the healthcare workers, health facility and the clients from medico-legal actions. Resistance to change among some health workers and national political instability are potential threats to successful implementation. These threats and challenges can be readily surmounted if all stakeholders are effectively engaged through strategic advocacy, involvement and participation at all stages of planning and implementation.20 The enforcement of the recent policy of inclusion of maternal deaths as a notifiable event and improvement in the civil registration/vital statistics system will ensure that virtually all maternal deaths are reported, reviewed and accounted for. The current convergence of factors including global support for the elimination of preventable maternal deaths and achievement of Millennium Development Goal 5, increasing government support and technical innovation provides an opportunity to consolidate the practice of MDR with potentials to progress to maternal death surveillance and response in the near future in Nigeria. The vision for improved accountability and reduction in maternal mortality in Nigeria can be achieved through a well-established and responsive national audit system that takes into consideration available resources. Facility-based MDR provides the initial platform from which a comprehensive national maternal audit system in the form of maternal death surveillance and response can be achieved. It is important to capitalise on the current political climate for this whole process to be successful. The authors declare that they have no conflicts of interest. COA prepared the initial draft and incorporated the comments of the co-author. FFA reviewed the manuscript for important intellectual content. It is a commentary on the process of establishing maternal death review in Nigeria. It did not involve human and animal subjects or medical records. Some of the activities listed in the article were undertaken as part of the Leadership in Obstetrics & Gynaecology for Impact and Change (LOGIC) project of Society of Gynaecology and Obstetrics of Nigeria (SOGON), which received financial support from the International Federation of Gynaecology and Obstetrics (FIGO). We are grateful to Professor Gwyneth Lewis and Professor Jack Moodley for facilitating the MDR sensitisation and training workshops. The MDR workshops and training were undertaken as part of the FIGO–LOGIC Project.