Strengthening Maternal Death Reviews for Quality Maternity Care in Nigeria

Onyedikachi Ewe (Lead Writer)

Every day, women in Nigeria, embark on a journey from pregnancy and childbirth, with the expectation of a successful outcome. Unfortunately for some, this journey ends in maternal or perinatal death that could have been prevented, through evidence-based solutions.

But what happens when these deaths occur?

Establishing an accountability mechanism for maternal deaths ensures that stakeholders take action to prevent future occurrences. Maternal and Perinatal Death Surveillance and Response (MPDSR) is a system instituted and recommended by the World Health Organization (WHO) to establish an enquiry into every maternal and perinatal death. It involves routine identification, notification, and investigation of the causes of these deaths and promotes continuous quality improvement in maternal healthcare.

MPDSR in Nigeria

In 2019, WHO, with support from MSD for Mothers implemented the Maternal and Perinatal Database for Equity and Dignity (MPD-4-QED) Programme in Nigeria, aiming to provide real-time access to data on the quality of care provided to mothers and their newborns. In the event of a maternal or perinatal death, the local mortality audit team (led by an obstetrician and neonatologist) analysed and documented the primary cause of death (using the International Classification of Diseases for Maternal Mortality, ICD-MM and the International Classification of Diseases for Perinatal Mortality, ICD-PM) and the avoidable contributing factors. The MPD-4-QED project database yielded high-quality data, proving valuable for assessing the quality of maternal and perinatal care at the facility level.

Image credit: Nigeria Health Watch

MPDSR is included in the National Strategic Health Development Plan and is currently implemented at the national level. At the sub-national, state-level, MPDSR committees, chaired by the Honourable Commissioner for Health and a co-chaired by a consultant obstetrician and gynaecologist, along with other key departmental staff, have been established to oversee facility-level MPDSR. However, implementation of MPDSR is still largely limited to deaths occurring in secondary and tertiary facilities, even though only about 40% of deliveries occur in health facilities As a result, many deaths in the country are unaudited as they take place in communities, and the causes of deaths occuring outside health facilities remain unaccounted for.

To support MPDSR efforts at the primary health care (PHC) and community levels, development partners, such as E4A-Mamaye and Project Aisha work with communities to design and implement strategies that strengthen community-based MPDSR. This is achieved by providing training and mentorship to PHC and community committees on systematically gathering information about maternal and perinatal deaths, irrespective of whether these occur at home or on the way to a facility. The approach promotes open discussion on the causes of these deaths through verbal and social autopsies, increases awareness and encourages community dialogue on the causes of maternal and perinatal mortality. In addition, it assists in the development of joint action plans between facilities and communities to address identified causes and prevent future occurrences. Scaling these efforts nationwide is recommended to achieve better results.

MPDSR should be strengthened and funded

In an interview with Dr Saidu Abdullahi Diyo, Deputy Director of the Reproductive Health Division, Federal Ministry of Health and Social Welfare, he noted that for mPDSR implementation in Nigeria, there is low notification, review, and action on maternal deaths. He stated that “notifications are low, review is lower, action is even much lower”, revealing an even broader issue for maternal health improvement. MPDSR is a quality improvement tool in maternal healthcare. Understanding the circumstances surrounding the death of a mother during pregnancy, delivery or postpartum period can facilitate targeted interventions to improve the quality of care and improved outcomes for mothers and babies. Through the MPDSR review process, healthcare providers can identify gaps in maternal healthcare delivery, which is a step towards addressing those gaps. Strengthening the MPDSR process across all levels is therefore imperative for addressing issues of quality gaps effectively.

A strengthened review system will not only improved healthcare quality but also empower healthcare workers to report adverse outcomes without fear of blame, thereby improving accountability. MPDSR also generates data on the causes of death, and key contributing factors of maternal and perinatal deaths, which can then inform the development of evidence-based policies and strategies aimed at reducing mortality rates. This valuable information allows government and health organisations to effectively allocate resources and address specific gaps in care.

Image credit: Nigeria Health Watch

An effective community MPDSR process would enable community participation and engagement, where community members can voice their concerns and contribute to identifying barriers to accessing maternal healthcare services. This participatory approach helps build trust between healthcare providers and the communities they serve.

There is also need for increased investment in MPDSR implementation. To ensure the success of these reviews, it is essential to create and fund a dedicated budget line for MPDSR implementation across all levels of care, including private sector facilities and the community. A dedicated budget is essential for providing the necessary resources to establish and maintain effective Maternal and Perinatal Death Surveillance and Response (MPDSR) processes.

This includes facilitating training and capacity building for healthcare providers, as well as ensuring the timely and accurate collection of data. Incorporating private sector facilities and community settings into the budget, will lead to a more comprehensive approach to maternal death reviews, effectively addressing gaps and barriers across different healthcare environments. This investment is critical for the long-term sustainability and effectiveness of MPDSR initiatives, ultimately leading to improved maternal health outcomes and reduced mortality rates.

MPDSR bill on the way

Although the legislative process for the MPDSR bill has commenced, having passed both the first and second readings, it still awaits presidential assent. Enacting this bill will establish a legal framework for MPDSR implementation, mandating and enforcing the prompt notification, review, and action on all maternal and perinatal deaths, to improve the quality of maternal health care delivery. Comprehensive engagement from all stakeholders, including government, healthcare institutions, civil society, development agencies, and communities, is critical to advocate for this legal framework, which is crucial for driving effective MPDSR and improving maternal health outcomes in Nigeria.