Institutionalising Maternal Death Reviews in Jigawa State, Nigeria – from guidelines to implementation
This case study was written by Tunde Segun, Aminu Magashi Garba and Sarah Bandali from Evidence for Action-MamaYe.
The Society of Gynaecology and Obstetrics of Nigeria (SOGON), Evidence for Action (E4A) and other partners worked with the Federal Ministry of Health (FMoH) to draft National Guidelines for Maternal Death Review (MDR) in Nigeria. After a long delay, the guidelines were approved by the Minister of Health in 2013 and subsequently at the National Council on Health. E4A helped facilitate the approval process by mobilising senior medical doctors and disseminating a policy brief to encourage the Minister of Health to prioritise MDRs.
A thematic panel session was also convened by E4A titled "Maternal Death Reviews – Emerging issues" which brought together speakers from the FMOH, SOGON, the State Ministry of Health in Ondo and private sector partners involved in mobile-health (m-health) work. The aim was to sensitise participants on the importance of MDRs in improving quality of care to contribute to reductions in maternal mortality. There was overall agreement on the need to ensure actions are implemented from MDR findings and also to explore the use of technology in better capturing and using data.
With support from E4A and SOGON, Jigawa became one of the first States in the country where the national guidelines and tools, while in process of obtaining national approval, were used to train and establish State and facility-level MDR committees. The State committees oversee and support the facility level committees, providing monitoring and supportive supervision reviews. The facility level MDR committees, which are meant to meet every 2-4 weeks, comprise a medical officer, nurse/midwife, labour ward and antenatal attendant and use a paper based system to conduct MDRs. In 2014, a total of 503 maternal deaths were recorded in the 12 general hospitals in Jigawa state of which 214 were reviewed1.
Challenges revealed by the analysis of Jigawa MDR data include, among others: frequent staff redeployment or retirement, where trained staff are replaced with those that are not trained in MDR. Refresher trainings on MDRs have been conducted in Jigawa State to mitigate some of the effects of staff turnover. Occasionally as noted above, there are disparities between the number of maternal deaths which occurred at the facility compared to those recorded by the maternity ward and record office.
The reasons for this discrepancy are likely due to delays in facility staff receiving MDR tools making it difficult to systematically record maternal deaths. There are also instances where facilities were not conducting maternal death reviews of women who had already died prior to or on arrival. Due to transportation challenges and lack of printed MDR forms, facilities in rural areas have difficulties in sending data to the State MDR committee.
In Jigawa State, attention has been directed at the response and action components of MDRs with findings already influencing improvements in service delivery and quality of care.
For example, one facility found more maternal deaths occurring at night (65%) compared to the morning and afternoon/evening shifts (17% each), which was not due to insufficient numbers of staff, but because fewer of the most qualified ones were assigned to night duties. The facility management thus took a decision to redistribute the staff, combining higher cadre midwives/nurses with a lower cadre.
In another facility, MDR data helped uncover the unavailability of essential drugs at the point of delivery. As a result, the facility made the decision to ensure that drugs are always kept at the maternity, not at the pharmacy or in the storehouse.
The future, next steps
Data from the 2014 October-December MDR reviews from Jigawa State have been packaged into a traffic light scorecard to assess the strength of the current MDR system and where improvements can be made. The scorecard includes questions adapted from WHO indicators such as the frequency of MDR committee meetings, number of maternal deaths reviewed and whether action plans based on MDR findings have been developed and implemented (see Annex 1 for draft of the Jigawa MDR scorecard).
At the national level, the current maternal death review guidelines and tools have been expanded to include perinatal deaths which will enable a comprehensive Maternal and Perinatal Death Surveillance and Response (MPDSR) system to be implemented. The inauguration of the National Steering Committee has paved the way for the launch and subsequent implementation of the MPDSR guidelines. To date, four zonal orientation meetings have taken place with E4A facilitating and sharing experiences at these meetings and a Facebook group titled ‘Maternal and Perinatal Death Surveillance and Response in Nigeria’ has been created. The purpose of this virtual group is to share findings, learnings and experiences of MPDSR implementation at the different State levels.
Digitalising the MDR process is an area E4A hopes to add value, by placing MDR tools into an electronic tablet to enable rapid collection and use of real time data compared to the current paper based MDR system. The electronic system would enable data to be captured at facility and State level with a vision for creating a centralised MDSR database. Funds are needed to pilot the tablet however there is huge interest from the FMOH to implement this system.
Electronic data can facilitate a more comprehensive analysis of MDR findings across facilities to be tracked and acted upon by the State MDR committee which may be beyond the control of an individual facility including systemic gaps such as insufficient supplies of magnesium sulphate to treat eclampsia, or non-functional blood banks with insufficient and unsafe blood stocks to treat haemorrhage.
Annex 1: Jigawa Maternal Death Reviews
1Summary review of MDR reports in 12 General Hospitals in Jigawa state