By Dr. Chibugo Okoli (Guest Writer)
The maternal mortality ratio in Nigeria is estimated at 512 per 100,000 live births whilst non-communicable diseases (NCDs) accounted for 27% of total deaths in 2008. The Federal Ministry of Health (FMOH) has demonstrated its commitment to address NCDs via the creation of an NCDs division, the development of a national non-communicable diseases (NCDs) multi-sectorial plan (2019 – 2025) and the inclusion of coverage for diabetes and hypertension (HTN) as part of the Basic Health Care Provision Fund (BHCPF). There has been limited attention, however, paid to the unique vulnerabilities of women of reproductive age (WRA) with NCDs and associated risk factors, despite the substantial burden of NCD-related ‘indirect causes’ of maternal mortality and morbidity (MMM) among women of reproductive age. A systemic approach to improving maternal health needs to address the global burden of NCDs contributing to maternal morbidity and mortality.
Partnership for Quality of Care
In November 2018, MSD for Mothers funded the consortium of Jhpiego, mDoc and Health Strategy Delivery Foundation (HSDF) to develop and pilot a Quality of Care (QoC) model to prevent and manage risk factors for indirect causes of maternal morbidity and mortality (MMM) associated with pre-eclampsia/eclampsia (PE/E) as part of maternal health (MH) and reproductive health (RH) services in Lagos State and the Federal Capital Territory (FCT).
An initial assessment in two LGAs in Lagos State, Alimosho and Ikorodu, and Area Councils in the FCT, Bwari and AMAC, demonstrated a high prevalence of risk factors for indirect causes of MMM, low knowledge among providers and women and low quality of care. As a result, the project supported the participatory design of a woman-centered QoC model. This functioned to improve prevention and to manage best practices for leading risk factors for the indirect causes of MMM; high blood pressure, anemia, diabetes and obesity.
The QoC model promotes the reliable provision of high-impact interventions for modifiable risk factors at key touchpoints across a continuum of antenatal care (ANC), labor and delivery, postnatal care (PNC) and Family Planning (FP) care, including self-care support via a digital platform. In October 2019, the project began piloting the QoC model in 20 public and private facilities in Lagos and FCT. Quality improvement teams were established at each of the facilities with improvement aims identified and action plans put in place. The quality improvement teams were supported to measure their progress and use their data to make decisions including conducting learning reviews. During this period, a total of 58,388 pregnant women benefited from these services out of which 8,113 were supported on a digital health platform to modify their lifestyles through self-care. Early results demonstrated improved quality of ANC for targeted risk factors such as blood pressure measurement, screening for diabetes mellitus (DM), increased knowledge of health care workers and women, increasing utilisation of antenatal services and strong self-management support among women enrolled on the digital platform.
A cost assessment of the model, led by the HSDF team, demonstrated only marginal differences between the unit costs of this integrated QoC model compared to the traditional model of care. The patient-centred story below illustrates the impact of the RICOM3 project in the last one year.
Going the Extra Mile to Implement Quality of Care – A Patient Story
There is a 20-year old young lady, let’s call her Mary. Life has been tough for Mary. While her classmates went on to study at universities after secondary school, she stayed home to work as a hairdresser. With this job she could make a living but not enough to provide for all her needs – not even enough to buy a phone for herself. She spent her days working long hours and her nights looking for solace at the bottom of a bottle. She drank, smoked and used recreational drugs, waking up each morning to repeat the process.
Mary met a young man and thought she was in love. He wooed her and chased her but it all changed when she broke the news that she was pregnant for him. He wanted nothing to do with her when she rejected the N5000 ($14) he offered her to have the pregnancy aborted.
Once again, she was alone.
Mary knew she had to make changes for the sake of her baby. She quit smoking and got herself registered for antenatal care (ANC) at a private hospital in Lagos Nigeria, even though she could not afford most of the required laboratory tests. Putting down the bottle was an even bigger challenge. Nevertheless, she attended her ANC clinics regularly, found out that she was pregnant with twins and had normal blood pressure readings, although she was overweight. On her fourth ANC visit when she was 32 weeks pregnant, however, her blood pressure was very high with a value of 160/110mmHg. Both feet were swollen with significant levels of protein found in her urine. She also complained about blurry vision and pain in her upper abdomen. Mary was prescribed antihypertensive medicine and given two doses of intramuscular dexamethasone to encourage her baby’s lungs to mature prior to delivery.
During the implementation of the Reducing Indirect Causes of Maternal Mortality and Morbidity (RICOM3) project, funded by MSD for Mothers, led by Jhpiego and in collaboration with mDoc Healthcare and HSDF, Mary’s condition drew the attention of an mDoc Health Coach. The coach was at the ANC clinic to register pregnant women on mDoc’s CompleteHealthTM platform for virtual support in providing health education and coaching towards lifestyle modifications. The coach provided Mary with her phone number and scheduled an appointment to follow-up on Mary after the clinic
When Mary did not call her or show up for the virtual appointment, the coach became concerned and tried to find a way to get in touch with her. She could not directly contact Mary, so she turned to the hospital’s administration for help. In the company of an equally concerned nurse from the RICOM3-supported hospital and another mDoc Health Coach, they went in search for Mary in her community. The address Mary had given during her registration led them to a shop but Mary was not there. Asking around, they were eventually able to locate Mary’s step-mother but not Mary. They left an urgent message for her to visit the hospital as soon as possible. When Mary received the message, she was surprised that they had come looking for her and shocked at the level of concern this kind act had revealed, so much so that she visited the hospital the very next day because of their concern.
Mary’s blood pressure was found to be even higher than it had been previously, with a value of 180/120mmHg. Shen was diagnosed with severe pre-eclampsia and magnesium sulphate was administered to her in line with the on-site training the staff had received from the Jhpiego team. Mary also told them that she had begun feeling contractions. However, as she could not afford the cost of a caesarean section, she was prepared for a vaginal delivery. The moment of birth came and though she was scared, she felt more confident knowing that people were looking out for her. She was wheeled into the delivery room and wheeled out a few hours later with two healthy baby boys. At the time of her discharge from the hospital, her blood pressure had fallen significantly from what it had been in the last trimester of her pregnancy. The hospital waived her outstanding bills and the mDoc health coach provided anticipatory guidance and provided her with baby blankets inscribed with best practices and danger sign messages. Now, both mother and babies are thriving.
“It takes a village” to save our mothers and babies
In Nigeria, where risk factors for pre-eclampsia and eclampsia such as high blood pressure are key drivers of maternal mortality and morbidity, trained, activated health care workers and informed, empowered women can make all the difference between life and death.
This is only one example of the level of support that has been provided to pregnant women and empowerment given to health care workers through the RICOM3 project, a story of three lives saved and protected, one story in thousands.
There are still many more stories to be told.
This program is funded by MSD, through MSD for Mothers, the company’s $500 million initiative to help create a world where no woman dies giving life. MSD for Mothers is an initiative of Merck and Co. Inc of Kenilworth, NJ.