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Maternal Death Review in Ondo State – a Case Study

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The Confidential Enquiries into Maternal Deaths in Ondo State (CEMDOS) By Dr. Lawal Oyeneyin (FWACS, FMCOG) Consultant Obstetrician & Gynaecologist Chief Medical Director, Mother & Child Hospital, Laje rd, Ondo Chairman, Committee on Confidential Enquiries into Maternal Deaths in Ondo State (CEMDOS) Greetings from the Sunshine State . a place of pride rd Created 3 February 1976 3 INTRODUCTION 4 • Nigeria presently accounts for the second highest global burden of maternal deaths in the world and one of the top 5 of child deaths • Despite only contributing to 2% of world population, Nigeria actually accounts for about 14% of maternal deaths MDGs • United Nations Millennium Development Goal 5 - mandates improving maternal health - targets reduction of maternal deaths by 75% by the year 2015 • Brought to the fore the sorry state of maternal health in many countries, including Nigeria 6 On assumption in 2009.. • Dr. Olusegun Mimiko administration met a poorly funded and grossly inadequate health infrastructure populated by ill-motivated and demoralized professional workforce • Unflattering Nigeria Demographic and Health Survey (NDHS) of 2008 put us as having the worst maternal and child care indices in the Southwestern zone of Nigeria – we had nothing in place to corroborate or disprove these stats • In view of the foregoing we quickly put in place a program that was a paradigm shift, by taking health care services to the vulnerable populace wherever they live, work and play in order to meet our stated goals 7 ONDO ABIYE (SAFE MOTHERHOOD) PROGRAMME Launched on October 28, 2009 at Ifedore LGA to: • track every pregnant woman and take qualitative and effective health care to them • develop sustainable equity- based health care services that will provide universal access by removing all impediments militating against inter-phasing between our women and the health care system • implement equitable allocation of our limited resources premised on specific needs and performance driven principles • Multi-pronged health interventions and strategies were promoted and implemented under the Abiye safe-motherhood program to counter the 4 phases of delay predisposing to maternal and child deaths • We knew we were at the threshold of history in achieving MDG 5 • Paucity of knowledge about baseline maternal health indicators, however, made it difficult to appropriately plan and subsequently track the impact of these interventions and strategies • We decided to take several pragmatic steps in institutionalizing a maternal audit system – including the idea of the Confidential Enquiry into Maternal Deaths in Ondo State (CEMDOS) An adhoc committee was set up in Feb 2010 to draft the contents of the Bill and produce the framework for successful implementation and enforcement The CEMDOS Bill was signed into Law by Dr. Olusegun Mimiko, Executive Governor of Ondo State on May 24, 2010 Objectives 1. Laying the foundation for accurate measurement of Maternal Mortality Ratio (MMR) in Ondo State 2. Determining the common causes of maternal deaths 3. Determining the geographical distribution of maternal deaths 4. Determining the factors contributing to maternal deaths Methodology I • The Law mandates reporting of a maternal death irrespective of where the death occurred • Such voluntary reporting carries no punitive measures so long as it is done within the specified time frame i.e. within 48 hours of the incident • Failure to report attracts a jail term and an option of fine, or both for the spouse, significant other and/or care-giver at the facility where the death occurred • The Law goes a long way in protecting the confidentiality of the informant Methodology II The line of reporting using customized community-based Maternal Death Notification Forms (MDNFs) is at; • Ward / community level via the Disease Surveillance and Notification Officers • Local government level via the Monitoring and Evaluation Officers • And, state level via the CEMDOS Secretariat domiciled in the Directorate of Planning, Research and Statistics (DPRS) of the Ministry of Health Methodology III The line of reporting using customized facility-based Maternal Death Notification Forms (MDNFs) will be at; • Primary facility level via the Health Information Management (HIM) Officers • Hospitals’ Management Board (HMB) level via the Focal Officer/DPRS Officer • And, state level via the CEMDOS Secretariat domiciled in the Directorate of Planning, Research and Statistics (DPRS) of the Ministry of Health CEMDOS Line of Reporting I Community DSNO’s M & E Officers State CEMDOS Commissioner Secretariat for Health CEMDOS Line of Reporting II HMB/DPRS Facility HIM officer officer State CEMDOS Commissioner Secretariat for Health 12-month results of CEMDOS (1st June 2012 – 31st May 2013) Maternal Mortality Ratio (MMR) • The total number of maternal deaths reported was 114 and estimated number of annual births is 45,000, giving a “crude” MMR of 253 per 100,000 births Causes of Maternal Deaths 40 37 35 30 24 25 20 15 15 11 Series1 10 8 6 5 5 5 3 0 Geographical Distribution of Maternal Deaths S/N LGA FREQUENCY PERCENTAGE 1 AKOKO NORTH EAST 10 8.8 2 AKOKO NORTH WEST 0 0 3 AKOKO SOUTH EAST 0 0 4 AKOKO SOUTH WEST 2 1.8 5 AKURE NORTH 2 1.8 6 AKURE SOUTH 31 27.2 7 ESE-ODO 2 1.8 8 IDANRE 0 0 9 ILAJE 2 1.8 10 ILE-OLUJI/ OKE-IGBO 1 0.9 11 IFEDORE 1 0.9 12 IRELE 1 0.9 13 ODIGBO 2 1.8 14 OKITIPUPA 11 9.6 15 ONDO EAST 0 0 16 ONDO WEST 24 21.1 17 OSE 0 0 18 OWO 25 21.9 TOTAL 114 100.3 Factors Contributing to Maternal Deaths I – Place S/N PLACE OF DEATH FREQUENCY PERCENTAGE 1 Public health facilities* 101** 88.6*** 2 Traditional birth homes 4 3.5 3 Private health facilities 3 2.6 4 Maternity churches 2 1.7 5 In transit 1 0.9 6 Home 1 0.9 7 Patent medicine store 1 0.9 8 Unknown 1 0.9 TOTAL 114 100.0 Factors Contributing to Maternal Deaths II – Age S/N AGE FREQUENCY PERCENTAGE 1 18 - 24YRS 16 14.0 2 25 - 30YRS 36 31.6 3 31 - 36YRS 43 37.7 4 37 & ABOVE 16 14.0 5 unknown 3 2.6 TOTAL 114 99.9 Factors Contributing to Maternal Deaths III – Parity S/N PREVIOUS FREQUENCY PERCENTAGE DELIVERIES 1 NONE 40 35.1 2 1 - 4 54 47.4 3 5 & ABOVE 20 17.5 TOTAL 114 100.0 Summary of Ondo state MMR • NDHS ‘08 - Household survey – 545 / 100,000* (baseline) • CAUP ‘12 - Sisterhood method – 317 /100,000 • CEMDOS ‘12/’13 (actual) -Verbal autopsies – 253/100,000 • CEMDOS ‘12/’13 (extrapolated) – 351/100,000 • MCHA ‘12 - Mortality (facility) studies – 390 /100,000 Recommendations • Amendment of the enabling law to strengthen informant protection and remove duplication of duties – sent to State House of Assembly for processing • Establishment of 2 more MCHs in Akoko NE and Okitipupa LGAs – site identified for Ikare Akoko and work to begin before year end • Gradual phasing out of TBAs by incentivizing referral of labour cases and forming cooperatives for other vocational activities – Agbebiye project being piloted in Akure south LGA • Advocating peer pressure for faith-based maternity centres through Christian Association of Nigeria branch – pan-religion committee already formed and working • Launching of facility based “adolescent-friendly” centres to enhance reproductive health practices – implementation stage • Establishing state-of-the-art pathology department with a mandate to conduct post mortems – mega-structure in place, awaiting delivery of equipment CONCLUSION • Institutionalizing a state wide MDR system is the panacea for the dearth of reliable maternal mortality statistics in the country • This will make the allocation of scarce human and material resources towards stemming the scourge more prudent and result-based • We have decided to take the bull by the horns in Ondo state towards achieving our goals 28 THANK YOU FOR LISTENING 30.
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