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LAGOS STATE MATERNAL AND CHILD MORTALITY REDUCTION (MCMR) PROGRAM

LAGOS STATE MATERNAL AND CHILD MORTALITY REDUCTION (MCMR) PROGRAM
LAGOS STATE MATERNAL AND CHILD MORTALITY REDUCTION (MCMR) PROGRAM: GOOD PRACTICES MEMO

BACKGROUND/RATIONALE
Nigeria is one of the 187 countries that signed the Millennium Declaration in 2000 with the aim of reducing the 8 identified goals/targets substantially by 2015. With the deadline for the attainment of the Millennium Development Goals rapidly approaching, many Countries are developing strategies aimed at fast-tracking efforts being made towards the attainment of the MDGs.

Nigeria still has one of the highest maternal mortality rates in the World. The figures for the Country varies between 800 to 1,000 live births based on the geographical location. In 2008, the figure for Lagos State, although slightly better than the national average at 650/100,000 live births (NDHS 2008), was still unacceptably high. Although Nigeria is on track for some of its targets, it is showing slow progress especially with the health related ones. Nigeria is a major contributor to the global burden of maternal deaths and requires intensified efforts to rapidly reduce the high mortality indices.

Two decades of various Safe Motherhood initiatives since the Launch in Nairobi 1987 has failed to make any remarkable impact on the maternal health indices in Nigeria.

The main causes of maternal mortality identified in Nigeria are:

1. Hemorrhage (23%)
2. Infection (17%).
3. Unsafe abortion (11%)
4. Obstructed labour (11%)
5. Eclampsia (11%)
6. Malaria (11%)
7. Anaemia (11%)
8. And others including HIV/AIDs (5%).

Surprisingly majority of the conditions could be prevented, and thus minimizing the impact to such an extent that they do not cause maternal death. 75 percent of neonatal deaths occur within the first week of life, therefore linking the survival of the newborn to the quality of maternal care.

LAGOS STATE

In 2008, the State Government inaugurated a committee to offer technical guidance on the various modalities needed for the reduction of the maternal mortality using the National guidelines for the Integrated Maternal, Newborn and Child Health strategy (IMNCH) and the SOGON National Partnership plan for sustainable Reduction in maternal and Newborn Death in Nigeria as templates.

The committee was made up of representatives from the Public and Private Sector as follows:

• Honourable Commissioner for Health- Chairman
• Permanent Secretary Ministry of Health
• Permanent Secretary PHCB
• Permanent Secretary HSC
• Chairman Medical Advisory Committee
• Representative of SOGON
• Representative of PAN
• Chairman Lagos Sector AGPMPN
• Chairman HEFAMMA
• Chairman and Secretary Blood Transfusion Agency.
• Coordinator School of Nursing and Midwifery
• Lagos State Traditional Medicine Board
• Ministry of Women Affairs and Poverty Alleviation
• Ministry of Rural Development
• Ministry of Local Government & Chieftaincy Affairs

At the inaugural meeting, major challenges identified were:

1. Inadequate manpower especially doctors and midwives at the primary, secondary and tertiary level of care.
2. Prevalence of traditional birth attendants at the community level and the refusal of their Body to follow laid down rules.
3. Inadequate blood transfusion services at the secondary and tertiary centres.
4. Poor two-way referral system.
5. Lack of community based insurance scheme.

Situation analysis showed the following:

PHCs-
A total of 208 PHCs were distributed across the Local Government Areas in the State. 198 were in various stages of functionality, however majority were poor staffed and unable to deliver basic emergency obstetric care.

General Hospitals:
Most of them had complement of doctors, nurses and midwives, but were unable to provide comprehensive emergency obstetric care due to inadequate staffing, unavailability of necessary equipment and infrastructure and lack of blood banking facilities.

Suggestions/Recommendations from the inaugural meeting:
1. Sustained advocacy to Government for improved budgetary allocation and social mobilization to communities.
2. Increased community and public awareness on issues concerning maternal and child health care to address type 1 delay through the development, printing and dissemination of information, education and communication (IEC) materials.
3. Capacity building of health workers on the various maternal and child health interventions.
4. Integrated services for maternal, newborn and child health (IMNCH)
5. Strengthening of Primary Health Care and effective referral systems.
6. Training and retraining of birth attendants: (Faith based, Community and Traditional).
7. Effective supervision of Community and Faith Based Organizations.
8. Linking of community based ambulances with LASAMBUS.
9. Reorientation of health workers on interpersonal communication.
10. Promotion of Public-Private Partnership and community financing.
11. Financing of the Maternal and Child Health activities through the State’s Health Financing options.
12. Rapid assessment of the existing obstetric services for establishment of a baseline for monitoring and evaluation.
13. Effective supervision, monitoring and evaluation of services and programs.
14. Promotion of research on reproductive health issues.

Based on the findings and recommendations of the committee, a 5-year work-plan (attached as Annexure A) was developed for the implementation of the above mentioned findings, The implementation modalities for the developed work plan culminated in the Project termed ‘The Maternal and Child Mortality Reduction Program’.

LAGOS STATE MATERNAL AND CHILD MORTALITY REDUCTION PROGRAM

GOAL:
The Maternal and Child Mortality Reduction Program was establish to map out strategies
for the reduction of the high mortality indices in the State. The overarching goal was to reduce the maternal and child mortality rates in line the MDGs 4, 5 and 6.

OBJECTIVES OF THE MCMR PROGRAM
• To improve the health seeking behaviors of women of child bearing age in the state.
• To increase the quality of care provided to pregnant women and children.
• To improve the knowledge and skills of health providers to provide qualitative maternal and child health services.
• To increase utilization of the Public Health Facilities in the State.

Prior to commencement of the MCMR Program, a survey was conducted to serve as a baseline for program implementation. The survey gave a guide to the present status of the maternal mortality ratio in the State, and also assisting in knowing the commonest causes of maternal mortality.

The Survey was conducted by a Non-Governmental Organization: Campaign Against Unwanted Pregnancy (CAUP) using the sisterhood method. The results which were state and LGA specific gave the maternal mortality ratio in Lagos State as 555,100,000 live births. This figure was higher than the national average of 545/100,000 live births (NDHS 2008). LGA desegregated result attached as Annexure B.

Other Surveys and needs assessment conducted by Development Partners such as UNFPA and JICA assisted the on-going MCMR Program.

PROCESS/METHODOLOGY

The 5-year plan of action contained various strategies/activities aimed at addressing the short term impacts of maternal mortality.

1. Advocacy/sensitization campaigns:

This is aimed at creating awareness to members of the Community and Women of child bearing ages of the problems associated with pregnancy, delivery and postnatal period. It also serves to inform them of the services available at the Primary Heath Care Centres and the need for prompt referral. Since the commencement of the program, several community dialogues/sensitization meeting have been held with key members of the community.

SENATORIAL DISTRICT TOWN HALL MEETINGS:
4 Town Hall meetings have been held across the three Senatorial Districts in the State. The meetings recorded great success and were attended by market women, community leaders, traditional and religious leaders, women of child bearing ages etc.

LGA TOWN HALL MEETINGS:
In 2013, 2 Town hall meetings were held in Epe and Ibeju-Lekki LGAs respectively, this was due to the high number of unavoidable deaths within communities arising from quackery.

1. 2. Upgrading of existing Public Health Facilities to provide basic and comprehensive emergency care by renovation and provision of equipment.

• Emergency Obstetric Care Equipment
In 2010, fifty-seven Primary Health Care Centres in each of the 57 LGAs/LCDAs were provided with basic emergency obstetrics equipment (names of PHCs attached as Annexure C) to ensure optimal functionality in the provision of basic obstetrics care. With the revitalization of the Primary Heath Care Services in 2012, the Flagship PHCs were instituted to ensure provision of not only basic obstetrics services, but also treatment of non-communicable diseases. This is in line with the ‘bringing PHC under one roof’ strategy of the Federal Government instituted in 2011 to integrate management of PHC and end fragmentation in the health sector and thus ensure essential health services gets to the grassroots where they are most needed.

• Blood Banking Equipment
In 2010, twenty-two secondary Health Facilities were also provided with blood banking Equipment to ensure functionality as Comprehensive Emergency Obstetrics Care Centres.

1. 3. Infrastructural development and provision of supplies including basic obstetric drugs (misoprostol and magnesium sulphate) for health facilities.

• Anti-shock Garments:
Twenty three percent of maternal death are from hemorrhage. The Non Pneumatic anti-shock garment (NASG) is a lower body garment which causes circumferential compression of abdomen and legs thereby reducing total vascular volume whilst expending the central circulation. Evidence based studies have shown that the use of anti-shock garment reduces blood loss in pregnant women by 61 percent, mortality by 60 percent and morbidity by 85 percent by stabilizing the pregnant women whilst other life-saving interventions are conducted on her.

In an effort to reduce death from the commonest cause of maternal mortality, a total of 191 NASG were procured and distributed to the Public Health Facilities in the State.

• Manual Vacuum Aspirators:
Death from complications of unsafe abortion accounts for 13 percent of maternal deaths. Pregnant women should have access to quality post abortal services and to guarantee this, the Ministry procured and distributed 137 manual vacuum aspirators for the management of women centred post abortion care to the primary and secondary health facilities in the State.

• Drugs for essential obstetric care:
The drugs are essentially misoprostol and magnesium sulpate. Misoprostol is used prophylactically for the reduction of haemorrhage during and after delivery and should be made available in all facilities. Magnesium sulpate is used for the treatment of eclampsia which accounts for 11 percent of maternal mortality worldwide. To reduce the morbidities and mortalities arising from pregnancy complications, on a yearly basis, the Ministry of Health procured the drugs for distribution to the Public Health Facilities in the State.

• Mama-kits.
The Mama-Kit is an all-in-one kit that contains everything needed to provide clean and safe delivery. It contains all the necessary requirement needed for normal delivery such as cotton wool, gauze, surgical gloves, plastic sheeting, razor blades, cotton wool (gauze pad), soap, cord clamp etc. It also serves as a motivating factor for utilization of the PHCs by the pregnant women. This is provided free to all pregnant women who deliver in the Primary Health Care Centres in the State. Since the launch of the MCMR Program, the State has procured 27,385 mama-kits and distributed 15,785 to the Primary Health Care Facilities.

• Neonatal Resuscitation bags
Neonatal mortality in recent years has increased in developing countries with Nigeria having the third highest neonatal mortality in the world. Presently with the integrated Maternal and Newborn and Child Health (IMNCH) strategy, rolled out by the Federal Government in 2011, to accelerate reduction in MDGs 4 and 5, there is an increase focus on the neonates, which account for 40 percent of children under five years of age, and have unfortunately been neglected in recent times.

Newborn infants resuscitated during the golden hour i.e the first hour of birth, have a greater chance of surviving. Provision of basic resuscitation equipment at the primary health care centers can reduce death of the newborn during the first 2hours of birth. The resuscitation bag known generically as a manual resuscitator or “self-inflating bag” is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately.

To address this, the State Government procured and distributed 230 neonatal resuscitation bags to Primary Health Care Centres offering maternal and child health services.

1. 4. Production of Behavioral Change Communication (B.C.C.) materials.
Since inception over 500,000 handbills on various maternal and child health interventions have been developed and distributed to the community members during the sensitization meetings. The hand bills and posters are in various languages. They are aimed at improving the health seeking behavior and Key house-hold practices of women, family members and the community in general on key issues affecting a woman’s health.

The handbills/posters include the following:
• Danger signs in pregnancy.
• Birth preparedness/complication readiness.
• Exclusive breastfeeding.
• 10 steps to safe delivery and healthy baby.
• Nutrition in pregnancy
• Benefits of family planning
• Types of family planning

1. 5. Development of protocols on Maternal Health interventions:
These are aimed at improving the quality of health services provided in the Health facilities. Protocols such as care of the baby at time of delivery, neonatal resuscitation, post natal care, active management of third stage of labour, management of post-partum haemorrhage, management of obstructed labour, septicaemia and labour ward protocol have been produced and distributed to the Primary and Secondary Health Facilities in the State.

The Maternal Health Booklet.
This is a comprehensive health promoting home-based booklet which includes Family Planning, pregnancy-related health check-up schedules and emergency care, delivery information, postnatal care, family planning, immunization, neonatal and child care guide. Since the launch in October, 2012, 200,000 booklets have been distributed to the Public Health facilities in the State.

Child Health Handbook for children aged 5 years and below.
It contains provision for reports on every visit to the Child Welfare Clinic e.g. routine immunization schedule and vaccinations actually received, growth monitoring, etc. Since the Launch, 450,000 booklets have been distributed till date.

1. 6. Capacity building of health workers on Maternal, Newborn and Child Health interventions.
Since the commencement of the Program in 2009, series of trainings have been held on a regular basis aimed at improving the skills and competency of health workers on the provision of essential obstetric and newborn services.

The trainings includes the following:
1. Emergency Obstetrics and newborn Care.
2. Essential newborn Care.
3. Family planning technology.
4. Community based newborn care.
5. Integrated management of childhood illnesses.
6. Active Management of Third Stage of Labour.
7. Post abortion Care
8. Life Saving Skills.
9. Modified Life Saving Skills.

1. 7. Production of pubic enlightment materials on maternal health interventions:
This includes radio jingles and documentary aimed at increasing awareness of members of the community on issues relating to maternal health. Radio jingles have also been developed by popular artists such as Pasuma Wonder and King Wasiu Ayinde Marshall (Kwam 1) in support of Safe Motherhood.

1. 8. Supervision, monitoring and evaluation.
An all-involving supervision and monitoring system has been developed by the Ministry of Health (Integrated Supportive Supervision). This also involves on-the-job training to ensure that set objectives of the MCMR program are accomplished.

1. 9. Equity and sustainability:
As part of the efforts to increase demand for Maternal and Child Health services being rolled out by the Government and also to enhance access to these services in the state irrespective of socio-economic status, the community based health insurance scheme has being rolled out in the State. This is presently being implemented in 3 Local Government Areas in the State.

LAUNCH OF THE MATERNAL AND CHILD MORTALITY REDUCTION PROGRAMME.

Although various activities of the MCMR program commence since 2009, The Program was launched officially by His Excellency the Executive Governor of Lagos State on Thursday 18thOctober, 2012. This date was named the Maternal and Child Mortality Reduction Program Day by His Excellency. During this annual event, the State is expected to give report of all programs aimed at improving the health of mothers, pregnant women and children.

Since the Launch of the MCMR Program in 2010, other interventions have been added to the MCMR program aimed at addressing key needs/gaps identified during the implementation:

1. 1. Family Planning Services:
The Family planning services has increased steadily from 2011 till date. Prior to April 2012, the Federal Government distributed family planning commodities to the State with a cost recovery margin aimed at providing necessary administrative logistics for collection and distribution of the commodities to the State. This was also retailed to the Family planning providers in the Public Health Facilities and subsequently to the end users

In 2012, the Federal Government in an effort to increase utilization of family planning services, and increase the national contraceptive prevalence rate to 36 percent by 2018 removed the cost recovery margin. However, this was not without challenges, as the commodities were not getting to the end users due to logistics costs. To address this, the State Government in 2012 commenced the review and resupply model of distribution of family planning commodities to the family planning service providers in the State. This eliminated the cost of collection and distribution of commodities from the State and the LGA level. Lagos State is the only state in Nigeria to provide create a budget line and release funds for family planning activities.

Since the commencement of the review and resupply model of distribution, family planning utilization has increased by almost 50 percent on a yearly basis.

1. 2. Public Private Partnership Initiative for neonatal services in Lagos State:
A major gap identified in the MCMR program was the poor access to specialist care for neonates especially in the State Public Secondary Health Facilities. To achieve this there was a need to increase the institutional capacity of acute neonatal services in the State. This was addressed by institution of a public private partnership Initiative between a Public Health facility (Outreach Medical Services) and the State Government.
A pilot phase commenced on the 21st of November 2011 in 4 Secondary Health Facilities. Till date a total of 910 neonates have been admitted and treated at the private facility, with 620 neonates (68%) saved.

To strengthen Neonatal services in the State, in 2014, the following were implemented:
• Development and distribution of 2,000 booklets on Standard operating procedures for neonatal care to the Public Health Facilities in the State.
• Procurement and distribution of neonatal equipment to Public Secondary Health Facilities offering neonatal services.

1. 3. Maternal Death Review (MDR).
The Ministry of Health in collaboration with Society of Gynecologists and Obstetrics (SOGON) institutionalized the Maternal Death Review in the State. Since May 2013, the maternal death reviews has been implemented in all the Secondary Health Facilities in the State. The MDR is not a sanction, but as a means of identifying the underlying causes of maternal mortality and recommending interventions to be carried out in the State. A Key concept of the review is “No name No blame”. The MDR has assisted the State Government in planning effectively, programs and activities for the on-going Maternal and Child Mortality Reduction Program. Since the commencement of the Program, 260 cases have been reviewed by the State MDR Committee. Some of the activities identified as a result of the MDR program includes:

• Inadequacy of the Blood banking Units of the Secondary Health Facilities to meet up with the demands of the Hospital due to inadequate personnel, lack of adequate space, non-functional blood banking equipment.
• The need for establishment of Zonal High Dependency Units in the States.
• The need for continuous refresher training of Health Workers.
• Provision of additional ambulances for the secondary Health facilities and linking them up with LASAMBUS services.
• Inadequacy of the Lagos State Traditional medicine Board to monitor effectively the activities of the TBAs.
• Inadequate following of laid down standards for management of Obstetric emergencies by the Health Workers.
• High number of maternal mortalities arising from quackery and mismanagement.

Activities implemented due to the MDR Program till date:
1. State wide auditing of the Blood Banking Units in the Public Health Facilities, with development of blood banking Protocols handbooks.
2. Maintenance agreement between the Ministry of Health & HPZ.
3. On-going process for the establishment of an Intensive Care Unit in Lagos Island Maternity Hospital.
4. Continuous training and retraining of Health workers.
5. Printing and distribution of protocols on Emergency Obstetrics Care to the Public Health Facilities.

1. 4. Voluntary Obstetrician Service Scheme

The Ministry of Heath signed a Memorandum of Understanding with SOGON Lagos State Chapter for commencement of Voluntary Obstetric Scheme. The Organization expressed willingness to offer their services voluntarily/pro bono by providing on-the-job training and mentoring services to selected PHCCs in the State on a regular basis. In this regard, interested members of SOGON (78) have adopted a primary health facility. The facilities are been visited on a regular basis with other requiring interventions addressed. The State has also developed a handbook in this regard.

OUTCOMES
The Maternal and Child Mortality Reduction Program has led to an increase in the utilization of the Primary Health Care Centres. The various maternal health indicators has also increased:

Table 1: Total antenatal attendance at the Primary Health Care level:

2011 2012 2013 Jan-Aug 2014
136,090 120,778 154,304 121,451

Table 2: Deliveries:

2011 2012 2013 Jan-Aug 2014
13,931 12,220 16,699 13,446

Table 3: Family Planning services:

2011 2012 2013 Jan-June 2014
New Acceptors 28,681 68,138 151,980 146,233
Revisit 43,239 83,914 144,892 76,540

OPPORTUNITIES:

• Tapping into the vibrant Public Sector Participation in the State especially for the provision of essential Health services.
• Continuous rehabilitation and revitalization of the Primary Health Care Centres and establishment of Flagship PHCs in an effort to bring essential health services closer to the people.
• Scaling up of Community based Health Insurance scheme to ensure equitable access across the wealth quintiles.
• Investing in human resources across all levels of care (primary, secondary and tertiary).
• Strengthening of the 2 way referral system to operationalize the pyramid of care.
• Continuous pro-active outreach programs to deliver key services such as immunization, family planning, antenatal care, HIV counseling and testing.
• Increased funding for Maternal, newborn and Child Health activities.
• Strengthening of the supply chain management of essential commodities especially for reproductive health services to prevent stock-out.
• Strengthening of neonatal services in the state.

LESSONS LEARNT:

• The need for active involvement of the private sector in all components of the program, and not just representation at the state level.
• Empowering the Traditional Medicine Board to effectively conduct its primary function of monitoring and regulating the activities of the unorthodox practitioners such as the traditional, faith based and community birth attendants.
• Late involvement of the State in the activities of the Primary Health Care system which is the primary responsibility of the Local Government. The constitution of the Health Sector Reform law and subsequent establishment of the Primary Heath Care Board has supported the State in addressing this deficit.

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