Confidential enquiries into maternal deaths in Ondo State, Nigeria – a comparative analysis

Maternal death is defined as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes” [1]. Globally, an estimated 303,000 maternal deaths occurred in 2015 with low- and middle-income countries accounting for 99%. At the country level, Nigeria and India accounted for a third of these maternal deaths with 58,000 (19%) and 45,000 (14%), respectively [2]. The maternal mortality ratios (MMR) in Nigeria were estimated to be 545 and 576 (per 100,000 live births) in 2008 and 2013, respectively [3]. These figures have a wide range depending on the region of the country. The states in the northern regions like Zamfara, Bauchi, Kano, etc. have worse health indices due to over population and less economic development when compared to those in the south like Lagos, Ondo, Anambra, etc. Identifying accurate information on specific circumstances surrounding the death of women in countries with inadequate vital registration statistics like Nigeria would enable efforts to reduce maternal mortality [4].

Confidential enquiries into maternal deaths are one type of maternal death surveillance and response, which intend to go beyond counting numbers of deaths for statistical purposes, and try to provide insight into possible factors that may be addressed to reduce future deaths. Confidential enquiry allows for analysis of what could be done in practical terms at facility, community and state levels [4]. The earliest reference to a maternal death surveillance system was in Sweden in 1660 which eventually led to presentation of the first national statistics on maternal mortality in 1751 [5]. The first modern-day formal reporting of a confidential enquiry covered England and Wales for the years 1952–1954, although the system on which it was based had been established as early as 1928 [6].

In October 2009, multi-pronged health interventions and strategies under the umbrella of the “Abiye” (“safe motherhood”) programme were promoted and implemented in Ondo State. They were to find solutions to the four phases of delay predisposing to maternal and child deaths i.e. delays in seeking, reaching, accessing and referring care [7]. The absence of accurate state-wide maternal health indicators, however, made it difficult to appropriately plan, monitor and evaluate the impact of these interventions and strategies. Several pragmatic steps were then taken to legislate the Confidential Enquiry into Maternal Deaths in Ondo State (CEMDOS) on 24th of May, 2010 [7]. Data generated were presented to stakeholders and policy-makers periodically for deliberation. This study aimed to compare 12-monthly trends of maternal mortality ratios (MMRs), deaths and their geographical distributions, reported to the CEMDOS.

The figures of consecutive annual births were 45,000, 46,350 and 47,700 in 2012, 2013 and 2014, respectively. The numbers of reported maternal deaths and MMRs (per 100,000 births) during the periods of study are shown in Table 1. This amounts to a 33%-reduction in MMR in the period of study. Assuming that the confidential enquiry process was the only intervention at the time aimed at reducing maternal mortality, simple linear regression with a correlation coefficient of 0.9314, showed a positive relationship. The difference in the values, however, were not statistically significant (95% CI: − 184.55 to 101.55, p = 0.169).

Postpartum haemorrhage (PPH), eclampsia, septicaemia and uterine rupture were consistently reported as the leading causes of maternal deaths throughout the study period. The indirect causes were individual cases of medical conditions in pregnancy like suspected pulmonary embolism, severe hepatitis, diabetic keto-acidosis, pneumonia, congestive heart failure, sickle cell anaemia, severe acute asthma and anaesthetic death. Figure 1 illustrates these major causes.

About 90% of the women died in public or private hospitals, irrespective of the duration of time spent on admission. Further enquiry by the data officers, however, showed that over 80% of those facility deaths were women who had not booked for antenatal care, were referred late or managed beforehand by either traditional birth attendants (TBAs) or faith-based healers. Other deaths actually occurred in transit to hospital or in mission (faith-based) clinics, traditional and domestic homes (Table 2).

In terms of geographical distributions, Akure South and Ondo West (of Ondo Central District), Owo and Akoko Northeast (Ondo North) as well as Okitipupa (Ondo South) being the most cosmopolitan LGAs in their respective senatorial districts had leading numbers of reported cases of maternal deaths. Table 3 illustrates the distributions of maternal deaths by LGA in the State during the period of study.

The age range of women most affected in the first and second periods of study was 31 to 36 years compared to 25 to 30 years in the third one. The distribution of maternal deaths by age is shown in Table 4. The parities most recorded were consistently those patients who had between one and four previous births. The distribution of deaths by parity is illustrated in Table 5. The differences in values for the parities were statistically significant while those of places of death and ages showed none.

To the best of the researchers’ knowledge this was Nigeria’s first implementation of a state-wide maternal death surveillance and response system in the form of a confidential enquiry into maternal deaths. The 33% reduction in MMR in Ondo State from 253 per 100,000 births (1st June 2012 to 31st May 2013) to 170 (1st June 2014 to 31st May 2015) is striking. This finding was in line with the 70% reduction found in a concurrent study that examined a five-year facility-based MMR trend in the busiest maternity centre in Ondo State [11]. These achievements could be attributed to the multi-pronged “Abiye” (safe motherhood) programme instituted by the state government between 2009 and 2015. The programme included free maternal and child health services in all public hospitals in the state, establishing dedicated tertiary facilities for the care of pregnant women and children as well as collaborating with unskilled traditional and faith-based birth attendants to refer uncomplicated labour cases in their care to designated hospitals in exchange for cash incentives.

In comparison, the South African model came into operation in 1998 but, unlike CEMDOS, was strictly facility–based. There was an initial increase in MMR in South Africa from 1998, peaking at 176 per 100,000 live births in 2010. This was followed by a reduction of 13% to 159 in 2011 and further reduction to 147 in 2012 [12]. Morocco, alongside far reaching health interventions, instituted its maternal death surveillance system in 2009 and showed an average annual decrease in MMR of 5% till 2012 [13].

The reduction in number of maternal deaths and MMRs in Ondo State since the introduction of the confidential enquiries was therefore anticipatory as year after year, measures to counter identified causative factors were instituted. To improve quality of care at the facility level, for instance, the identification of post-partum haemorrhage and eclampsia as the major direct causes of maternal deaths led to resources being invested in conducting targeted trainings and clinical drills among relevant staff in all secondary and tertiary hospitals in the state. In addition, meetings were held at community levels between ministry of health officials and commercial drivers’ unions to make vehicles available at odd hours of the day at subsidised rates to minimise delays in labour cases moving from their homes to maternity centres. Furthermore, trained community health officers were provided tricycle ambulances or motor cycles to assist in responding to home distress calls as well as evacuating patients to health facilities.

The major causes of maternal deaths in this study were the same as identified in other similar reports. For instance in Morocco, haemorrhage contributed 33% of direct causes of death followed by pre-eclampsia/eclampsia, infections and uterine rupture [13]. The South African data, however, showed that non-pregnancy related infections and acquired immuno-deficiency syndrome (AIDS), ranging from 54 to 73%, accounted for majority of their maternal deaths between 2002 and 2012 [12]. Thrombosis and thrombo-embolic disorders were found to predominate in the United Kingdom [9]. The identification of causes and surrounding circumstances leading to maternal deaths in any environment should lead to prioritisation and formulation of policies targeted at those particular challenges.

This study showed that about 90% of women died in hospitals though a majority of them had been delayed or managed elsewhere. Unique about CEMDOS is that deaths outside facilities are included. Hitherto, maternal death audits from Nigeria emanated from secondary and tertiary-level hospitals, a majority of which are located in urban or semi-urban areas. All these report contained data confined to individual hospitals, none did collate or compare data across hospitals or within a specified area [14]. Limiting data to facility deaths leads to significant underreporting of deaths in a country like Nigeria. Surveys showed only 35% of Nigerian women gave birth in hospitals [3]. The Moroccan report also took into cognizance events outside hospitals, giving a rate of about 70% facility deaths and 4%, in transit to hospitals [13]. In South Africa, however, their confidential enquiry contained facility-based data only, but in a setting where over 90% of the population gave birth in facilities [12].

With regard to geographical distribution of maternal deaths in Ondo State of Nigeria, the sharp drop of about 35% in Akure South compared to other LGAs in the initial 2 years was notable. This particular feat may be attributed to implementation of the home-grown “Agbebiye” initiative, a component of the “Abiye” programme, which involved registration of all TBAs in this LGA and establishing an incentive-based system for them to refer women in labour to hospitals before complications set in. In exchange each TBA received a payment voucher per referral to be redeemed at a later date.

In addition, entrepreneurship workshops were organised and seed money distributed to allow registered TBAs seek other vocations like catering, bead-making and soap production as alternative means of livelihood. The impact on number of reported deaths was so impressive that the initiative was replicated in phases, first in Ondo west then the other LGAs. Geographical pattern of maternal deaths also resulted in targeted health interventions in South Africa especially in Free State province that initially had relatively high numbers of reported deaths [12]. A three-pronged strategy involving inter-facility ambulance transport, intensive district training, and re-alignment of hospitals performing surgery contributed to a reduction [15].

The Ondo State pattern revealed that LGAs like Akoko Northwest, Ese-odo and Ilaje, which habour a predominantly rural population and difficult terrains, recorded paradoxically low numbers of reported deaths. This might have been due to under-reporting as a result of poor communication infrastructure as well as gravitation of complicated labour cases towards more developed LGAs in the State. There was evidence of ineffective integration of the CEMDOS scheme into existing but deficient structures in these areas like the radio, television and mobile networks made worse by the pervasive lack of electricity. These anticipated teething problems were limitations to the study as with any new health initiative requiring public participation. Additional interventions like reconnecting the areas to the national electricity grid must be instituted to address these specific challenges, in order to generate more accurate data.

This study showed that the overall age range-at-risk was 25 to 36 years accounting for an average 68% with no discernible trend. The Moroccan study also showed nearly 50% of the women were between 25 and 35 years old. In addition, they had on average, two children at time of death [13]. Similarly in this study, the parities most recorded were consistently of women with 1 to 4 previous births. This may point to an overall disproportionately large number of parturients falling in that parity range rather than suggesting they were at higher risk of maternal mortality. It is pertinent to note that a majority of maternal deaths were preventable and occurred when most women were contributing maximally to the socio-economic development of their households in particular and nation, as a whole. The implementation of a maternal death surveillance and response system as exemplified in this study by a state-wide confidential enquiry format appears to be a pre-requisite to combating this tragedy of our time.

Our recommendations for replication of Ondo State model include; utilisation of available employees (i.e. disease surveillance and notification as well as monitoring and evaluation officers) at the local government level as well as in hospitals at no significant extra cost. The limited resources could then be majorly expended on logistics and creating public awareness like the use of jingles in electronic media as was done in Ondo. In addition, there should be a focus on addressing delays in seeking and reaching care among parturients through the provision of vehicular means of transport to and from health facilities. Furthermore, collaborating with stakeholders at community level, particularly the TBAs have been shown to be worthwhile. Finally, improving quality of care in facilities through capacity building for relevant healthcare professionals in order to combat the leading causes of maternal deaths would go a long way to reduce deaths from complications of pregnancy, labour and puerperium.

There was a trend of a reduction in maternal mortality ratio during the period of study with postpartum haemorrhage as the major cause of death. This reduction, combined with the positive outcomes of interventions at local government levels as well as other factors enables us to recommend that our confidential enquiry model be adopted in other states and at the federal level. It should be a matter of best practice to routinely perform careful analysis of maternal deaths in a systematic and robust manner.