Maternal death reviews (MDR) in Nigeria are not new, as some states have been conducting them over the years. However the methods used were developed locally and unique to each state. Aminu Magashi Garba – Evidence Advisor with the Evidence for Action programme in Nigeria presents the case of a secondary level facility that has been able to make small but important changes after having adopted MDRs.
Earlier this year, national maternal death review guidelines were approved and adopted by the National Council of Health so that standardised methods could be used across the country. All states are now expected to roll out MDRs using the tools and guidelines approved by the Federal Ministry of Health.
To support the Jigawa State Government in implementing the national guidelines, the Evidence for Action programme supported the state to establish a broad based state wide MDR committee and facility based MDR committees at secondary health facilities. The committees at both levels were trained in using the approved national MDR guidelines and tools to conduct MDRs as well as how to analyse and disseminate MDR findings. Following the training, the team from secondary level health facilities tried to enhance the ways in which they conducted MDRs and the analysis of data to facilitate better decision-making, and planning for facility based improvements.
The facility-level MDR Process
The MDR committee is headed by a Chairman who is usually the chief medical director, and includes other members such as the medical doctor and the chief matron in charge of the maternity unit; one midwife and the Head of the pharmacy. The committee meets on a monthly-basis and uses the MDR formats included in the national guidelines.
At the end of each working-shift (morning and afternoon) a midwife documents any maternal deaths that may have taken place in her case notes including causes of death, timing as well as the case management details. This is passed on to the matron who presents the case for discussion at scheduled meetings of the MDR committee.
The MDR committee analyses the data presented to understand the demographic as well as medical influences. For example, they are expected to look at the age of the women, number of pregnancies, number of children, history of antenatal visits, complications if any and cause and/or probable cause of death. The committee then discusses all the deaths in the affected month and provides recommendations to prevent a repeat of the same problems.
Some findings and responses
The MDR process that was set in place since December 2013 has proven to be very useful for the facility level staff to quickly identify problems as well as devise solutions. Three significant examples presented below have all likely contributed to the reduction in maternal mortality in one secondary level health facility of Jigawa:
a. One of the MDR reviews found that women were dying as a result of post-partum haemorrhage despite the efforts of the health providers. The review showed that the drugs (such as Misoprostol and Oxytocin) that were being administered to the women were ineffective as they were substandard and out-of-date. The committee immediately apprised the Jigawa State Drug Management Agency about the situation and the agency changed the supply company which is now providing a better brand.
b. The monthly reviews revealed that the number of women dying in child birth was higher in the night than during the day. A deeper probe and analysis showed that the night-working shift had only a few health care providers, mainly junior midwives. In comparison the morning-working shifts had the senior and more experienced midwives. This led the committee to recommend that the hospital introduces a new staff roster that paired a senior midwife with a junior midwife, who would work together in either shift, thereby allowing adequate skills and experience to be available at all times of the day.
Maternal deaths in the night at this facility have not been reported to date, since the time this arrangement was put into place.
c. And finally, the committee’s review also found that waiting times were contributing to high rates of maternal morbidity because women were losing a substantial amount of time as they were directed for care or treatment from one department to the other, as well as sometimes waiting for the facility to let them know which unit they need to approach.
Following this finding, the hospital management organised an orientation meeting for all staff in the maternity unit and reorganised the department to make referrals within the unit smoother. Waiting times are now reported to have contributed to reduced maternal morbidity due to improved access to timely care.
This experience has shown that small but committed actions can be taken at the facility-level that have the potential to impact maternal mortality. Whilst it is important to work for more allocation of resources, it is equally crucial to ensure that existing resources are used better to improve the levels of care delivered.
By Aminu Magashi Garba – Evidence Advisor with the Evidence for Action programme in Nigeria. Aminu has been working with local government officials, medical professionals and other stakeholders to encourage the use of evidence-based decision making in maternal health, and MDSR is one of the components that he has been engaged in over the past year.