Maternal and Neonatal Health in Northern Nigeria – improvement by quality assurance of Obstetrics

In Northern Nigeria maternal and fetal death is one of the highest worldwide, ranging within the country from 500 maternal death per 100,000 deliveries in the South to 1,200 maternal death per 100,000 deliveries in the North. In addition a high rate of obstetric fistula is recorded yearly, resulting from long, protracted labor sometimes of more than 3-5 days. It is assumed, that each year 5,000 new cases of obstetric fistulas contribute to the suffering of mostly very young women. In parallel with the maternal tragedy, fetal death before, during and after delivery is dramatically elevated ranging from 2-22% in various hospitals.

Photo: Pep Bonet/Save the Children

Rotary International took up this challenge to reduce the burden of these young women by implementing awareness programs for pregnant women, promoting regular antenatal care, skilled attendance during labor and birth, in counseling the use of contraceptives, to prevent early marriages and to offer help to repair the fistulas by financing the surgery and to educate doctors to conduct the operations.

To repair fistulas is surely a big help for the single woman, but not a solution of the problem. The only way to handle the immense problem - and not only in Nigeria, but also in other parts of the developing world - is to improve the quality of the obstetrical service.

Three major activities can be employed to make pregnancy and childbirth safe: Community dialogues are aimed at educating the rural community – man, woman and adolescents – about the necessities of pregnancy care and safe deliveries. Insufficient information is often called the first delay which contributes to maternal and fetal death.

Far distance to a hospital and insufficient roads and transport systems are considered to be the second delay as a cause of maternal and newborn death. The third delay is generated by poorly equipped hospitals, i.e. insufficient newborn and maternal surveillance during labor, non-operational operating theatre and delivery wards under poor hygienic conditions, and not well trained staff,  are major contributors to the high maternal and fetal mortality in these countries.

What can be done to avoid this tragedy? Raise the awareness of insufficient care by quality assurance - that means by improving the quality of infrastructure of the hospitals and developing  the quality of obstetrical service (the process) to move forward the quality of outcome.

Teaching quality assurance in a hospital in discussing the data from that hospital in comparison to the others. Photo: Wolfgang Kunzel

A number of steps have to be routinely conducted to finally achieve a reduction of maternal and child mortality. Experience from 10 hospitals in Kano and Kaduna in Northern Nigeria shows that maternal mortality can be reduced by 60% and the fetal mortality by 15% by introducing the following steps:

•  At a meeting of representatives of various hospitals in Kano and Kaduna, representatives of Local Governments and Rotary International (RI) in December 2007 it was agreed to select 5 hospitals from Kano and 5 hospitals from Kaduna for a quality assurance project

•  For reason of confidentiality each hospital received an identification number only known by the respective hospital and the office of statistics.

•  All delivery data were registered in a uniform maternity delivery book according to an unchanging protocol. The statistics were collected monthly by a midwife.

•  These records were checked for completeness, fed into a computer by a statistician at the AKTH, Kano, and analyzed according to a protocol.

•  Regular visits of the hospitals were aimed at analyzing the condition of the hospital and their performance (quality of process).

•  Review meetings were conducted to discuss the results of the data evaluation and regular training of midwifes and doctors were held to investigate the quality of outcome. 

•  Obstetrical and other equipment was provided if necessary to improve the quality of structure.

The success of the project in reducing maternal and fetal mortality in these hospitals is mainly based on the “sudden” awareness of the medical personnel of their own performance in the hospitals. It can be used as a model also for other institutions and countries. One hospital doctor said during a site visit of the institution: “ I know now for the first time what I have done in comparison to the others and what we have to do in the future .”

Learn more:

Read the study, Obstetric quality assurance to reduce maternal and fetal mortality in Kano and Kaduna State hospitals in Nigeria

Download the Maternal and Child Health Hospital-Report 2010: Institute of Quality Assurance in Obstetrics of Kano State and Kaduna State