Revolutionizing Care: Integrated Networks for Maternal and Newborn Health in Nigeria

As I continue to reflect on the challenge of the maternal mortality crisis we face in Nigeria, I have been thinking about implementable, measurable, and results-focused practical system-level solutions. To reiterate, it is unacceptable that pregnancy in Nigeria comes with a high risk of death for women of all shapes and sizes. While there is a huge disparity between rich and poor, uneducated and educated, rural and urban women, the most recent data about our maternal mortality ratio is that we lose more than 1000 women for every 100,000 live births in Nigeria. Globally, we have the third highest Maternal mortality ratio after South Sudan and Chad. The World Health Organization categorizes Nigeria as one of the three countries with Extremely High rates of maternal mortality. Let this sink in for a minute.

One concept that could be revolutionary for the Nigerian context is the “Networks of Care” (NOCs). This innovative service delivery model has the potential to transform the antenatal to postnatal care continuum, addressing the country’s maternal mortality crisis. Imagine a Nigeria where every pregnant woman and newborn receives high-quality, respectful, and dignified care and where healthcare providers are united in their mission to prevent avoidable deaths. This is the vision that the NOC model can bring to reality.

What would this look like in practice, and why would it work?

The Networks of Care concept is about a model of care where there are deliberate interlinkages between providers of maternal and newborn care services across and within levels of the healthcare system, which are coordinated and adaptive to deliver patient-centered, respectful care. This may sound academic and too technical, so let me break it down using a hypothetical example.

Imagine this scenario in a state of your choice in Nigeria.

The state has a network of registered providers at different levels who are trained for their level and certified to provide specific types of services, which range from antenatal care and pregnancy counseling services to normal deliveries, as well as management of complicated deliveries, newborn care, postnatal care, and immunization services. Across this state, the following types of providers are included and registered in this network: 1) Community health workers (anybody who is not formally trained to deliver healthcare services), 2) Local Chemists and Pharmacies, 3) Primary healthcare centers, 4) Private clinics and hospital, 5) Secondary healthcare centers or General hospitals, and 6) Our tertiary hospitals or Federal medical centers. These providers are all interconnected by a common code of conduct to ensure that no pregnant woman dies from preventable causes, all newborns and pregnant women receive high quality, respectful, and dignified care, and joint accountability for achieving a high-performing healthcare system for maternal and newborn health. Not only do they have a common code of conduct, but they all know the other providers registered on the network, what type of care they are allowed/certified to provide, i.e., their limits, and where to refer cases beyond their capacity to manage. The patients also have access to the database of the providers in this network and know what kind of service they can access at what level and where to go, depending on their level of gestation at the first point of entry into the system.

The providers are connected by a common health information exchange platform that makes the communication and transfer processes seamless for the patients and providers. It does not matter where a mother and her child enter the system; they will receive timely care that builds on the care they had previously received. Of course, there is an emergency transportation system where patients with emergencies who are unable to physically transport themselves for specialized services receive timely transportation to the next level where this care would be provided.

This group of providers also regularly meets through several platforms to discuss operational and clinical challenges, identify cases of maternal or newborn deaths that could have been avoided, and jointly problem-solve to generate emerging solutions and ways to strengthen their code of conduct and SOPs over time.

Finally, imagine that in this system, every registered provider who is part of the network, irrespective of their affiliation, public or private, is reimbursed through a fee-for-service payment scheme for every maternal and newborn case managed with additional performance incentives linked to key metrics like 1) completion of all ANC visits and timely adherence to treatment protocols for high-risk pregnancies, 2) Completion of all immunization sessions for pregnant mothers and their infants up to the age of 1 year or 18 months, 3) proportion of pregnant women identified who receive a facility birth and return for other PNC services such as family planning, or management of postnatal mental health conditions e.t.c. All pregnant women and their infants are guaranteed free, government-covered healthcare services throughout their pregnancies and up to 18 months. This coverage is irrespective of income, location, or other demographics. All you need to do is register with the provider nearest to you, stay in the network, and continue receiving care as required. You also do not have to worry about buying any supplies for your baby’s birth nor worry about buying immediate post-delivery items like a warm blanket, diapers, baby food (where the mother cannot nurse through breastfeeding immediately after birth), or even the baby’s first set of clothes because these would be provided for every birth.

How wonderful would this state be for pregnant women, mothers, and infants? Not only will there be a drastic decline in the number of maternal and newborn deaths, but there will be improved healthcare worker well-being and satisfaction and a resilient healthcare system that is responsive to the needs of one of the most vulnerable groups in society. This system will also be a continuous learning system that serves as a foundation to layer more complex healthcare services over time.

I know it sounds daunting or impossible, but this is what obtains in other climes that many of the more affluent Nigerians choose to go and deliver their children. Why can’t we replicate the same in our country? There are five critical factors that can make this possible in our context:

1. A strong coordination platform with excellent managerial capacity and governed like a business entity. Unlike a corporate business, the focus is not on monetary ROIs but on maternal and newborn mortality reduction targets and improved health outcomes. Cost savings for the healthcare system would be one of the longer-term KPIs. This could be one of the existing platforms (agencies or boards) or a newly created board to oversee this integrated network.

2.????? An Electronic register for all pregnant women or an information exchange platform where existing Electronic Medical Records (EMRs) can communicate and share data, similar to what currently exists in the banking system in Nigeria, where we can search for other people’s banks accounts and transfer funds between banks.

3.????? A clear policy about reducing preventable maternal and newborn deaths. These don’t have to be fancy or lengthy documents but simple vision and mission statements that everyone can understand and interpret, which literally become the mantra for the provider network, the patients, and the communities. This policy is accompanied by the code of conduct, the SOPs, and other critical guidelines that define how services are organized and how relationships across and within levels are managed. They should be transparent and available for all network stakeholders to access and refer to regularly.

4.????? Adequate resource allocation and efficient use of the resources towards the common goal of saving mothers' and infants' lives. We need to determine the average cost of providing care to a mother-infant dyad with complications or uncomplicated where mothers and babies do not bear any financial burden. This cost should account for compensating all providers fairly for services provided and incentivizing providers at different levels to prioritize quality and equitable care. For example, suppose registered community health workers receive payment for every woman enrolled in the network within the first trimester who completes her ANC visits and delivers at a health facility with complete records of all the services received. In that case, we will see many pregnant women enrolled in the state network of integrated maternal and newborn health care. Or hospitals that receive adequate fee-for-service reimbursement for every delivery taken so that they can stock up with all necessary supplies, drugs, and instruments/equipment to continue to take deliveries and pay their doctors, nurses, and other staff adequately. We may start to see the end of mothers being given a list of everything from buckets to water to gauze, cotton pads, and bleaching agents to buy for their child's birth. We could also start having bed covers on the delivery beds and adequate drapes for patients in many of our health centers and hospitals.

5.????? Strong community engagement from co-design to implementation of this network, ensuring community leaders, pregnant women, intending mothers, and other community members are involved in the design, implementation, and evaluation.