Assessing the Impact of an Intervention to Improve the Quality of Emergency Obstetric Care on Maternal Health in Nigeria

Nigeria suffers some of the highest rates of maternal and perinatal mortality in the world. Poor quality of obstetric care is a key factor, and although not quantified at a national level, local studies suggest that high rates of maternal and perinatal deaths are due to clinical management errors in hospitals. This project therefore explored the nature of existing practices and quality of clinical management of three leading causes of maternal and perinatal deaths (primary postpartum haemorrhage, eclampsia, and obstructed labour); implement an intervention package aimed at improving the quality of clinical management of these causes of deaths; and test the effectiveness of this package on quality of care indicators and maternal and perinatal outcomes. 

The study follows a quasi-experimental research design, using interrupted time series analysis for assessment over a three year period.  Six public secondary care hospitals and two public tertiary care hospitals in both north and south of Nigeria were selected randomly. Formative research was conducted in all eight hospitals, and thereafter the intervention will be carried out in four hospitals, with the remaining four hospitals functioning as control sites. The package consists of training in use of evidence-based clinical protocols on postpartum haemorrhage (PPH), preeclampsia/eclampsia and obstructed labour, audit and feedback, reminders, commodity supply monitoring and replenishments and patients' education. 

Clinical outcomes will be compared between intervention and control sites in a total of 2334 cases of PPH, preeclampsia/eclampsia and obstructed labour (based on an anticipated 50% reduction in case fatality rates, significance level of 0.05 and 80% power). This will consist of 1167 cases in the intervention sites and 1167 in the control sites.  Maternal and perinatal mortality rates will serve as primary outcome measures. Secondary outcomes involve quality of care drawn from United Nations process indicators, skilled attendance index and data derived from the formative audit phase of the project.

The results will enable the identification of a system-wide quality of care framework for improving the delivery of emergency obstetric care for the prevention of maternal and perinatal morbidity and mortality in Nigeria.