Cynthia Kwukanin Ogaji, a 30-year-old hairdresser from Cross River State, Nigeria, was pregnant with her first child and in labor when she arrived at her local public primary health care center. But her labor was not progressing, due to cephalopelvic disproportion — a relatively common yet treatable complication that occurs when the baby’s head is too big for the birth canal. The facility staff promptly referred her to a private clinic an hour away, which specialized in maternity care.
That swift response very likely saved Cynthia’s life, and her baby’s. She delivered her son safely at the second facility, where the staff was equipped to manage obstetric emergencies and could perform the C-section she needed.
Cynthia’s case shines a light on some important changes happening in Cross River since the launch of a maternal and newborn health improvement project led by Pathfinder International, with support from Merck for Mothers (known as MSD for Mothers outside the U.S. and Canada) and USAID under the Saving Mothers Giving Life (SMGL) initiative. SMGL was formed in 2012 to significantly reduce preventable maternal and newborn deaths in countries with high rates of maternal mortality: Uganda, Zambia, and Nigeria. As a result of SMGL’s efforts in Uganda and Zambia, maternal deaths declined in initiative-supported districts in both countries by more than 40%.
The results achieved in Cross River have been even more dramatic. According to data from 108 public and private facilities, maternal deaths dropped 66% in just three years.
Improving women’s access to timely and appropriate care
To achieve these gains, Pathfinder implemented a total market, or whole-system approach — working at the community, facility, and state government system levels to improve women’s access to timely and appropriate care before, during, and after labor and delivery. The approach also entailed working with both public and private providers to significantly increase the number of women in the state who are less than two hours away from quality emergency obstetric services.
This meant building a robust referral network, with regular meetings to foster collaboration and trust among providers. The project team provided training, mentorship, and other support to ensure the delivery of quality maternity care services — wherever women decided to seek care first.
Pathfinder also engaged individuals, households and communities — as well as traditional birth attendants — to empower women to seek care and to demand quality by providing them with access to sufficient information and resources (such as emergency transportation) to do so.
The multi-pronged approach worked. Today, more than 90% of women in Cross River have access to quality emergency obstetric care within two hours of the onset of a complication.
Integrating private providers into quality improvement efforts
Bringing in private providers, and including them in capacity building and quality improvement efforts, was critical to the success of this project. In Nigeria, as in many low- and middle- income countries, up to 40% of women who seek facility care during pregnancy and childbirth already turn to these private providers, in some cases because there are no public options. In Cross River State for example, many rural areas lack a functional public hospital. But access to care is only half the answer – poor quality care drives up to 60% of preventable deaths.
Given the prominent role they already play in health care systems, it is clear that private providers must be integrated into efforts to ensure quality affordable maternity care is available to all women. Governments have a role to play in monitoring quality and providing mechanisms for the public to identify quality providers. Private providers will need to be included in state funding and insurance schemes, not only to keep their services affordable but also to help decongest public facilities that are already straining under the burden of increased demand for services.
Let’s not forget: private providers are also small business owners, so they are a motivated group. We need their entrepreneurial, can-do spirit, and their willingness to innovate to spark lasting change.
And governments need private providers to help fill critical information gaps — the patient and other data needed to inform national health policies. The African Union has called on all member states to strengthen their internal surveillance mechanisms, to count and investigate all maternal deaths and better understand why they’re happening. So it is encouraging to note that all SMGL-supported private providers in Cross River, having forged closer ties within the state’s broader public health system, are now sharing their data with district authorities. Previously, only about 20% of them were.
Collaborating to help end preventable maternal deaths
Going forward, we are advancing efforts to ensure that a total market approach in Cross River State is sustainable and is replicated in other states across Nigeria. We’ll be sharing best practices and lessons learned from this work, to continue to break down barriers and support public and private health sectors working together in an organized, systematic fashion — to end preventable maternal deaths. This learning may also be helpful in achieving Universal Health Coverage, a cornerstone of the Sustainable Development Goals.
There’s a lot at stake. There are too many points during a woman’s journey to motherhood where things can go wrong; where any delay in seeking, reaching or receiving quality care can mean the difference between a safe and healthy birth, and a tragic outcome.
We know what we need to do to end preventable maternal deaths. Let’s work together to end them once and for all.
Merck for Mothers is known as MSD for Mothers outside the United States and Canada.