Quality of labour and uncomplicated delivery care: a formative assessment of selected health facilities in Ebonyi and Kogi States, Nigeria

Gbenga Ishola, Adebayo Olukunle Ajala, Emmanuel Ugwa, Gabriel Alobo, Ugo Okoli, Barbara Rawlins, Mark Kabue, Adebayo Oluwatobi, Adetiloye Oniyire, Emmanuel Otolorin


Maternal Child Survival Program (MCSP) worked in Ebonyi and Kogi States between 2014 to 2018 to improve quality of maternal, child and newborn health care. A formative assessment was conducted in selected health facilities to examine the quality of care received by mothers and their newborns at all stages of normal birth on the day of birth.   Health providers attending deliveries at 13 facilities in the two states were observed by trained health professionals. Forty health facilities with a high volume of at least 50 Antenatal Care visits per month and deliveries were purposively selected from 120 quality improvement health facilities. Screening for danger signs at admission was conducted for only 10.5% cases in labor and providers adhered to most recommended infection prevention standards but only washed hands before birth in 19.5% of cases. Chlorhexidine gel was applied to the newborn’s umbilical stump in only 2% cases while partograph was used in 32% of the cases. No newborns received the full package of essential care. Potentially harmful practices were observed especially holding newborn babies upside down in 32% cases. Improved provider training and mentoring in high-quality care on the day of birth and strengthened supportive supervision may help to reduce maternal and newborn morbidity and mortality. (Afr J Reprod Health 2020; 24[4]:69-81).

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Canavan ME, Brault MA, Tatek D, Burssa D, Teshome

A, Linnander E and Bradley EH Maternal and neonatal services in Ethiopia: measuring and improving quality Bull World Health Organ 2017;95:473–477 http://dx.doi.org/10.2471/BLT.16.178806 Accessed April 23, 2020

Sharma G, Powell-Jackson T, Haldar K, Bradley J, and

Filippi V Quality of routine essential care during childbirth: clinical observations of uncomplicated births in Uttar Pradesh, India. Bull World Health

Organ 2017; 95:419–429 Retrieved from http://dx.doi.org/10.2471/BLT.16.179291 Accessed April 23, 2020

Sharma G, Mathai M, Dickson KE, Weeks A, Hofmeyr

G, Lavender T, Day LT, Matthews JE, Fawcus S, Simen-Kapeu A and de Bernis L. Quality care during labour and birth: a multi-country analysis of health system bottlenecks and potential solutions. BMC Pregnancy Childbirth. 2015;15(S2) Suppl 2: S2. www.biomedcentral.com/1471-2393/15/S2/S2 Accessed April 23, 2020

UNICEF. Trends in maternal mortality: 1990 to 2015;

estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva, Switzerland: WHO, 2015. https://data.unicef. org/wp-content/uploads/2015/12/Trends-in-MMR-1990-2015_Full-report_243.pdf. Accessed July 30, 2019.

United Nations. SDG indicators: global indicator

framework for the Sustainable Development Goals and targets of the 2030 Agenda for Sustainable Development. United Nations website, 2019. https://unstats.un.org/sdgs/indicators/indicators-list/. Accessed July 30, 2019.

Abegunde D, Orobaton N, Shoretire K, Ibrahim M,

Mohammed Z, Abdulazeez J, Gwamzhi R and Ganiyu A. Monitoring maternal, newborn, and child health interventions using lot quality assurance sampling in Sokoto State of northern Nigeria. Global Health Action 2015;8:27526. doi: 10.3402/gha.v8.27526.

Lawn JE, Lee ACC, Kinney M, Sibley L, Carlo WA,

Paul VK, Pattinson R and Darmstadt GL. Two million intrapartum‐related stillbirths and neonatal deaths: where, why, and what can be done? International Journal of Gynaecology and Obstetrics 2009;107: S5-19. doi: 10.1016/j.ijgo.2009.07.016

Lawn JE, Kinney M, Lee ACC, Chopra M, Donnay F,

Paul VK, Bhutta ZA, Bateman M and Darmstadt GL. Reducing intrapartum-related deaths and disability: can the health system deliver? International Journal of Gynaecology and Obstetrics 2009;107: S123-40, S140-2. doi: 10.1016/j.ijgo.2009.07.021.

Tunçalp Ӧ, Were WM, MacLennan C, Oladapo OT,

Gulmezoglu AM, Bahi R, Daelmans B, Mathai M, Say L, Kristensen F, Temmerman M and Bustreo F. Quality of care for pregnant women and newborns—the WHO vision. BJOG 2015;122:1045-9. doi: 10.1111/1471-0528.13451.

Smith H, Asfaw AG, Aung KM, Chikoti L, Mgawadere

F, d’Aquino L and van den Broek N. Implementing the WHO integrated tool to assess the quality of care for mothers, newborns and children: results and lessons learnt from five districts in Malawi. BMC Pregnancy Childbirth 2017;17:271. doi: 10.1186/s12884-017-1461-y.

Igwebueze OI. Clinical audit of the quality of intrapartum

care in a state university teaching hospital, Enugu, Southeast, Nigeria. J Women’s Health Care 2015;4:249. doi: 10.4172/2167-0420.1000249.

World Health Organization (WHO). Standards for

improving quality of maternal and newborn care in health facilities. Geneva, Switzerland, 2016. https://www.who.int/maternal_child_adolescent/documents/improving-maternal-newborn-care-quality/en/. Accessed July 30, 2019.

National Population Commission (NPC) [Nigeria] and

ICF International. Nigeria Demographic and Health Survey 2013. Abuja, Nigeria: NPC and ICF International, 2014. https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf. Accessed July 30, 2019.

African Population and Health Research Center

(APHRC). Maternal health in Nigeria: facts and figures. Nairobi, Kenya: APHRC, 2017. http://aphrc.org/wp-content/uploads/2017/06/APHRC-2017-fact-sheet-Maternal-Health-in-Nigeria-Facts-and-Figures.pdf. Accessed August 6, 2019.

Rasolofomanana JR, Rakotovao JP, Bazant E and

Tripathi V. Quality of care of the prevention and management of common maternal and newborn complications in health facilities in Madagascar. Baltimore, MD: Jhpiego, 2011. https://www.mchip.net/ sites/default/files/Madagascar QoC report-Final.pdf. Accessed July 30, 2019.

Ngabo F, Zoungrana J, Faye O, Rawlins B, Rosen H,

Levine R, Sethi R, MacDowell J, Arscott-Mills S, and Basinga P. Quality of care for prevention and management of common maternal and newborn complications: findings from a national health facility survey in Rwanda. Baltimore, MD: Jhpiego, 2012. https://www.mchip.net/sites/default/files/Rwanda_QoC.PDF. Accessed July 30, 2019.

Getachew A, Ricca J, Cantor D, Rawlins B, Rosen H,

Tekleberhan A, Bartlett L and Gibson H. Quality of care for prevention and management of common maternal and newborn complications: a study of Ethiopia’s hospitals. Baltimore, MD: Jhpiego, 2011. https://www.mchip.net/sites/default/files/Ethiopia_QoC_formatted_final.pdf. Accessed July 30, 2019.

Harrell CR, Gladwin B, and Hoag MP. Mitigating the

“Hawthorne Effect”. In Pasupathy R, Kim SH, Tolk A, Hill R, and Kuhl ME (Eds). Simulation Studies Proceedings of the 2013 Winter Simulation Conference 978-1-4799-2076-1/13 IEEE

Tripathi V. The Labor and Delivery Quality of Care

Short Observational Index: A User Guide – How to Apply an Innovative Tool for Observation-Based Assessment of Facility-Based Care for Mothers and Newborns. Maternal and Child Health Integrated Program, (MCHIP), Maternal and Child Survival Program (MCSP) 2016. www.mcsprogram.org Accessed April 25, 2020

Haws RA, Yakoob MY, Soomro T, Menezes EV,

Darmstadt GL, and Bhutta ZA. Reducing stillbirth: screening and monitoring during pregnancy and labour BMC Pregnancy and Childbirth 2009 9(Suppl 1)SS doi:10.1186/1471-2393-9-S1-S5. Retrieved from www.biomedcentral.com/1471-2393/9/S1/S5 Accessed April 24, 2020

Okonofua F, Okpokunu E, Aigbogun O, Nwandu C,

Mokwenye C, Kanguru L and Hussein J. Assessment of infection control practices in maternity units in Southern Nigeria International Journal for Quality in Health Care 2012 24(6):634-640

Iliyasu G, Dayyab FM, Habib ZG, Tiamiyu AB,

Abubakar S, Mijinyawa S, and Habib AG. Knowledge and Practices of Infection Control Among Healthcare Workers in a Tertiary Referral Center in North-Western Nigeria. Ann Afr Med 2016;15:34-40. doi: 10.4103/1596-3519.161724.

Osuala EO, and Oluwatosin OA. Infection control by

nurses in selected hospitals in Anambra State, Nigeria. Trop J Med Res 2017;20:53-60. doi: 10.4103/1119-0388.198122.

Esan OT and Fatusi AO. Performance needs assessment

of maternal and newborn health service delivery in urban and rural areas of Osun State, South-West, Nigeria. Afr J Reprod Health 2014;18(2):105-16. https://www.ajol.info/index.php/ajrh/article/viewFile/104431/94514. Accessed July 30, 2019.

Yisma E, Dessalegn B, Astatkie A, and Fesseha N.

Completion of the modified World Health Organization (WHO) partograph during labour in public health institutions of Addis Ababa, Ethiopia. Reprod Health 2013;10:23. doi:


Iyengar K, Jain M, Thomas S, Dashora K, Liu W, Saini

P, Dattatreya R, Parker I, and Iyengar S. Adherence to evidence-based care practices for childbirth before and after a quality improvement intervention in health facilities of Rajasthan, India BMC Pregnancy and Childbirth 2014, 14:270 http:www.biomedcentral.com/1471-2393/14/270 Accessed on

April 25, 2020

Souza JP, Oladapo OT, Bohren MA, Mugerwa K, Fawole

B, Moscovici L, Alves D, Perdona G, Oliveira-Ciabati L, Vogel JP, Tuncalp O, Zhang J, Hofmeyr J, Bahl R, and Gulmezoglu AM. The development of a Simplified, Effective, Labour Monitoring-to-Action (SELMA) tool for Better Outcomes in Labour Difficulty (BOLD): study protocol. Reprod Health 2015;12:49. doi: 10.1186/s12978-015-0029-4.

Litwin LE, Maly C, Khamis AR, Hiner C, Zoungrana J,

Mohamed K, Drake M, Machaku M, Njozi M, Muhsin S.A, Kulindwa YK, and Gomez PP. Use of an electronic partograph: feasibility and acceptability study in Zanzibar, Tanzania. BMC Pregnancy Childbirth 2018;18:147. doi: 10.1186/s12884-018-1760-y.

Orobaton N, Abegunde D, Shoretire K, Abdulazeez J,

Fapohunda B, Lamiri G, Maishanu, A, Ganiyu A, Ndifon E, Gwamzhi R. and Osborne-Smith M. A Report of At-Scale Distribution of Chlorhexidine Digluconate 7.1% Gel for Newborn Cord Care to 36,404 Newborns in Sokoto State, Nigeria: Initial Lessons Learned. PLoS One 2015;10:e0134040. doi: 10.1371/journal.pone.0134040.

Abegunde D, Orobaton N, Beal K, Bassi, A, Bamidele

M, Akomolafe T, Ohanyido F, Umar-Farouk O. and Danladi S. Trends in newborn umbilical cord care practices in Sokoto and Bauchi States of Nigeria: the where who, how what and the ubiquitous role of traditional birth attendants; a lot of quality assurance sampling survey. BMC Pregnancy Childbirth

;17:368. doi: 10.1186/s12884-017-1551-x.

Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK,

Souza JP, Aguiar C, Coneglian FS, Luiz, A, Diniz A, Tuncalp O, Javadi D, Oladapo OT, Khosla R, Hindn MJ, and Gulmezoglu AM. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med 2015;12:e1001847. doi: 10.1371/journal.pmed.1001847.

Bohren MA, Vogel JP, Tunçalp Ö, Fawole B, Titiloye

MA, Olutayo AO, Ogunlade M, Oyeniran AA, Osunsan OR, Metiboba L, Idris HA, Alu FE, Oladapo OT, Gulmezogglu AM and Hindin MJ. Mistreatment of women during childbirth in Abuja, Nigeria: a qualitative study on perceptions and experiences of women and healthcare providers. Reprod Health 2017;14:9. doi: 10.1186/s12978-016-0265-2.

Sacks E. Defining disrespect and abuse of newborns: a

review of the evidence and an expanded typology of respectful maternity care. Reprod Health 2017;14:66. doi: 10.1186/s12978-017-0326-1.

Rosen HE, Lynam PF, Carr C, Reis V, Ricca J, Bazant

ES, and Bartlet LA. Direct observation of respectful maternity care in five countries: a cross-sectional study of health facilities in East and Southern Africa. BMC Pregnancy Childbirth 2015;15:306. doi: 10.1186/s12884-015-0728-4.


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