Mr. and Mrs. Balogun* had been married for 10 years and had three beautiful daughters. When Mrs. Balogun became pregnant again, an ultrasound scan revealed she was having a boy. The couple was excited; finally, their wish for a son – a common desire in Nigeria, where they live – had been granted. Mrs. Balogun was registered at a government hospital in Calabar, Cross River State (CRS), and received routine antenatal care there. At term, she went into labor and safely arrived at the hospital. The skilled birth attendants on duty monitored her labor, and she progressed well… or so they thought.
Finally, it was time for her to push. The baby boy was stillborn, and Mr. and Mrs. Balogun were devastated. Their baby was delivered as a fresh stillbirth with the umbilical cord wrapped around his neck. How did health care providers miss the fetal distress associated with this condition?
Unfortunately, many parents experience the loss of a newborn in Nigeria. In Nigeria, Africa’s most populous country, a mother dies every 13 minutes due to pregnancy-related complications such as obstetric hemorrhage and sepsis, and newborns face a high risk of mortality. The main causes of neonatal deaths are largely preventable and treatable: birth asphyxia, prematurity, and sepsis. However, the health facilities in Nigeria are challenged by limited staffing and gaps in training. Staff shortages and lack of capacity are leading obstacles to providing quality Emergency Obstetric and Newborn Care (EmONC) Services.
The Saving Mothers Giving Life (SMGL) initiative, in collaboration with the CRS government, conducted an initial health facilities assessment. The baseline findings from SMGL-supported sites in CRS revealed that less than 10 percent of community health workers and midwives had the capacity to provide more than three EmONC signal functions, key components of life-saving care such as providing parental uterotonics (medication to induce labor and prevent hemorrhage), manually removing the placenta, assisting in vaginal delivery, and resuscitating newborns. Health facilities also lacked resources such as functional newborn ventilator bags.
In 2016, SMGL and national partner organizations trained 132 community health extension workers (CHEWs) and 89 midwives in supported facilities in basic emergency obstetric and newborn care services. Using the national curriculum, the training incorporated lectures, roleplays, and practical sessions with clinical models. Additionally, 114 CHEWs and 78 midwives completed the WHO’s Essential Newborn Care Course with components such as helping babies to breathe. The group also provided supported sites with a functional newborn ventilation bag and suction equipment, as well as on-the-job mentoring.
The maternal mortality ratio (MMR) fell from 313 deaths per 100,00 live births at baseline to 206 deaths per 100,00 live births, surpassing the target ratio of 235 deaths per 100,000 live births.
In the 18 months since the training, the CHEWs and midwives have delivered more than 4,500 babies and actively managed the third stage of labor with parenteral uterotonics in 99 percent of deliveries. Skilled birth attendants successfully resuscitated 98 percent of newborns not breathing at birth. Basic facilities provided seven signal functions and comprehensive facilities performed nine. Since the project’s implementation, maternal mortality in the supported facilities decreased from 313 to 206 deaths per 100,000 live births. Additionally, neonatal mortality fell from 58 to 41 deaths per 1,000 live births.
One of the specific quality improvement approaches we used was regular review of facility level measures. For example, we discovered at one health facility that the number of cases of prolonged labor was high and that providers did not routinely use a partograph, a graphical tool for monitoring labor. Discussions with facility management revealed attrition of trained staff. This led to hands-on training of all skilled birth attendants on use of partograph and deployment of mentors to the facility. Partograph use has improved and cases of prolonged labor have decreased at the facility.
One challenge we faced was the current human resources gap in the state. We staggered the timing of trainings so as not to take too much staff time at once at the facility level. Facilities have few specialized health providers; the state has very few doctors and midwives and is not employing new staff, and there is staff attrition due to retirement and frequent transfers of trained staff. To better support the audience, we used a lot of repetition within each training and intense follow-up mentoring afterwards to reinforce the materials.
Going forward, residents in Obstetrics & Gynecology as well as Pediatrics will be posted in rural state hospitals. These residents will help to address some of the human resources gaps and to monitor quality. The rural posting has begun in one of the high-volume secondary health facilities and plans are underway to expand to more facilities.
Throughout the trainings, we saw that health providers must be involved with identifying, planning, and implementing changes to foster ownership and inspire improvements. With improved capacity, health care workers can make changes to provide better care for Mr. and Mrs. Balogun’s family and others like them.
The initial results of this work were shared as an abstract at the 2018 IHI Africa Forum on Quality and Safety in Healthcare. Reserve your spot now for the 2020 conference.
*Pseudonyms are used here to protect patient privacy.
Dr. Oluwayemisi Femi-Pius of Pathfinder International is Program Manager of the Saving Mothers Giving Life in Cross River State, Nigeria.
