Maternal death review and surveillance: The case of Central Hospital, Benin City, Nigeria

Background: Despite the adoption of Maternal and Perinatal Death Surveillance and Response (MPDSR) by Nigeria’s Federal Ministry of Health to track and rectify the causes of maternal mortality, very limited documentation exists on experiences with the method and its outcomes at institutional and policy levels. Objective: The objective of this study was to identify through the MPDSR process, the medical causes and contributory factors of maternal mortality, and to elucidate the policy response that took place after the dissemination of the results. Methods: The study was conducted at the Central Hospital, Benin between October 1, 2017, and May 31, 2019. We first developed a strategic plan with the objective to reduce maternal mortality by 50% in the hospital in two years. An MPDSR committee was established and the members and all staff of the Maternity Department of the hospital were trained to use the nationally approved protocol. All consecutive cases of maternal deaths in the hospital were then reviewed using the MPDSR protocol. The results were submitted to the hospital Management and its supporting agencies for administrative action to correct the identified deficiencies. Results: There were 18 maternal deaths in the hospital during the period, and 4,557 deliveries giving a maternal mortality ratio (MMR) of 395/100,000 deliveries. This amounted to a seven-fold reduction in MMR in the hospital at the onset of the project. The main medical causes identified were obstetric hemorrhage (n = 10), pulmonary embolism (n = 2), ruptured uterus (n = 2), eclampsia (n = 1), anemic heart failure (n = 1) and post-partum sepsis (n = 2). Several facility-based and patient contributory factors were identified such as lack of blood in the hospital and late reporting with severe obstetric complication among others. Response to the recommendations from the committee include increased commitment of hospital managers to immediately rectify the attributable causes of deaths, the establishment of a couples health education program, mobilization and sensitization of staff to handle pregnant women with great sensitivity, promptness and care, the refurbishing of an intensive care unit, and the increased availability of blood for transfusion through the intensification of blood donation drive in the hospital. Conclusion: We conclude that the results of MPDSR, when acted upon by hospital managers and policymakers can lead to an improvement in quality of care and a consequent decline in maternal mortality ratio in referral hospitals. The study was conducted at the Central Hospital (CH) in Benin City, Edo State, one of the 36 States in Nigeria. Nigeria operates a three-tier health care system with primary health care as the first tier. The second and third tiers are referral hospitals comprising secondary hospitals as the second tier and tertiary or teaching hospitals as the third tier. The Central Hospital Benin City is the main secondary referral hospital established more than 60 years ago in Benin City that has an estimated population of over 1.7million people. The hospital offers comprehensive antenatal, delivery and post-natal care as well as Comprehensive Emergency Obstetric Care (CEOC). This study is a part of a lager quasi-experimental research on improving the quality of emergency obstetric care for preventing maternal and perinatal mortality in referral hospitals in Nigeria. At the baseline of the larger project, a high maternal mortality ratio of 2992 per 100, 000 live births was observed at Central Hospital Benin [8]. Establishing a MPDSR was identified as one of the strategies to reduce maternal mortality in that hospital. The current study was conducted in three Phases. In Phase I, we conducted strategic planning sessions with the senior management staff of the hospital, as well as policymakers at the State Ministry of Health that supervise the hospital. We broached the issue of the high rate of maternal mortality and conducted a SWOT (strength, weakness, opportunities, and threats) analysis to identify the bottlenecks that needed to be addressed in the hospital to resolve the problem and initiated a strategic operation plan to improve emergency obstetric care delivery and reduce maternal mortality ratio (MMR) by 50% in two years. A consensus was reached among all stakeholders (policymakers of the State ministry of health and senior management staff of the hospital) involved in the strategic planning process to work towards reducing the maternal mortality ratio in the hospital within two years. One of the activities identified as critical to achieve this outcome was the establishment and implementation of a policy on compulsory review of all maternal deaths that occur in the hospital. Such deaths would be reviewed for medical and contributory causes of mortality, with the idea to rectify the identified causes to avert future deaths in the hospital. In the second phase of the study, we conducted a needs assessment of the knowledge of clinical staff about MPDSR, which showed poor knowledge and non-availability of the service in the hospital. Thereafter, we trained all staff of the maternity section of the hospital on the processes and methods of the MPDSR using the Federal Ministry of Health training protocol [25]. This was followed by the establishment of the MPDSR Committee of the hospital following the guidelines for establishing such committees approved by the Nigerian Federal Ministry of Health [25]. This Committee was made up of Medical Director of the hospital as the Chairman, the Head, Obstetrics and Gynaecology as Secretary, Heads of Departments of Nursing/Midwifery, Paediatrics, Pathology, Anesthesia, Hematology and Blood Bank, Labour/Maternity ward, Medical Records, and Pharmacy as members. An advocacy team that will notify the relevant stakeholders in the State Ministry of Health of the findings of the MPDSR committee was also constituted. The third phase of the project was carried out over the next 20 months (October 2017 to May 2019). During this period, the MPDSR Committee of the hospital held bimonthly meetings and reviewed consecutive maternal deaths that occurred in the hospital. As part of the procedure, the case notes and associated information relating to each maternal death were retrieved by the Secretary of the Committee as soon as the deaths occurred. These were preserved privately until the reviews were conducted. The reviews were conducted confidentially. Only members of the committee were allowed into the room, while all information obtained in connection with the reviews were handled confidentially, and in a value-free manner. The names and contact details of the women who suffered maternal deaths and the names of the health providers that attended to the women were not revealed during the meetings. The reviews were conducted in a “no-blame manner” as recommended by the Federal Ministry of Health. It was designed only to explore the true medical, socio-economic and situational reasons for the death, so as to obtain information to prevent future deaths in the hospital [S1 File]. All maternal deaths that occurred at the facility from October 2017 to May 2019 were included in this study. The nationally approved MPDSR tool (semi-structured, pretested and validated data collection questionnaire) was used for the notification of the deaths. The information required in the questionnaire was entered by the Secretary of the MPDSR Committee and a timely review of the deaths was conducted by the MPDSR committee. Data was collected from the case files of the deceased women as soon as the death occurred and entered into the questionnaire attached in the MPDSR document by the Secretary of the MPDSR Committee. Data collected included pregnancy—related characteristics of the deceased women, time of admission to the hospital, gestational age at time of death, duration of hospital stay and medical and contributory causes of death. Following the reviews, the medical causes, as well as the contributory factors associated with the deaths were identified. The committee made recommendations to the head of the institution and to the State government for rectifying the identified medical and contributory causes of deaths. An advocacy committee consisting of two members of the research team, the Head of Department of Obstetrics and Gynecology, and a senior nursing officer was constituted to follow up with the various Departments of the Hospital and the State to ensure that the recommendations are put into appropriate policies and actions. A flow chart of the MPDSR process is presented in ‘‘Fig 1“. Using a data extraction form designed for this study, the researchers collected data from the MPDSR committee immediately after each review meeting. We extracted data from the MPDSR questionnaire on the pregnancy-related characteristics of the deceased, the identified medical causes, contributory factors, and the recommendations. Data on policy responses were collected as documented by the committee. We also collected data on the number of deliveries during the period, the number of maternal deaths, and the proportion of women who died that received antenatal care in Central hospital (booked cases) versus those who did not receive antenatal care in the hospital (unbooked cases). The SPSS software 21.0 was used in analyzing the data. To ensure the validity of the data entered, double entry and random checks were carried out. Univariate analysis was done and presented using frequency tables. We calculated the maternal mortality ratio (MMR) as number of maternal deaths per 100,000 live births in the hospital. To identify the nature of recommendations made for averting maternal mortality in the hospital we compiled the recommendations from the MPDSR committee and analyzed them qualitatively for form, theme, and content. The results were presented qualitatively. We also presented reports of ways that the government and policymakers responded to the recommendations made, and the specific policy actions put in place to address the bottlenecks that were identified during the review. Ethical approval for the study was obtained from the World Health Organization and the National Health Research Ethics Committee (NHREC) of Nigeria–number NHREC/01/01/2007–16/07/2014, renewed in 2015 with NHREC 01/01/20047-12/12/2015b. The Chief Medical Director of the Hospital and the Head of the Department of Obstetrics and Gynaecology were informed of the purpose of the study, and consent was obtained from them to conduct the review and the study. No names or specific contact information were obtained from the study participants. Ethical approval for the study was also obtained from the Edo State Ethical Review Board, as well as consent from the Edo State Ministry of Health. Additionally, all data were anonymized before access to the researchers and the MPDSR committees.