A government-led approach to dramatically and sustainably reduce maternal and neonatal mortality
After Zainab Abubakar unexpectedly gave birth at 28 weeks during her first pregnancy, her child survived for just four short hours. Today Zainab describes how fearful she was when, living in an isolated, rural village in Kaduna State in Northern Nigeria, she again went into premature labor at a similar stage during her second pregnancy. This time, though, things were different. A recently trained and well-equipped community birth attendant was present at the delivery and a motorbike ambulance was available to rapidly transfer Zainab to a facility able to provide appropriate care to her and her baby.
Zainab and her baby both survived, but not everyone is as fortunate in Nigeria, where each year more than 300,000 mothers and their newborns die from complications of pregnancy and childbirth. Of all women who die during childbirth globally, 19 percent are Nigerian; in fact, the country accounts for the largest number of maternal and neonatal deaths and stillbirths worldwide. The highest mortality rates in Nigeria occur in the impoverished Northern region, an area marked by poor access to health care and major challenges towards improving health care and reducing mortality.
Most of these maternal and neonatal deaths are preventable, with the majority caused by a small number of treatable conditions. The three leading causes of maternal mortality, which account for more than half of all maternal deaths, are hemorrhage, sepsis, and eclampsia. The complications resulting in 80 percent of all neonatal mortality include preterm birth complications, birth asphyxia, and neonatal infections.
Sample of a log book used by volunteer drivers and Motorbike Ambulance riders as part of the referral system set up by CHAI
Despite billions of dollars spent, the relative lack of success in addressing these conditions over the past two decades represents a unique and targeted opportunity for improvement. The Clinton Health Access Initiative (CHAI) has developed a comprehensive strategy to dramatically reduce maternal and neonatal mortality. Consistent with World Health Organization guidelines, the approach focuses on averting the preventable deaths that can occur in the 24-48 hour window around the birth process by implementing the interventions necessary to deliver the following, straightforward results:
- Potential complications are identified early to prevent them becoming life threatening;
- Simple interventions are applied immediately to stabilize and ensure survival; and
- Cases are referred quickly to the appropriate health system level for proper treatment.
Beginning in July 2014, CHAI working with the Nigerian Federal Ministry of Health, initiated a program informed by this strategy funded by the Norwegian Ministry of Foreign Affairs to reduce maternal and newborn mortality in Nigeria, focusing on the northern states of Kaduna, Kano, and Katsina, which together contributed 20 percent of the total maternal and neonatal mortality in the country. Across the three states, 81 percent of women deliver at home, according to Nigeria DHS data. The program covers 30 Local Government Areas (LGAs), which have a total population of approximately 10 million people.
The primary objective of the MNH program is to accelerate progress toward reducing maternal and neonatal deaths by addressing critical gaps and creating linkages through the entire health system – from the community level to primary healthcare facilities to the hospital. The comprehensive approach focuses on averting the preventable deaths that can occur in the 24-48 hour window around the birth process through early identification of complications, prompt and effective clinical management of delivery, and when necessary, timely referral to more robust, fully-prepared treatment centers.
In particular, CHAI assisted the state governments to undertake six main activities to work toward a comprehensive approach to reducing mortality associated with childbirth:
- Clear protocols were established about what to do in each birth setting to address each of the potential complications that can lead to mortality or poor outcomes.
- Skilled birth attendants were deployed to be available during all births and a hands-on mentoring system was established to train these skilled birth attendants in these protocols.
- Procurement and supply chain systems were strengthened to ensure the reliable delivery of all the tools and drugs necessary to the skilled birth attendants to diagnose and treat these conditions when they arise according to the protocols.
- A referral system was established so that communications and transportation is available for those cases where women must be transferred to hospitals and health centers to be treated.
- Hospitals are equipped with blood banks and emergency response equipment and nurses and doctors at those hospitals were properly trained so that women who are referred can be properly treated.
- A management system was set up to establish and update the protocols, keep track of all births and to oversee the mentoring, supply chain, and referral systems necessary for the comprehensive approach to work.
To ensure community acceptance, buy-in, and ownership of the program, CHAI and partners implemented a community program and reactivated the Community-Based Management Information System (CBMIS), a census-style data reporting system leveraging the traditional community structures, to identify maternal and neonatal outcomes on a monthly basis in order to assess program impact.
Photograph taken with emergency transport system drivers, FMOH, and CHAI staff during a visit by Norwegian representative to the field, Katsina State
This integrated approach, championed by the national and state governments and community leaders, has demonstrated dramatic results. Based on a conservative baseline to overcome incomplete early vital events reporting, an independent external evaluator recently validated that CHAI’s MNH program led to substantial, significant, and sustained reductions between Q3 2015 and Q2 2016:
· Maternal mortality reduction: 37%;
· Neonatal mortality reduction: 43%;
· Stillbirth reduction: 15%; and
· Perinatal mortality reduction: 27%.
These declines are both biologically plausible and comparable to those reductions achieved globally in the previous 15-20 years. However these results were achieved in just 18 months and reflect CHAI’s core value of working with urgency. With hundreds of thousands of women and newborns dying of birth-related complications every year, this urgency is crucial. As we expand our MNH program, we intend to ensure that more and more women like Zainab are able to access a robust health system wherever they are live and, if they or their baby develop complications at birth, have the confidence that they will receive timely, quality care.
 Evaluation of the Clinton Health Access Initiative Maternal Neonatal Health Program in Nigeria: Final Report, Dr. Nancy Sloan, Independent Evaluator
To learn more, contact Andrew Storey at the Clinton Health Access Initiative, Inc.