Health experts have, over the years, associated bad maternal outcomes like stillbirths, miscarriages, the need for C-section and its complications, and even death, to causes like maternal obesity.
But for Mchivir Idyondgon, what could have been a disaster was quickly averted with just a text to her phone. It was during the birth of her second child.
“I started my labour at 6am and at 12 pm I had already delivered. By 4pm, I stood up by myself and went to the bathroom, had my bath and went home,” Idyondgon recalled.
Idyondgon, 36, a farmer living in a rural community in Gboko, Benue State, is one of the beneficiaries of Maternal Expert Thinking Analyzer (META), a project aimed at preventing women from dying during childbirth.
The META project developed a mobile diagnostic, training, and outreach application called Community Maternal Danger Score (CMDS) to help midwives function as experts in remote locations where access to medical doctors is limited.
Using the CMDS App, midwives use patient data to highlight obstetric danger signs via an automated risk-based assessment for pregnant mothers. This process enables midwives as well as Community Health Extension Workers (CHEWs) to promote maternal healthcare as patient-specific text messages, originated from CNIS servers in Canada, are sent to pregnant mothers delivering their peculiar risk level and recommendations on course of action.
Essentially, the CMDS app assesses mortality risks, builds skills with interactive cases, and provides risk and delivery resources/information to empower pregnant women in caregiving decisions.
Idyondgon’s first pregnancy did not come with any concern, but when she became pregnant last year, she did not expect that her weight would be a problem, until her data were captured in the app which indicated a relatively high danger score of 3/5.
CMDS instantly notified her via a text message that her weight was a potential risk and provided advice on how to scale it down—something she described as “the greatest help” she got from the project.
“When I was pregnant and my details were inputted, the danger sign that was red-flagged for me was that my weight was too much (in some cases referred to as pregnancy-induced obesity). I was then advised to scale down on the kind of foods I was eating at the time. I did that and my weight normalised and then I delivered without issues,” she said, passing her four-month-old son to her husband.
The rate at which women die during childbirth worries global health bodies such that the target of the Sustainable Development Goals (SDGs) is to reduce the global maternal mortality ratio (MMR) to less than 70 per 100,000 live births by 2030.
But it continues to be a serious problem in Nigeria, a country where nearly 20 percent of all global maternal deaths happen, according to the World Health Organisation (WHO).
According to WHO, a Nigerian woman has a 1-in-22 lifetime risk of dying during pregnancy, childbirth or postpartum/post-abortion, compared to most developed countries, where the lifetime risk is 1 in 4,900.
In 2015, Nigeria’s estimated maternal mortality ratio (MMR) was over 800 maternal deaths per 100,000 live births, with approximately 58,000 maternal deaths during that year.
Poor health systems, infrastructure, insufficient staff, as well as crude processes in data handling in Nigerian health facilities contribute to the misfortunes of pregnant women.
But the META project is giving women a chance of surviving childbirth complications in rural communities across Gboko local government area, as the women are being closely monitored for potential risks up to the point of delivery by midwives using the CMDS app.
“My baby is four months old. The messages that were sent to me and the advice they gave me really helped me in delivering well and safely,” said Comfort, another beneficiary who promised to continue visiting Tsei-Akeme, a rural primary health centre where she delivered, for immunization.
How META works
The project is implemented by the Canadian Network for International Surgery (CNIS) with support from Grand Challenges Canada. But midwives in Benue’s Primary Healthcare Centres (PHCs), mostly in rural areas, are the major drivers.
The midwives input data collected from pregnant mothers into the CMDS app (hosted on Google Play Store) to show the level of risk facing women and their pregnancies.
It then automatically analyses the data and sends an SMS to the pregnant mother informing her of her risk level and the need to see a doctor, and also ensures that she is armed with information that advises her to deliver at a healthcare facility.
Data is collated at post-partum (after delivery) to verify the status of the mother and baby. The data is also used to show the level of success being recorded by the programme.
A total of 33 midwives spread across 14 rural PHCs in Gboko have been trained on how to use the app which is downloaded to their phones. The intent is to inform pregnant mothers of the risk levels and need to seek medical care to avert cases of maternal mortality.
“It has helped my work with pregnant women so much,” said Nancy Ayagwae, a midwife at PHC Tsei-Akeme in rural Gboko LGA. “Some are excited when we collect their numbers. A lot of the women come back to tell us that they got messages in Tiv language.”
She noted that the danger signs help them to know what they are likely going to face, and allow them to initiate preventive measures.
In addition to text messages sent to women, midwives also follow up with them through phone calls to remind them to visit a healthcare facility, especially when their expected date of delivery (EDD) is near.
Also narrating his experience from managing pregnant women with the CMDS app, Levi Kwaghngee, nurse and project desk officer, told BusinessDay that the app has been very helpful due to its swift identification of potential problems.
He said indices like the weight, the height, the gestation period, total number of pregnancies, fundal height (a measurement of the size of the uterus used to assess foetal growth and development during pregnancy), preeclampsia signs, co-existing conditions (such as anaemia, HIV, diabetes, malaria, vaginal bleeding, etc), blood pressure of expectant mothers, age, and others are keyed into to the app to determine risk factors.
Kwaghngee noted that CMDS’ quick response helps him and other midwives to better manage the patients, and also in the swift identification of problems.
“And since we began to follow the management of the patients along those lines identified as potential problems and we have not had any issue,” he said.
Before the META project, and its successes
Benue State has one of the highest fertility rates in Nigeria with 4.5 births per woman, according to Nigeria’s Demographic Health Survey (NDHS) of 2018. It also has one of the highest maternal mortality ratios.
The state has a total maternal mortality ratio of 1,118 deaths per 100,000 live births, according to a research titled ‘Maternal Mortality Statistics and Risk Factors at a Tertiary Hospital in Makurdi, Nigeria’, authored by Samuel Hemabh-Hilekaan, Michael Tyodoo Maanongun and two others.
To determine MMR in the state, the authors conducted a retrospective institutional review of all the case notes of maternal mortality at the Benue State University Teaching Hospital, Makurdi, over a six-year study period from July 2012 to June 2018. They found that a total of 2,442 deliveries took place within that period, out of which 2,325 were live births.
The total maternal deaths were 26, giving a total maternal mortality ratio (MMR) of 1, 118 deaths per 100,000, according to the authors.
The research also found that unsafe abortion and its complications, hypertensive diseases in pregnancy, puerperal sepsis (infection of the genital tract occurring at labour or within 42 days of the postpartum period) and obstetric hemorrhage were major causes of maternal mortality during that period.
Although it is said to be an under-representation of the cases, this high MMR could be connected to how midwives managed pregnant women before the META project.
Midwives told our correspondent that previously they found it difficult managing pregnant women. The best they could do was counsel them on Infant and Young Child Feeding (IYCF).
There was no means to follow up on the women who sometimes forget to visit hospitals, and the midwives were not collecting their phone numbers, as it was not mandatory.
In fact, most of the things they do now, like knowing the danger signs and reminding them to visit hospitals, were not done before, BusinessDay learnt.
Though 85 percent of maternal deaths happen in impoverished communities in Africa and Asia where socioeconomic and cultural factors play a role, the narrative could be changing for women in Benue State.
Terumbur Miriam Adekaa, a midwife at CHC, Gboko North-West, said the mortality rate and also the rate at which mothers complain of losing their babies during childbirth have reduced greatly since the project started.
“We’ve had cases of stillbirths here before the app came. But not maternal death. We once had a case that nearly gave up here. We transferred her to another place but she gave up at another facility,” Adekaa said.
“But now they have been minimised through this app. In fact, so many things have been minimised,” she said.
Adekaa said she uses the app to determine what will happen to pregnant mothers and that she quickly refers them to a higher facility to deliver when she sees a danger score of 3/5 and above, which could be a potentially deadly situation.
Improved antenatal care
Speaking to our correspondent, Elizabeth Apkehe, director, Local Government Health Authority (LGHA), Gboko, said that META’s progress goes beyond bringing midwives closer to pregnant women.
Apkehe, who supervises the META project and helps to collect data when women give birth, said it has helped a lot in reminding women to attend antenatal care at clinics, because some of them forget after visiting a clinic twice and sometimes they deliver at home.
“So, the rate they come for antenatal has improved,” she said. “With this project, they have seen the importance of delivering at a facility and the way they are delivering at the facility has improved.”
This, she explained, has led to more live births than stillbirths. According to data collected by Apkehe, out of about 500 women who have been captured, zero stillbirths were reported and only one reported case of C-section among participating women.
Fanan Ujoh, head of research and data collection/analysis, CNIS, while sharing on the META’s success, noted that data is still being collated after which a detailed analysis would be done to arrive at the exact level of success or otherwise of the project.
But preliminary documentation from the app’s servers in Canada indicate that there is some level of improvement in terms of reduced level of stillbirths and high-risk births due to the early warning system delivered by the CMDS App.
The project targets about 2,000 women after which the exact outcome would be published. But from already collated data of over 600 pregnant mothers, about 200 have delivered out of which zero stillbirth and zero maternal mortality were recorded, Ujoh said.
The other 400 women are still being monitored and more deliveries are expected within the year. Ujoh said the entire process ends when the women deliver.
“Hopefully, by the end of June 2021, CNIS would have concluded the trials of the CMDS App and the outcome would be published in a high net-worth peer-reviewed medical journal and also presented at the Annual Bethune Roundtable in Canada,” he said.
Challenges and barriers to replication
While the midwives say they are excited about the CMDS app, it is not all nice and dandy. The challenges around the app are a reflection of Nigeria’s poor internet access, poverty, and the technological exclusion from which women suffer.
The midwives complain of a bad network which slows down data upload to remote servers located at CNIS’ office in Vancouver, British Columbia, Canada.
Sometimes, they are unable to reach women when they call them for follow-ups because many of them do not own phones. This also affects data collection, especially at post-partum.
“I also have challenges with logistics like data to subscribe my phone,” a source said.
A significant number of the midwives do not also have smartphones to install the app. But more significantly, they pointed out that some possible conditions that a patient could be exposed to are not specifically captured in the app.
For instance, the issue of a previously recorded stillbirth is not specifically captured, they said, adding that some anaemic conditions are not also captured in the app, suggesting an improvement on other conditions too.
Ujoh said some of the challenges, like poor internet connection and data subscription, were anticipated, but a plan to address these defects would be incorporated after initial analysis of the collated data and a SWOT analysis of the outcome of the proof of concept are done.
This is also a reason the programme, which is currently being implemented in Benue State and still in its trial phase, cannot be replicated elsewhere yet.
He noted that the programme will be replicated once the medical and scientific community approves of its effectiveness.
“Replicating this programme can only happen after the CNIS Team collates the data and makes a convincing and verifiable scientific case on the usefulness of the CMDS App in reducing MMR. At the moment, the proof of concept is being implemented only in PHCs within Gboko LGA in Benue State where we trained midwives on the use of the app,” Ujoh said.
When the app was created as a scoring system for the risk of maternal mortality, it was first used as a tool for teaching midwifery students in Makurdi and Mkar Schools of Midwifery to enable them understand what scientific factors contributed to maternal death.
Ronald Lett, CEO of CNIS, was pushed to create the META project which led to the development of the app, after he witnessed many women—mostly teenagers—die during childbirth as a young practitioner in various parts of Africa including Nigeria, Tanzania, Kenya and Ethiopia.
He said about 80 percent of the women are not getting skilled birth attendance in Benue and many other areas of Africa and their preliminary studies prior to the app found Benue’s maternal mortality to be similar or above the average of Nigeria’s MMR.
“These deaths traumatised me personally,” Lett said. “I was concerned about it.”
The objective was to try to get the high-risk women to get skilled birth attendants, and also empower midwives and women to have a better understanding of the risk that women are facing.
Experts have argued that most maternal deaths and injuries are entirely preventable with the right information, expert assessment, and healthcare.
This is one major success area of META as patients could get text messages using the Nigerian telecoms systems, thereby making it possible to provide information to patients.
“Our app is on a smartphone but we deliver texting to a variety of low-end phones. The ultimate objective is to have better care of pregnant women,” Lett said.
At Lett’s end, however, the challenges are bigger. One challenge he would need to address, in addition to the ones earlier mentioned, would be to formalise it within the curriculum of the midwifery schools, and within the Ministry of Health’s data collection system so that it is considered a regular part of their work.
Next is the inconsistency in data collection and getting the CMDS app to be officially part of Benue State and across all PHCs for true impact.
Lett said he hopes for more funding so that he can deal with the community obstacles—getting the family members of women to believe the information they receive from CMDS and acting on it.
“We need to do some community education on the whole issue,” he told BusinessDay.
Abraham Ijer, director of Nursing and Midwifery Services, Benue State Ministry of Health and Human Services, commended CNIS for bringing the project to the state.
He described it as a project that has been beneficial to people of the rural parts of the state as women can now know if their pregnancy would come with some risks.
Although CMDS is making work easy for Gboko midwives, women like Mchivir Idyondgon, who encouraged other women to key into it, stand to gain more. But much of that possibility depends on each state government.
This story was produced with the support of a reporting grant from Maternal Figures.