The World Health Organization (WHO) defines maternal death as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes’’.
Globally over 303,000 women die annually from pregnancy or childbirth related complications. In Nigeria, it is estimated that one woman dies every minute, resulting in 109 women dying each day from pregnancy related causes, but the big question remains; why are these women dying, especially after arriving at the health care facility? The truth is that most of the statistics given for maternal mortalities are often estimates, with more than half of the deaths in Low and Medium Income Countries (LMICs) undocumented. This is a cause for concern as the true picture of maternal mortality is not revealed.
The death of a woman has multiple effects especially in LMICs. A mother’s death affects her children, who often will lack good nutrition and care and may drop out of school, with adverse social consequences for the girl-child, her death also affects her husband who will miss her love and companionship, her family, community and even her country. In view of this, ensuring accountability with respect to maternal deaths cannot be over-emphasized particularly when we know that the biological causes of maternal deaths, i.e. Postpartum Hemorrhage, Eclampsia, Obstructed Labour, etc., are the same both in the advanced countries and the LMICs.
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Getting reliable and accurate cause of death data is crucial for health planning, prioritization and interventions. In many settings, what we don’t know prevent us from reducing maternal mortality.
The WHO recognizes the contribution of maternal death reviews (MDR) in improving maternal health and has promoted its use in countries. A maternal death review is defined as a "qualitative, in-depth investigation of the causes and circumstances surrounding maternal deaths occurring either at health facilities or in the community".
A maternal death review provides a rare opportunity for a group of health staff and community members to learn from a tragic – and often preventable - event. Maternal death reviews are usually conducted as learning exercises that are done in a no-name, no-blame, and no-shame (i.e. no finger-pointing or punishment) environment. The purpose of a maternal death review is to improve the quality of obstetric care to prevent future maternal and neonatal morbidity and mortality.
In a country like Nigeria, where the maternal mortality rate is very high, the maternal death review is expected to help professionals identify avoidable factors behind deaths, related either to delays in care-seeking or substandard provision of care.
Some Objectives of Maternal Death Reviews include;
- To notify and collect accurate data on all maternal deaths in a country
- To analyze and interpret data collected in respect of trends in maternal mortality and causes of maternal deaths
- To use the data to make evidence-based recommendations
- To disseminate findings and recommendations to civil society, health personnel and policy makers to increase awareness about the magnitude, social effects and preventability of maternal mortality
- To allocate resources more effectively and efficiently by identifying specific needs
- To enhance accountability for maternal health
A maternal death review is often done using two approaches. These are the Facility-Based Maternal Death Review and the Community-Based Maternal Death Review.
The Facility-Based Maternal Death Review is a process to investigate and identify causes, mainly clinical and systemic causes of maternal deaths in health facilities; and to take appropriate corrective measures to prevent future deaths.
The Community-Based Maternal Death Review is a process in which deceased’s family members, relatives, neighbors or other informants and care providers are interviewed, through a technique called Verbal Autopsy, to elicit information for the purpose of identification of various factors—whether medical, socioeconomic or systemic, which lead to maternal deaths; and thereby enabling the health system to take appropriate corrective measures at various levels to prevent such deaths.
The Women’s Health and Action Research Centre (WHARC), with support from the MacArthur Foundation is committed to ensuring accountability with regards to maternal and child health. In doing this, WHARC is currently handling a project to Scale-Up Capacity Building for Maternal and Perinatal Death Review Accountability to three Nigerian States. This intervention is ongoing in Lagos, Edo and Niger States.
The goal of this project is to Scale-Up the Uptake of the Best Practices in the Maternal and Perinatal Death Surveillance and Response (MPDSR) to other States of Nigeria for the Prevention of Maternal and Perinatal Deaths in Nigeria.
The MPDSR is a form of continuous surveillance that links the health information system and quality improvement processes from local to national levels, which includes the routine identification, notification, quantification and determination of causes and avoidability of all maternal deaths, as well as the use of this information to respond with actions that will prevent future deaths. The primary goal of the MPDSR is to eliminate preventable maternal mortality by obtaining and strategically using information to guide public health actions and monitoring their impact.
This accountability project has been completed and consolidated in three health facilities in Lagos State (Lagos Island Maternity Hospital, Ajeromi General Hospital and Gbagada General Hospital) with a lot of positive outcomes. It is currently being implemented in Edo and Niger States of Nigeria. The site of intervention in Edo State is the Central Hospital, Benin City, Edo State while that of Niger is the Jummai Babangida Aliu Maternal and Neonatal Hospital, Minna, Niger State. Currently, WHARC has trained over three hundred (300) Healthcare Providers on the proper use of the MPDSR in these project States, printed over 1000 copies of the MPDSR National Gidelines and has also inaugurated the MPDSR Committees in these health facilities. Also, WHARC regularly supports the monthly MPDSR review meetings held in these facilities. The training was also extended to Irrua Specialist Teaching Hospital, although not a project site. Verbal Autopsy Committees have also been established in Okpekpe and Ewatto Communities in Edo State and Ajeromi - Ifelodun Community in Lagos State.
There have been a lot of revelations and lessons learnt from each of these maternal death reviews as to the reasons why women have been dying from pregnancy and childbirth related complications.
The beautiful thing about each of these reviews is that recommendations are being made on how to prevent a reoccurrence of the factors that have been established as having caused a particular death, with each of these recommendations been adhered to in a systematic manner in order to reduce maternal mortality in the facilities.
Following reports from these health facilities, we can report that blood transfusion services to pregnant women have improved, Maternal Intensive Care Unit (ICU) facilities have also improved in one of the hospitals, two of the hospitals are having monthly comprehensive health talk for pregnant women and their partners to improve antenatal care uptake. Most of the health facilities in which WHARC is intervening now have dedicated emergency packs for Caesarian Sessions, and healthcare professionals who are duty bearers are showing more commitment to service delivery because the providers, facilities, management and government are steadily and systematically being held accountable through the process of MPDSR.
- Trends in Maternal Mortality: 1990 to 2015. Geneva, New York (NY) and Washington (DC): World Health Organization, United Nations Children’s Fund, United Nations Population Fund, World Bank, United Nations Population Division; 2015
- Maternal Health in Nigeria: Facts and Figures. Fact Sheet 2017: African Population and Health Research Centre
- Maternal Death Reviews. Training programme for health professionals. (2013). De Brouwere V., Zinnen V., Delvaux T.
- Maternal death review and outcomes: An assessment in Lagos State, Nigeria (2017) Okonofua F, Imosemi D, Igboin B, Adeyemi A, Chibuko C, Idowu A, et al.
- National Guidelines for Maternal and Perinatal Death Surveillance and Response in Nigeria (2015).