Over their lifetime, one in every 30 women in Nigeria are likely to die due to pregnancy and childbearing. Nigeria alone accounts for one in seven maternal deaths observed in the world today. This post, the fourth in a series on partnerships, innovation, and evaluation in Rotary, tells the story of a project that has succeeded in reducing maternal mortality in Nigeria.
Project and Partners
Many factors lead to maternal mortality, but a key risk is that of obstetric fistula (a hole in the birth canal). The World Health Organization estimates that each year between 50,000 and 100,000 women suffer from obstetric fistula, which by obstructing labor can lead to maternal death.
Quality assurance mechanisms in hospitals can improve obstetric services and contribute to reducing maternal mortality. This was the premise of a series of Rotary projects aiming to reduce maternal (and fetal) mortality in Nigeria led by Robert Zinser and the Rotarian Action Group for Population Growth and Development (RFPD) between 2005 and 2010.
With support from RFPD and some 200 Rotary, Rotaract and Inner Wheel Clubs, Rotary implemented a first project to improve quality assurance mechanisms in ten hospitals in Kano and Kaduna States in Northern Nigeria. Apart from funding from Rotary clubs and the Rotary Foundation, support was also provided by the German Ministry for Economic Cooperation and Development (BMZ), the Aventis Foundation and the International Association for Maternal and Neonatal Health (IAMANEH). The project was implemented by Nigerian Rotarians.
Conceptually, reducing maternal and fetal morbidity and mortality can be achieved through an improvement in the quality of the infrastructure and other inputs used to provide treatment (availability of medicine, better hospital facilities, etc.) as well as improvements in the process of providing treatment (more experienced health personnel). The project team worked on both fronts.
In terms of improvements in infrastructure, a number of investments were made, including two specialized fistula wards (one for each of the two Nigerian states) with rehabilitation facilities. Medical equipment was provided to ten hospitals and some hospitals were equipped with better water supply and solar energy. Hospitals also received intrauterine devices for women requesting them for family planning as well as drugs preventing mother-to-child transmission of HIV.
To improve the capacity of hospital personnel, seven doctors were trained as fistula surgeons and 15 ward nurses were trained in fistula care. Many more doctors, nurses and midwives, and other health personnel such as traditional birth attendants were also trained on how to improve obstetric services. Hospital teams were trained in emergency obstetric care including (among others) in the use of magnesium sulfate to manage eclampsia and the use of an anti-shock garment to treat postpartum hemorrhage.
Apart from providing support to the hospitals participating in the project, support was also given to communities in the hospitals’ catchment areas. Mosquito nets were provided to reduce the risk of contracting malaria. Awareness and advocacy campaigns were held using radio, television, print media, and even drama (public plays on the streets) to inform the population about obstetric fistula, its causes and how to prevent it, and its impact on maternal and fetal mortality. These awareness campaigns enlisted the support of traditional and religious leaders who have substantial influence on behaviors in the community.
Perhaps the most important innovation was the development of a quality assurance mechanism that involved setting standards and systematically collecting data on the quality of the care being provided and the outcomes in terms of maternal and fetal mortality and morbidity. This was done through a “quality circle” process to monitor, review, and improve performance over time. Data were collected in participating hospitals, analyzed statistically, discussed by the teams, and used to assess improvements and take corrective measures as needed.
An evaluation based on the data collected by the hospitals as part of the quality assurance mechanism before, during and after the intervention suggests that the project achieved a 60 percent reduction in maternal mortality in participating hospitals and 15 percent reduction of newborn mortality.
RFPD’s obstetric fistula project combines all three ingredients of a winning combination for impact: partnerships, innovation, and evaluation.
The team established multiple partnerships for funding (the investment for the pilot project in the ten hospitals amounted to one million Euros) and implementation (securing buy-in from the hospitals, the state authorities, the communities, and even traditional and religious leaders).
The project included innovative components in the Nigerian context, especially the quality assurance mechanism and data collection process to improve the quality of obstetric care.
The project was evaluated using data from the quality assurance mechanism and the evaluation was published in an academic journal.
The project has been considered a success by stakeholders and the Kano and Kaduna state governments. This led to a subsequent project to continue to build capacity in the original 10 participating hospitals, and extend the model to 15 more hospitals (five rural hospitals in FCT Abuja, five hospitals in Ondo State, and five more in Enugu State). Additional scaling up is being considered by the RFPD team.
A brief on the project and the Nigerian context is available here.