Sunday Ehigiator takes a look at the Maternal and Perinatal Death Survey Response, MPDSR, Bill, its practicality and importance in reducing maternal and perinatal death in Nigeria
The expected medical and social outcome of every intended pregnancy is to have a healthy mother with a baby that is endowed with full potential for its existence and survival.
This outcome is cherished in Nigeria which is home to one in five Africans, with a population of over 200 million people, an estimated 1 per cent of the global population.
Although Nigeria’s current infant mortality rate in 2023 stands at 54.740 deaths per 1000 live births, which is a 2.63 per cent decline from 2022, it remains the country with the second-highest number of maternal and child deaths globally.
If the country’s quests to attain the SDG-3 by 2030 and be ranked among the top 20 leading global economies are to remain on course, these mortalities must be sharply reduced.
The MPDSR Bill
In 2013, the World Health Organization (WHO) launched the Maternal Death Surveillance and Response (MDSR) guidance to strengthen notification, review, and response to maternal deaths.
This guide emphasized the need for each maternal death to be a notifiable event and reviewed to be able to understand the underlying causes of any death to create a response mechanism to avert future deaths and to have a continuous cycle of surveillance and response.
Following this introduction by WHO in 2013, there arose a global consensus that accurate information about causes of death through mortality audits is needed to help inform and enhance efforts to end preventable maternal and perinatal deaths.
Against the backdrop of achieving the Sustainable Development Goals (SDGs), Nigeria introduced the MPDSR Bill; ‘a Bill for an act to provide for the effective surveillance, review and prevention of maternal and perinatal deaths and related matters for the Federal Republic of Nigeria, 2020 (SB. 581)’ introduced by Senator Yahaya Oloriegbe, representing Kwara Central Senatorial District.
Senator Oloriegbe believes the data on maternal and perinatal deaths would be useful in making recommendations on how to address the problem.
Senator Sadiq Umar, who seconded that the bill should be read for the second time, explained the rationale behind his decision.
He said, “I support this bill because the maternal deaths in this country are unacceptable; these deaths affect the poor primarily and we all have the poor in our constituencies.
“To achieve our goal by 2030, we need to have data that is properly interpreted and informs decision-making. I urge us all for this bill to be read the second time.”
The bill is also aimed at accelerating efforts to improve outcomes for women and babies and is expected to be passed into law, and implemented as both a national policy and state policy.
But not much has been heard about it since it was passed by the national assembly and yet to be signed into law by the President, especially now that Senator Oloriegbe lost his bid to return to the Senate in the 2023 general elections.
Maternal and Perinatal Death in Nigeria
According to the WHO, Maternal death or maternal mortality is defined as the death of a pregnant mother due to complications related to pregnancy, underlying conditions worsened by the pregnancy or management of these conditions. This can occur either while they are pregnant or within six weeks of the resolution of the pregnancy.
While perinatal death or perinatal mortality is defined as the number of fetal deaths after a fetus has passed 22 or 28 completed weeks of pregnancy, plus the number of deaths among live-born children up to seven completed days of life, per 1000 total births (live births and stillbirths).
According to the WHO, it is the “number of stillbirths and deaths in the first week of life per 1,000 total births, the perinatal period commences at 22 completed weeks (154 days) of gestation and ends seven completed days after birth.”
Latest United Nations Children’s Fund (UNICEF) report titled ‘Situation of Women and Children in Nigeria’ states that Nigeria records 576 maternal mortality per 100,000 live births, while approximately 262,000 babies die at birth every year.
Also, infant mortality currently stands at 69 per 1,000 live births, while under-five deaths is 128 per 1,000 live births with more than 64 per cent of the deaths caused by pneumonia, malaria and diarrhoea.
Also, a new report by the WHO, showed that Nigeria accounts for the second-highest number of maternal and child deaths globally.
The report titled, ‘Improving maternal and newborn health and survival and reducing stillbirth: Progress Report 2023’ and released by the World Health Organisation (WHO) on May 9, 2023, shows that Nigeria, Africa’s most populous nation is only behind India in the latest ranking.
This further emphasises the importance of the MPDSR Bill, targeted at using detailed record-keeping on death, and causes of death, among others to get an informed recommendation on how to improve maternal healthcare and thereby reduce the negative indices.
Importance of Quality Maternal Care
Although maternal deaths have declined by nearly 40 per cent worldwide over the past two decades, maternal mortality continues to be a significant public health challenge.
A large proportion of maternal deaths are preventable, even in countries with limited resources. In low- and lower-middle-income countries, almost 60 per cent of preventable deaths are the result of poor-quality care.
Quality of maternal health care services is poor in many of the 81 countries that account for 95 per cent of all maternal deaths and 90 per cent of all child deaths worldwide.
High-quality maternal health care sets the foundation for women, children, families, communities and societies to thrive for generations to come. Quality care underpins efforts to build resilient health systems that can manage health emergencies while delivering primary care, saving more lives and advancing equity
According to a brief by MSD for Mothers, “To achieve high-quality maternity care, every maternal death, wherever it occurs, should be counted, reported and examined, and the findings from these reviews should drive action to prevent future deaths.”
Goals and Objective of the National MPDSR
The National MPDSR guideline has a simple goal “to eliminate preventable maternal and perinatal deaths.”
It also has eight objectives, which are, “to notify and collect accurate data on all maternal and perinatal deaths in the country; including, notify on every maternal and perinatal death; number, identify and report all maternal and perinatal deaths; and determine the causes of death, contributing factors and review all maternal and perinatal deaths using facility records, and verbal autopsies.
“To analyse and interpret data collected, in respect of trends in maternal and perinatal mortality, causes of death (medical) and contributing factors (quality of care, barriers to care, nonmedical factors e.g. socio-cultural, religious factors, health-seeking behaviour, etc.), avoidability of the deaths, focusing on those factors that can be remedied, risk factors, groups at increased risk, and maps of maternal and perinatal deaths, demographic and socio-political and religious factors.
“To use the data to make evidence-based recommendations for action to decrease maternal and perinatal mortality, and the recommendations will be on applicable subjects, such as community education and involvement; timeliness of referrals; access to and delivery of services; quality of care; training needs of healthcare personnel or protocols use; deployment of resources where they are likely to have an impact; regulations and policy; billing and cost of care, emergency services; and advocacy for MNCH interventions.
“The objective also includes disseminating of findings and recommendations to civil society, health personnel, and decision/policymakers to increase awareness about the magnitude, social effects and preventability of maternal and perinatal mortality.”
The fifth objective is to ensure actions take place, by monitoring, evaluating and reporting the implementation of recommendations. The sixth objective is to inform programmes on the effectiveness of interventions and their impact on maternal and perinatal mortality, including feedback.
The seventh objective is to guide and prioritize research related to maternal and perinatal mortality, while the eighth objective is to strengthen referrals and linkages between and across the levels of care.
WHO, UNICEF Recommendation
The World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) recommend that all countries institutionalize maternal death reviews as a key strategy to prevent maternal deaths.
According to MSD for Mothers, “Effective surveillance systems are comprehensive and include data from public and private clinical settings and both health facilities and communities equipped with more representative data, health systems and providers can make better-informed decisions about how to improve the quality of care they deliver before, during and after childbirth.
“When these data are integrated into national health information systems, policymakers and governments have the facts they need to develop evidence-informed maternal health policies and interventions that will improve access to quality healthcare services.
“In addition to supporting better allocation of resources, annual reports from surveillance systems also help hold policymakers, health providers and communities accountable for improving the quality of maternity care so that all women have a healthy pregnancy and safe childbirth.”
Current Status of the MPDSR in Nigeria
On June 28, 2022, the Federal Government (FG) launched the revised guidelines and tools for Maternal Perinatal and Child Death Surveillance and Response (MPCDSR).
Speaking at the launch, the former Minister of Health, Dr Osagie Ehanire revealed that the MPDSR initiative “has been expanded to incorporate child mortality audit, making it now Maternal, Perinatal, and Child Death Survey Response (MPCDSR).”
He also revealed that the enabling “bill has been passed by the National Assembly and is awaiting Presidential assent.”
At the event, Dr Ehanire also inaugurated the MPCDSR Steering Committee, and he was announced as the chairman of the committee.
Other members of the committee are the Chairman, of the Senate Committee on Health; Chairman, of the House Committee on Health; Commissioners of Health of every state responsibility of Reproductive, Maternal, Newborn, Child and Adolescent Health + Nutrition (RMNCAH+N) in their states, and Heads of Departments of FMoH.
“Others are Family Health; Hospital Services; Public Health; Health Planning, Research and Statistics; Food and Drugs Services; and ICT, amongst many other stakeholders,” Ehanire said.
He explained that the committee will serve for four years.
The former minister said that the committee will also provide oversight on MPCDSR nationwide, support knowledge management, documentation, and research and Give support to the state MPDSR steering committee in the implementation of MPDSR plans and programmes.
Implementation and Practicality of the MPDSR in Nigeria
Since 2015, the WHO and UNICEF have recommended the institutionalisation of Maternal and Perinatal Death Surveillance and Response, MPDSR to track and prevent maternal and perinatal deaths in countries around the world.
Speaking on the implementation in Nigeria, the Nigeria Health Watch in a recent report said, the Federal Ministry of Health adopted the Maternal and Perinatal Death Surveillance and Response, MPDSR in November 2016.
However, “state-level implementation of MPDSR in Nigeria is inadequate, because it is focused on facility-based maternal deaths alone and sub-national MPDSR committees are unable to effectively turn the data into action.
“Consequently, this gap fueled the ‘Giving Birth’ in Nigeria programme’s approach to reviewing maternal deaths in communities, with the involvement of family decision-makers, traditional leaders, religious influencers, health workers and government-level officers in inquiries, awareness, and dialogue.
“Community MPSDR, as recommended in the ‘Why Are Women Dying While Giving Birth in Nigeria’ report, will provide a mechanism for policymakers and other decision-makers to be well aware of the causes of maternal deaths and address these causes at all levels by creating actionable solutions that could reach women in local communities.
“As a framework for monitoring maternal deaths, it will ensure the timely reporting and surveillance of women dying while giving birth in communities.
“Consequently, this vital information can be used to guide public health’s response and government action at all levels and prevent the occurrence of future maternal deaths in communities.
“Also, through community MPDSR, every maternal death at home, at a faith-based centre or with a Traditional Birth Attendant (TBA) can be counted, assessed, and avoidable factors aggregated. The information generated can be used to guide the immediate implementation of solutions as well as long-term actions to reduce maternal mortality in Nigeria.”
In many communities across Nigeria, women continue to face barriers to accessing safe maternal health care during pregnancy. Some of these challenges include a lack of adequate health infrastructure and a lack of skilled birth attendants.
Consequently, pregnant women increasingly patronise traditional birth attendants (TBAs) during childbirth to deliver their babies. A traditional birth attendant is a person who assists pregnant women when giving birth.
But traditional birth attendants are scientifically unskilled and lack formal training, adequate health information, and a proper understanding of pregnancy complications and risk factors that lead to maternal deaths. They also lack access to requisite tools for clean delivery such as medicine and equipment for obstetric care. However, they never lack patronage.
Some of the reasons for the continuous patronage of traditional birth attendants could be attributed to the elements of the ‘Three Delay Model’ which identifies three groups of factors including, delay in decision to seek health care, delay in reaching health care points and delay in receiving adequate health care , which are capable of hindering women from accessing the maternal health care they need.
These altogether may form a big barrier in the community-based implementation of the MPDSR.
Also speaking on limitations, Dr Ehanire noted that an analysis of bottlenecks indicated a need to examine the coordination architecture at strategic and technical levels and reposition the National Reproductive Health Technical Working Group to address the thematic areas of Sexual and Reproductive Health and Rights against this backdrop.
He however said the ministry was resolute in ensuring that women had a safe pregnancy and delivery services.
Aside from the lack of technical know-how, another current limitation surrounding the MPDSR is tied to the delay in Nigeria’s President, Bola Ahmed Tinubu, in naming a new Minister of Health who should automatically take over from Dr Ehanire as the MPCDSR Steering Committee Chairman.
Also, failure to appoint a new Minister of Health is capable of slowing down the operations of the committee, even as some states have begun implementation of the MPDSR.
Effort by States
While many state governments are yet to implement or roll out any concrete strategy to implement the MPDSR in their states, some states are taking the lead and setting the pace for others to follow.
Lagos State began the implementation of the MPDSR in 2016. A year later, in its characteristic style of pioneering innovative health initiatives, the state government launched a fully digitalised auditing scheme of the MPDSR.
The launch concludes the transition from paper-based Maternal Death Review (MDR) to Maternal and Perinatal Death Surveillance and Response (MPDSR) and digitisation of the scheme.
At the point of the launch, the Lagos State University Teaching Hospital, LASUTH, and 23 secondary health facilities had already commenced electronic auditing of maternal and perinatal deaths to improve the survival of vulnerable groups.
The initiative was flagged off with the distribution of electronic tablets to Heads of the 23 facilities.
The tablets, which were procured by MamaYe-Evidence for Action (E4A), a maternal and neonatal health support programme funded by the Bill and Melinda Gates Foundation, were configured and supplied by InstratGobal Health Solutions of the United States.
Speaking at the launch, former Director of Family Health and Nutrition, Lagos State Ministry of Health, Dr Folasade Oludara, who represented the former Commissioner for Health, Dr Jide Idris, at the flag-off, remarked that the use of tablets for data capture and submission will provide real-time information on MPDSR in Lagos State, improve decision-making processes, and ultimately increase the survival of pregnant women and newborn children.
Also speaking, former Permanent Secretary of Lagos State Health Service Commission, Dr Jemilade Longe, said, “This great initiative of digitizing our MPDSR process is an opportunity we are going to maximize to improve the survival of pregnant women and our babies in Lagos State. We greatly appreciate MamaYe-E4A for supporting it.”
Other states that have begun the implementation include Ebonyi, Kano, Kogi, Kaduna, Cross River, and Plateau States, among others.