Maternal deaths and near-misses in Nigerian hospitals

We can eliminate maternal deaths in resource-poor countries

EJ Kongnyuy
United Nations Population Fund, Kinshasa, Democratic Republic of Congo

Linked article: This is a mini commentary on OT Oladapo et al., pp. 928938 in this issue. To view this article visit
http://dx.doi.org/10.1111/1471-0528.13450.

Published Online 3 July 2015.

Globally, an estimated 289 000 mater-
nal deaths occur each year and 99% of
these deaths occur in developing
countries (WHO, Trends in Maternal
Mortality 19902013;2014:122).
Nigeria alone accounts for 14% of the
worlds burden of maternal mortality.
The authors of the Nigeria Near-Miss
and Maternal Mortality Survey
reported unacceptably high numbers
of maternal deaths in Nigerian,
reflecting deficiencies in public ter-
tiary hospitals (Oladapo et al. BJOG
2016; 928938).
The situation reported by Olap-
ado et al. is just the tip of the ice-
berg. It reflects what is happening
in many developing countries in
general and sub-Saharan Africa in
particular. The majority of determi-
nants of high maternal mortality
fall into one or more of the seven
dimensions of quality: safe, effec-
tive, patient-centred, timely, effi-
cient, accessible and equitable
(Schneider A, Bull World Health
Org 2006;84:259). If the majority of
factors contributing to maternal
mortality can be seen as quality-
related, quality improvement
approaches should be central to
reducing maternal mortality.
Improving the quality of maternal
care requires interventions at com-
munity, district and health facility
levels. Community level interven-
tions include community engage-
ment and participation,
community-based maternal death
reviews, and outreach services/refer-
rals. Critical elements at district
level include the strengthening gov-
ernance, accountability, infrastruc-
ture, health service information
system, and health workforce train-
ing/staffing. Quality of care can be
improved at facility level through
organisation of service delivery,
appropriate financing, health worker
training and motivation, improving
service infrastructure, improving
interpersonal processes, and facility-
based maternal death reviews.
The barriers to improving the
quality of maternal care at facility
level are multiple. Improving qual-
ity of care through maternal death
reviews (MDR) requires adequate
numbers of care providers with
skills to conduct MDR in a blame-
free manner, good patient records,
effective leadership to provide the
necessary staff motivation, and
resources to implement recommen-
dations. Unfortunately these prereq-
uisites to effective MDR are often
absent. Even basic quality improve-
ment approaches that require only
common sense such as strong lead-
ership, client focus, re-organisation
of service delivery, involving people,
process approach, system approach,
continuous quality improvement
and factual approach to decision-
making are often inadequate or
absent.
Although quality is central to
improving maternal care and reduc-
ing maternal mortality, quality inter-
ventions in developing countries are
often fragmented and are carried out
as small pilot projects which are not
adapted to a countrys realities.
Achieving the vision no woman
should lose her life when giving
birth and eliminating maternal
deaths (Gilmore K, et al., Lancet
2012;380:878) in the post-2015 era
is possible if we implement quality
improvement approaches on a large
scale while addressing the barriers to
introducing and providing quality
care. One of such approaches is
Maternal Death Surveillance and
Response (MDSR), which has the
potential to improve quality of care
and measure progress in the short
term. MDSR encompasses maternal
death reviews, death notification,
analysis and coordinated response to
prevent similar deaths in the future.
Disclosure of interests
None declared. Completed disclo-
sure of interests form available to
view online as supporting informa-
tion. &

2015 Royal College of Obstetricians and Gynaecologists 939