In Nigeria, systemic gaps in the quality of maternal care includes the lack of life-saving medical equipment, the low adoption of the Maternal and Perinatal Death Surveillance and Response (MPDSR) in facilities, and the ineffectiveness of MPDSR platforms and their inability to translate to better quality of care. These are challenges that must be addressed to close the gaps in quality healthcare.
Understanding current solutions being implemented and Quality of Care (QoC) gaps, provides blueprints for implementing scalable and sustainable solutions. These blueprints help us understand how to focus the advocacy for better maternal health care in Nigeria.
Systematic measurements of quality of maternal health care services should be carried out in health facilities and must include all the critical components of a woman's pregnancy journey; antenatal care, postnatal care, delivery, management of maternal complications, blood transfusion services, and infection prevention. Hospital management boards, through health care workers, must regularly review the different stages of maternal health care delivery, document outcomes for a clear understanding of gaps, and take necessary action to improve the QoC.
Thaddeus and Maine (1994) proposed a conceptual framework of "three delays", referred to as the 'Three Delays Model' to explain barriers to timely care that contribute to maternal mortality;
(a) delay in deciding to seek care
(b) delay in reaching an adequate health care facility
©delay in receiving adequate, or quality, care at the facility.
As reflected in this framework, delays to life-saving care occur at the individual, community, and facility levels. To continue to reduce maternal deaths and support quality maternal health care, we need a system-wide approach that supports community members' abilities to recognise emergencies, provide transportation to facilities, and receive timely and quality medical interventions at the facilities.
Between 2014-2019, the Saving Mothers, Giving Life (SMGL) initiative set out to apply this system-wide approach to select districts in Cross River State. The SMGL approach is based on the hypothesis that district-based systems strengthening that targets the three delays to care and engages the public and private sectors will contribute to drastic reductions in maternal and neonatal mortality over a short period.
The approach is guided by five organising principles:
(a) The whole system must be involved
(b) There can be no weak links
© Women must have access to lifesaving care no more than two hours away
(d) All neonatal and maternal deaths must be counted, analysed, and reported
(e) All women deserve respectful, quality care at all times.
SMGL adapted its 'Whole System Approach' in its Maternal and Neonatal Health (MNH) work in Cross River State, focusing on improving maternal and newborn outcomes by employing a systems approach to strengthening maternal health care in the state. The initiative achieved a substantial decline in maternal mortality in its first three years of implementation, where 812 health facilities were assessed for their readiness to deliver QoC, divided into clusters, and equipped with quality Improvement tools such as medicines, solar-powered blood banks and hospital beds. Facility maternal deaths reduced by 66% by the end of the entire program.
For the next three years, the 'Saving Mothers, Giving Life' initiative aims to contribute to the goal of the Kaduna State Government in reducing maternal and perinatal mortality through three key objectives:
(I) Improve access to Maternal and Newborn Health (MNH) services
(ii) Improve quality of maternal and newborn care and institutional delivery services including, Emergency Obstetric and Newborn Care (EmONC)
(iii) Strengthen collaboration and partnership between Kaduna State Ministry of Health and the private health sector
The goal of this initiative is to engage private for-profit providers (PFP) and health facilities in Kaduna State to increase demand for skilled birth attendance, reduce barriers to accessing maternal and newborn health (MNH) care, particularly EmONC, and to strengthen the capacity of the Kaduna State Ministry of Health to sustain engagement of PFP in a Total Market Approach to meeting the State's MNH goals.
With support from MSD for Mothers, Pathfinder is implementing the SMGL project in Kaduna State to develop strategies that can improve MNH services in in the State. The organisation is working with the Kaduna State Government and other private-sector organisations to facilitate QoC in private health facilities in Kaduna State. The Kaduna State Government provides technical support to Pathfinder's efforts in the State.
To get community members to attend health facilities to receive maternal health care in communities in Kaduna State, the Pathfinder team has taken the quality-improvement approach to improve QoC and improve the efficiency and effectiveness of the health facilities by working with Ward Heads, Local Transport Associations and Traditional Birth Attendants so that women in the community can be safely transported to the health facility at their point of need.
On the other hand, personnel in health facilities have limited knowledge on quality management. Pathfinder is supporting health facility quality improvement teams in 25 selected health facilities across Kaduna State to improve QoC for women seeking maternal health care. Pathfinder is working with PharmAccess Foundation, employing its Safecare Quality Improvement methodology, a proprietary tool to provide the project's 25 select health care providers with the Safecare Quality Assessment and customised Quality Improvement plans per facility that will be implemented by each of these facilities.
Dr. Ibironke Dada, Program Director of Safecare at PharmAccess Foundation, said the Foundation has trained four Safecare assessors at Pathfinder to conduct quality assessments at the 25 health facilities. They are also trained as Quality Facilitators to coach and mentor the Quality Assessment teams in each of these health facilities to implement the Quality Improvement Plans (QIPs). Safecare's approach to quality improvement is holistic, in the sense that every part of the health care delivery is addressed, from clinical and non-clinical perspectives. Non-clinical areas such as facility hygiene, amenities and cleanliness and attitudes of health care workers are assessed alongside clinical areas of service delivery to be able to assess and address the QoC in these health facilities. In this respect, Safecare is introducing a horizontal approach to quality assessment and quality improvement. Through this tool, Pathfinder and Safecare are enabling health facilities to identify their individual gaps in QoC, understand the gaps and address them using tools at their disposal so that women can be availed with better quality care. "The Safecare tool provides for capacity transfer from the Pathfinder teams to the facility Quality Improvement teams to be able to implement their Quality Improvement Plans," Dr. Dada said.
To improve the quality of care that women experience when they attend the 25 selected health facilities in Kaduna State, Pathfinder partnered with Nivi, a cloud-based digital health service, to support every woman from the start of her pregnancy journey until she gives birth and in the post-partum stage. Nivi works by utilising messaging platforms such as Facebook Messenger and WhatsApp to reach women with life-saving resources to aid their pregnancy journey. From the point where she finds out that she is pregnant i.e., early in her pregnancy, before she goes to the health facility, Nivi provides relevant guidance and advice for each gestational period. On Facebook Messenger and WhatsApp, a woman can chat with Nivi as a friend that guides her through her pregnancy; if she is in her first trimester, Nivi provides her with tools needed to navigate that period of her pregnancy.
For Pathfinder's SMGL initiative, Nivi's support is two-pronged. According to Ben Bellows, Co-founder and Chief Business Officer at Nivi, the two main goals of the Nivi tool for the women in these local communities in Kaduna State are; to raise awareness early on in a woman's pregnancy journey so that she attends antenatal care (ANC) early, and to help the woman attend all eight ANC visits. "Nivi is a bridge connecting the woman to better quality care at the health facility," Bellows said. To measure and track QoC, Nivi not only schedules ANC sessions for the woman, but also goes ahead and asks her about her assessment of, and satisfaction with these sessions, to gauge the quality of services offered. All the data to and from the woman are then aggregated and disseminated to the trained Quality Assessor's/Facilitator's health facility.
Quality of Care must be an ongoing, multifaceted process, where all stakeholders, from the woman, to her community, the health facility, the religious and traditional leaders and professional associations, come together to work to attain quality, and not just access. When it comes to health care, quality of care is more important than access to care, with more women dying while giving birth as a result of poor quality than as a result of poor access to maternal health care services. The Saving Mothers, Giving Life initiative's approach to Quality Assessment and Quality Improvement throws light on how the understanding of gaps in quality generates pathways for the creation of better tailored and sustainable solutions for maternal health care.
SMGL's collaboration with stakeholders is a lesson in the power of multi-stakeholder collaborations, bringing to the fore the essence of the African Proverb; "If you want to go fast, go alone; but if you want to go far, go together ".