It is known that although 60% of pregnant women in Nigeria receive antenatal care in health facilities, only about 33% of the women eventually deliver in health facilities. By contrast, up to 65% of women deliver at home or in the homes of traditional birth attendants, faith-based clinics or in poorly equipped private hospitals. Thus, women who experience pregnancy complications in late labor often present as emergencies to referral hospitals in many parts of the country. The World Health Organization recommends that such hospitals must have the full complement of facilities to be able to deal with such complications promptly and effectively in order to avert unwarranted maternal deaths.
The Central Hospital in Benin City, Edo State of Nigeria is the main referral hospital funded by the Edo State Government that provides emergency obstetric services to a large population of pregnant women spanning the entire Edo South Senatorial District of the State and parts of Delta and Ondo States. In 2016, the Central Hospital, Benin was one of eight secondary/tertiary hospitals in four geo-political zones of the country where the Women’s Health and Action Research Centre (WHARC), with support from the World Health Organization1 conducted formative research to determine the rates of maternal deaths, the circumstances under which women receive emergency obstetrics care in the hospitals and the views and perspectives of patients, care-givers and senior officials with regards to the quality of care offered in the hospitals. The other hospitals were: 1) State Hospital, Ijaye, Abeokuta; 2) the Adeoyo Maternity hospital, Ibadan; 3) the Central Hospital, Warri; 4) the General Hospital, Minna; 5) the General Hospital, Abuja; 6) the Aminu Kano, hospital, Kano; and 7) the Ahmadu Bello University Teaching Hospital, Zaria. The results2,3,4,5,6,7,8,9,10,11 showed that of these 8 hospitals, the Central Hospital, Benin had the highest maternal mortality ratio of 1,469 per 100,000 births, while the Adeoyo Hospital had the lowest ratio of 177 per 100,000 births.
The results also showed that the Central Hospital, Benin also had the highest clients-provider ratios as compared to the other hospitals, which suggest that fewer numbers of midwives, nurses and doctors are managing the large concentration of patients in the hospital.
It is within this context that WHARC, with support from the World Health Organization and the Macarthur Foundation13 has designed a series of activities and interventions aimed at improving the provision of quality maternal health care and reducing maternal mortality ratios at the Central hospital, Benin. One of the first activities under the intervention plan is to develop a multi-stakeholder strategic plan to bring everyone on board with the desire to improve emergency obstetric care practices in the hospital. We believe this is extremely crucial to build the necessary commitments at every level – the hospital staff, the Hospital Management, the Hospital Management Board, the Ministry of Health and the State Government – in efforts to work coherently and decidedly to address the bottlenecks that affect the delivery of services in the hospital. We believe very strongly that this approach has implications for the development of policies and programs for improving the quality of emergency obstetric care, not only in this hospital but in other referral hospitals throughout the country.
Method of Strategic Plan Development
The process of strategic development was organized in 3 phases. In phase one, we conducted a needs assessment in the hospital with support from the hospital staff. This included 1) review of the maternity records of the hospital over a six-month period – January 1, 2014-June 30, 2014; 2) key informant interviews with key officials of the hospital, the hospital management board and the Ministry of health; 3) focus groups discussions with women using the hospital; 4) questionnaire interviews with staff (nurses, midwives and doctors) to determine their knowledge, attitudes and practice of various elements of emergency obstetric care; and 5) client flow study to determine the time spent by women in receiving services at designated service delivery points of the hospital.
In Phase 2 of the project, we analyzed the results of the formative research to identify areas needing remediating action for improving the quality of maternal health care and reducing maternal mortality ratio in the hospital. The results of the intervention design and formative research have been published elsewhere2,3,4,5,6,7,8,9,10. The intervention activities identified for the Central Hospital, Benin include the following: 1) the development and implementation of a multi-stakeholder strategic plan; 2) the establishment and implementation of Maternal and Perinatal Death Reviews and Surveillance (MPDRS); 3) the development and training of staff to use protocols, guidelines and algorithms for management of pregnancy complications; 4) the development and implementation of a computerized system to give appointments to patients and reduce delays; 5) the training and re-training of staff; 6) the development and implementation of a model approach to educate patients and receive their feedbacks on aspects of care in the hospital; and 7) high-level advocacy to mobilize resources for improving infrastructure, facilities and increase human resources for the management of the hospital. This strategic plan is therefore being developed as one of the first activities being conducted for implementing the project activities.
In the final phase of the strategic plan development, WHARC convened a workshop with all staff of relevant departments of the hospital, senior management team, officials of the State Hospital Management Board, and the Edo Commissioner of Health. The one-day workshop took place in the hospital on October 31, 2017. The objective of the workshop was to build consensus on the challenges facing the hospital and to agree on issues that need to be addressed in developing a strategic plan to improve the situation.
- Okonofua FE, Ogu Rosemary et al. An intervention to improve the management of obstetric emergencies and prevent maternal and perinatal deaths in Nigeria: A quasi-experimental research design. Proposal approved for funding by the WHO and the FMOH, Nigeria. 2016. H9-TSA-282.
- Okonofua F, Randawa A, Ogu R, Agholor K, Okike O, Abdus-salam RA, et al. Views of senior health personnel about quality of emergency obstetric care: A qualitative study in Nigeria. PLoS ONE 2017; 12(3): e0173414. doi:10.1371/journal.pone.0173414.
- Okonofua F, Ogu R, Agholor K, Okike O, Abdus-salam R, Gana M, et al. Qualitative assessment of women’s satisfaction with maternal health care in referral hospitals in Nigeria. Reproductive Health 2017; 14:44 DOI 10.1186/s12978-017-0305-6.
- Okonofua FE, Ntoimo LF, Ogu RN. Women’s Perceptions of Reasons for Maternal Deaths: Implications for policies and programs for preventing maternal deaths in low-income countries. Health care for women international. 2017.http://dx.doi.org/10.1080/07399332.2017.1365868
- Ogu RN, Ntoimo LF, OkonofuaFE.Perceptions of women on workloads in health facilities and its effect on maternal health care: a multi-site qualitative study in Nigeria. Midwifery 2017; 55(12) 1-6. http://dx.doi.org/10.1016/j.midw.2017.08.008
- Friday Okonofua, LorrettaNtoimo, Rosemary Ogu, HadizaGaladanci, RukiyatAbdus-salam, Mohammed Gana, et al. Association of client-provider ratio with risk of maternal mortality in referral hospitals: A multi-site study in Nigeria. Reproductive Health Manuscript ID: REPH-D-17-00242
- Friday E Okonofua, Rosemary N Ogu, Lorretta F Ntoimo, MohammedGana, Ola Okike,AdetoyeDurodola, HadizaGaladanci. Where do delays occur when women receive antenatal care in referral hospitals in Nigeria? A client flow multi-site study. Ghana Medical Journal Manuscript ID: GMJ-2017-08-0137.
- LorrettaNtoimo, Friday Okonofua, Rosemary Ogu, HadizaGaladanci, Mohammed Gana Mohammed, Ola Okike, et al. Prevalence and Determinants of Maternal Mortality in Referral Hospitals in Nigeria: A multi-Centre study. Intl J Women’s Health Manuscript ID:151784
- Friday Okonofua, RukiyatAbdus-salam, Rosemary Ogu, HadizaGaladanci, Mohammed Gana, et al. Assessment of facilities and essential commodities for maternal health care services in 8 secondary and tertiary hospitals in Nigeria. International Journal for Quality in Health Care – Manuscript ID: INTQHC-2017-06-0365.
- Okonofua Friday, LorrettaNtoimo, OludamilolaAdejumo, Wilson Imongan, and RosemaryOgu, Effectiveness of Primary Health Care in improving access to maternal, newborn and child health services in sub-Saharan African countries: A review of the scientific evidence. International Journal of Primary Health Care. Submitted.
- OkonofuaF, Ntiomo L, Ogu R, Galadanci H, Gana M, Abdus-salam A, Galadanci H.,Durodola A, Randawa A. Prevalence and risk factors for stillbirths in referral hospitals in Nigeria. A multi-Centre study. British Journal of Obstetrics and Gynaecology, Submitted.