A multi-year partnership funded by MSD for Mothers to reduce preventable maternal deaths from key obstetric complications in Lagos and Kaduna states within Nigeria.

Summary

Project Aisha is the effort of a consortium of organizations funded by MSD for Mothers, in close partnership with the State Ministry of Health and State Primary Health Care Board, in Lagos and Kaduna states in Nigeria. The consortium comprises Health Strategy and Delivery Foundation (HSDF), Ingress Health Partners, mDoc, and IHI.

The aim of Project Aisha is to reduce preventable maternal deaths from key obstetric complications (postpartum hemorrhage, preeclampsia/eclampsia, and obstructed labor) in Nigeria’s Lagos and Kaduna states by 20 percent from 2022 to 2025. The results included a 64 percent reduction in the facility-based maternal death rate (deaths per deliveries) due to key obstetric complications, far exceeding the 20 percent goal articulated in the aim statement.

Each organization leveraged their unique expertise to contribute to the project:

• HSDF has the overall accountability for the project and focuses on government and private sector engagement; strengthen financial management; and, in partnership with IHI, overseeing quality improvement (QI) implementation, monitoring, learning, and evaluation.
• Ingress Health Partners focuses on community-based interventions — use of maternal health influencers to improve health literacy of women of reproductive health and their caregivers, and competency building of community providers (traditional birth attendants) and nurse-led practitioners.
• mDoc leads the deployment and implementation of digital-focused interventions that promote patient-centered care via a digital patient review platform (NaviHealth.ai™) and builds clinical competency of health care workers via tele-education platforms.
• IHI is responsible for quality improvement (QI) capability building of frontline health workers, middle managers, and senior leaders; effective knowledge transfer; the use of data for improvement; and the design and execution of learning collaboratives.

The project produced a detailed change package designed to:

• Improve antenatal care
• Improve labor & delivery care
• Ensure prompt identification and management of complications
• Improve referral systems
• Respond to concerns from women and their communities
• Integrate voices from the community to improve maternal health literacy and leverage traditional resources

Background

Nigeria — Africa’s most populous nation — has one of the highest maternal mortality ratios globally. Approximately 1 in 5 women who die during pregnancy or childbirth will die in Nigeria. Addressing the key underlying challenges, including the availability of services and resources, low demand for services (resulting from financial barriers, cultural norms, and other socioeconomic factors), and the governance and delivery of care, requires a comprehensive, innovative approach rooted in improvement science.

A baseline assessment of 32 participating facilities revealed that the three principal drivers of maternal mortality in the communities served by these facilities were post-partum hemorrhage (PPH), pre-eclampsia and eclampsia (PEE), and obstructed labor (OL). This assessment informed the aim of the project (a 20 percent reduction in deaths due to these conditions) and answered the first key question of the Model for Improvement: What are we trying to accomplish?

Approach

Project Aisha used a 3-pronged approach to achieve its aim:

1. Address delays in seeking care;
2. Address delays in receiving appropriate care; and
3. Address cross-cutting issues.

Crucially, the project solicited and integrated the voices of the women in the communities into all approaches to delivering respectful and high-quality care.

IHI trained QI teams from the selected 32 health facilities, building local and enduring capability in improvement science and tools. Middle managers and senior leaders were also trained to be QI coaches and mentors, drive the use of QI to close health system gaps, and provide an enabling environment for QI to thrive. Tools used by the teams to generate change ideas included process maps, the 5 Whys root cause tool, fishbone diagrams, and driver diagrams. Project Aisha also used IHI’s Breakthrough Series Collaborative model as the structure for learning from QI experts and each other, testing change ideas, reviewing and analyzing results, and adapting changes to local contexts.

The QI teams developed and executed projects focused on improving 13 clinical processes including antenatal care, prompt identification of complications, correct use of partographs, adherence to PPH protocols, two-way referrals, and more. Working with clinical experts, Project Aisha also helped the QI teams innovate new solutions using clinical work aids such as all-or-none checklists; audit partographs; and retrain staff in the use of protocols. The patient reviews collected via mDoc’s NaviHealth.aiTM informed change ideas tested and deployed in the health facilities, ensuring patient-centered care. Tele-education sessions were used to improve clinical knowledge and skills of frontline workers to provide quality care. Other change ideas were informed by active listening and capture of feedback from the community, including the use of maternal health influencers in the community to create dialogue with expecting mothers, their partners, and their families. This feedback led directly to new approaches to improving health education, improving waiting times, and addressing sanitation and malaria concerns. Community-level interventions also involved training traditional birth attendants (TBAs) in identifying danger signs and referring promptly. Synergy meetings were held to improve prompt referrals and coordination between the informal (TBAs) and formal (health facilities) health sector, including change ideas such as “silent” ambulances (no sirens) to move patients from the community to the hospital.

The facility QI teams were taught how to collect, collate, and analyze results using annotated run charts. With the evidence showing which changes led to positive results, the state ministries of health, frontline health care workers, and project team formalized the interventions in a comprehensive change package designed to help scale up these changes across Nigeria.

Results

The headline result of Project Aisha was a 64 percent reduction in the rate of facility-based maternal deaths due to PEE, PPH, and OL (see chart below). Additional results include:

• 85 percent increase in delivery of quality antenatal care services
• Increase in the correct use of partographs from 36 percent to 88 percent
• More than 237,000 people reached with interventions
• 840 health care workers (nurses, midwives, doctors, and community health extension workers) trained in quality improvement methods and tools as well as clinical processes
• A detailed change package designed to help facilities across Nigeria in:
  • Improving antenatal care
  • Improving labor & delivery care
  • Ensuring prompt identification and management of complications
  • Improving referral systems
  • Responding to concerns from women and their communities
  • Integrating voices from the community to improve maternal health literacy and leverage traditional resources

Following the successful results, Project Aisha received supplementary funding to strengthen sustainability, spread, and scale across Lagos state working with the State Ministry of Health and State Primary Health Care Board.

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Related Information

• Health Strategy and Delivery Foundation’s Project Aisha site
• Ingress Health Partners’ Project Aisha site
• mDoc's NaviHealth.aiTM site used throughout Project Aisha
• How-To-Guide Change Package for Improving Quality of Care and Reducing Maternal Deaths