By Eric Ojo
In the Federal Capital Territory (FCT), the Quality of Care (QoC) programme is attempting to reduce maternal deaths by improving the quality of care given to mothers and newborns in their facilities. Introduced in March 2019 by the Federal Government of Nigeria with support from WHO, the QoC programme is demonstrably changing the narrative underpinning maternal and neonatal care in PHCs across three Council Areas in FCT which include, Abuja Municipal Area Council (AMAC), Bwari Area Council, and Kwali Area Council, as well as three other secondary health facilities within the territory.
The growing emphasis on quality of care in health facilities globally, particularly within the context of reducing maternal and neonatal mortality, is driven by the vision of the World Health Organization (WHO). The WHO has set up standards aimed at improving the quality of maternal and newborn care in health facilities under the QoC guidelines. These are contained in its widely publicized and internationally accepted framework for maternal and newborn care, which identifies critical areas of quality of care that should be assessed, improved and monitored within health systems.
Under this dispensation, it is the responsibility of the health system to provide the structure for access to high-quality care with six areas of focus: clinical guidelines, standards of care, effective interventions, measures of quality of care, relevant research as well as capacity building. Moreover, in order to further promote safe, timely, effective, efficient and people-centred healthcare, the WHO also set up an initiative called QoC Quality, Equity and Dignity (QED), with a network of countries including Nigeria.
Notably, the data collated from the PHCs a few months after the implementation showed some improvement in the quality of pre and postnatal care across all the facilities. At the stakeholders meeting attended by health workers from 10 health facilities including seven PHCs and three Secondary Health facilities, on the 23 of October 2019, the PHCs were able to show how the positive changes were accomplished and have continued to demonstrate their performance index at subsequent meetings. In addition, the FCT administration is upgrading infrastructural facilities and equipment to enhance the quality of services rendered by the PHCs in this regard.
Meanwhile, the scenario playing out on issues relating to maternal mortality in Nigeria remains largely worrisome, to the extent that between 1990 and 2015, the country records about 58,000 maternal deaths annually. Worse still, the lifetime risk of a Nigerian woman dying during pregnancy, childbirth, or postpartum is one in 22, in contrast to the lifetime risk in developed countries, estimated at one in 4,900.
Maternal healthcare in rural communities is worse than in urban centres. Rural PHCs across the country are handicapped due to poor governance, lack of basic amenities and equipment, shortage of qualified health workers to cater for the needs of new mothers and their babies, and a host of other limitations.
Prior to the implementation of the new standards, the WHO provided technical support to the Federal Government in the area of capacity building for health workers and service providers in the health centres involved in the implementation of the Quality of Care programme in the FCT. Also, the WHO supports the facilities to hold monthly meetings and regular Quality Improvement (QI) coaching visits via quarterly peer-to-peer experience sharing meetings to ensure that the milestones are sustained so far.
The WHO focal person for Maternal Health, Dr. Muyiwa Ojo emphasized the need for all health facilities in Nigeria to provide care that takes into account the preference and aspirations of individuals service users and ensure the provision of highest level of quality and the cultures of their communities, adding that WHO will continue to provide technical support to the Federal Government and states ministries of Health on implementation of maternal, newborn and child health QoC.
Similarly, the focal person for FCT QoC implementation, Dr. Iniobong Ekong said the frontline health workers in the PHCs were trained on a new approach to care which, according to him, involves identifying problems and proffering local solutions that will reliably deliver better care for mothers and newborns around the time of birth without seeking significant additional resources.
Dr. Ekong further disclosed that QI approaches have also been adopted in preventing hypothermia (high temperature) in newborns by ensuring immediate skin-to-skin contact for at least one hour after delivery, immediately drying them as well as measuring and recording their temperature exactly 1 hour after birth. “As a result, on the average across the facilities, hypothermia has remarkably reduced from 95 percent to 19 per. In addition, the proportion of women receiving uterotonics within 1 minute of delivery (used to prevent postpartum hemorrhage) has also increased from 0 percent at baseline (no records kept previously) to 66.6 percent,” he said.
Officer in Charge (OIC) of Ushafa PHC in Kwali Council Area, Adama Shekwolo acknowledged that the adoption of the skin-to-skin has reduced the rate of infants becoming hypothermic after birth, adding that hypothermia has been reduced drastically because the babies are kept warm by this new method. Shekwolo also admitted that before the introduction of the QoC programme, there were things they were doing that were not done the way they ought to be done and that she is glad that they now know better.
“We were delivering babies and cutting the umbilical cord immediately after delivery, we didn’t know that we had to delay the cutting for oxygen to reach the baby’s brain. So, we have been doing so now and it has really helped us. Even the oxytocin injection that we give to mothers, we discovered that if we don’t do so within one minute, the mother will start bleeding and we have to bridge it. Before we used to wait until the placenta is delivered before we give, we now learnt that we have to give immediately after delivery. It has helped mothers from having complications drastically,” she further disclosed.
She also disclosed that they have cascaded the training to other staff in their facility and that they are now fully aware and are complying with the new practice. She added that there is also a high level of compliance from the mothers because they are enlightened and sensitized on what to do during the antenatal care.
Lending credence to this, the Monitoring and Evaluation Officer, Public Health Department of the Bwari Council Area, Mr. Sunday Peter said the implementation of the QoC programme in FCT has introduced a lot of new skills on how nurses and midwives can take proper care of new mothers and their babies shortly after birth. Mr. Peter also noted that the monthly meetings have created a veritable platform for healthcare workers in the PHCs, to share ideas, their experiences as well as the challenges they are having and the way forward.
The OIC of Kogo PHC in Bwari Area Council, Mrs. Comfort Nuhu said the programme has helped in transforming the scope and quality of antenatal care in their facility. “It has helped us a lot in our facility when pregnant women come to our facility we give them health talk, we educate them on how to cope with the skin-to-skin contact, preparing their mind because we have to tell them ahead so that they can cope with the new practice when they come for delivery”, she added.
Mrs. Nuhu noted that when they started implementing the programme in 2019, some mothers were scared of using the skin-to-skin contact but their fears were subsequently allayed when the process and its importance was thoroughly explained to them and they started cooperating and complying with it. She added that some of them are now happy with the skin-to-skin contact because it creates bonding between mother and baby. “Some of them love it when the baby is placed on their abdomen, breathing and feeling so close, it is a joyful experience and some of them say they feel joyful and satisfied. At times we involve the husband when a woman gives birth to twins. We invite the husband to also support the second baby and they are so happy about it too. You know it is a good thing having your baby alive”, she stressed.
She said they were not only trained on how to implement the programme, but their facilitators have equally kept following up on their progress, so that they can hear their challenges and counsel them accordingly during the monthly meetings. “The coaches train us and tell us what they have found out in other facilities, we share our experience and do peer review and they advise us on so many things and when they go for meetings, they will brief us again. We are very happy with our coaches and we work hand-in-hand in the implementation of this programme”, she further explained.
Moreover, experts and stakeholders in the health sector have also identified a number of catalysts driving the progress that has been made in the implementation of the programme in FCT and other states so far. Such drivers include, the establishment of QoC coordinating structures, formation of facility QoC committee and stepdown training on QI and having a functional technical Working Committees Group on QoC for Maternal and Newborn Health (MNH) at the national level coordinating the quarterly meetings for evaluation and update.
In a chat with Metro Daily Nigeria, a Consultant Obstetrician and Gynecologist with Maitama General Hospital Abuja, Dr. Rotimi Oluwasiji Joseph observed that the implementation of the QoC programme is gaining traction in FCT because of the availability of basic facilities, personnel and regular training and re-training of health workers in primary, secondary and tertiary health facilities within the territory. Dr. Rotimi further explained that the OoC initiative has created an avenue for nurses and midwives in the PHCs to benefit maximally from the capacity building and sensitization programmes, facilitated by seasoned Obstetricians and Gynecologists on a regular basis since the inception of the programme, adding that this has tremendously empowered primary healthcare workers and optimized their performance.
Corroborating Dr. Rotimi’s assertion, the OIC of Kuchigoro PHC in AMAC, Dr. Uduak Christine Archibong described the programme as very good and a much needed intervention. She also acknowledged that the initial training, the subsequent regular capacity building programmes, supervisory role of experts and meetings with healthcare workers, have contributed immensely to the effective and result-oriented implementation of the QoC in their facility, which has resulted in a lot of success stories that have been recorded in Kuchigoro PHC since inception.
“If so far, we have never had a single case of mortality when it comes to maternal healthcare, that is a success story for me. Also when it comes to the outcomes, particularly on the number of babies that are delivered safely here, it’s been very much impressive as well. My biggest lesson is that our people are trainable and if effort is made to train and retrain healthcare workers, it will definitely impact on the quality of service that is rendered. That is one lesson I have learnt from this,” she added.
While sharing their own experience, a Staff Midwife and Principal Nursing Officer (PNO) at Kwali Central PHC, Oladipo Oyebisi said the programme has been so beneficial to them in their facility and even the community at large. “In the way we care for newborns, our knowledge is being updated and we are able to upgrade ourselves and adapt to it. Initially we just deliver the baby, clean the baby up and give the baby to the mother. With the knowledge of QoC, we now understand that when the baby is kept at the mother’s abdomen, it keeps the baby warm for at least one hour before you do other things”, she stressed. She also recalled that most babies used to be brought back to the facility for reasons relating to high body temperature and other related medical conditions but all that, according to her, has reduced drastically since the inception of the programme.
A PNO at Dabi Bako PHC in Kwali, Esther Simire said the implementation of the QoC programme has helped them to assess the quality of care that they give to patients, especially the pregnant women and that it has also helped their work and enable them make corrections where necessary. “Based on the training we are able to look back at the kind of services we are rendering to our patients, the pregnant women, that is where the major work is for us, starting from pregnancy, antenatal, labour to postnatal care. It has been very helpful, we now have days that we see our women and their babies, it has helped us to discover issues that some mothers may be having after delivery. For a long time now, we don’t have issues with neonatal deaths and I discovered that for a very long time we haven’t had babies coming down with jaundice”, she added.
Another striking attribute of the QoC programme is its impact on the behaviour and attitude of nurses and midwives towards pregnant women, particularly in the labour room. A PNO at Kuchigoro PHC, Esther Adepoju said she really appreciates the training and exposure that this programme has given to them, adding that they are learning a lot from the series of capacity building on child health and maternal care issues. “We have learnt a lot of things, before when a woman is not cooperating with us during delivery, we shout at them and that approach did not help the situation but due to what we have learnt from the QoC programme, we keep on encouraging them, if need be, we help them to massage their back or call the husband to come and support them during labour, it makes the work much easier”, she added.
Mrs. Isa Halima, who delivered her baby safely at Dabi Bako PHC in Kwali Council Area on 5th of August this year, said she is very impressed with the services she received at the facility, adding that she did not face any challenge and the altitude of the health workers was very nice and welcoming. “I came in the night around 5am and as we knocked the security man came out and opened the gate and we went in. So, the people in charge took over and I delivered successfully. Everything went well. I am calling on other women out there in our community to come to the health centre, their services are very affordable, instead of staying at home to deliver, they can come to the centre in case of emergency and to save their life and that of the baby,”she added.
Interestingly, the implementation of the programme has equally impacted positively on the record keeping tradition in the PHCs within the FCT. A cross section of respondents in some of the facilities, who spoke to our reporter said they were simply using what they referred to as their official Delivery Register for record keeping before the introduction of QoC, but they now have a robust and comprehensive record keeping system in place which captures all the details ranging from the time a baby is born, the date, the weight, the duration of the skin-to-skin to every other relevant information.
In addition, the programme has also to some extent, improved the referral system in PHCs which is also part of the quality of care. Sources in Kwali Central PHC and Ushafa PHC confirmed that there is a cordial working relationship between their facility and Kwali General Hospital because the hospital is also implementing QoC programme, adding that they meet every month to share experience and review their activities.
Some respondents pointed out that getting patients to go to secondary or tertiary centres for treatment can be very challenging sometimes due to either lack of mobility on the part of the patients or the inefficient referral transportation system at the PHCs.
Other identified limitations of the programme are those relating to poor infrastructure system, inadequate skilled staff, fears over sustainability efforts by the government and the restriction of the programme to only public health sector and northern part of Nigeria. While proffering solutions to these challenges in a recent article entitled, “Building National Systems and Strengthening Coordination to Sustain Scaling Up of QOC for MNCH –Nigeria”, the Director of Family Health at Federal Ministry of Health, Dr. Salma Ibrahim Anas harped on the need to scale up the QoC programme to all the states in Nigeria, seek collaboration with academic institutions in the 6 geopolitical zones in Nigeria for research and mentoring support to health facilities, to strengthen coordination mechanisms, initiate more advocacy led by the Federal Government to the states and private sector for more ownership and sustainability, continuous monitoring and sharing results for the implementation as well as strengthening data measurement and feedback into the health system.
This story was produced with the support of a reporting grant from Maternal Figures.
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