Introducing early warning systems to reduce maternal deaths in Nigeria

Globally, maternal mortality ratio (MMR) has fallen by almost 50 percent since 1990. Despite this progress, there are still significant inequalities in the quality of care available to mothers and babies worldwide. MMR in low- and middle-income countries is 14 times higher than in high-income regions.

One of the proposed strategies to reduce maternal deaths has been by Obstetric Early Warning Systems (EWS). These systems assign weighted values to few parameters based on their degree of deviation from normal, and define thresholds beyond which mandatory actions must be taken to prevent irreversible morbidity or death. Although EWS are useful in reducing maternal deaths and are widely used in maternal care in the UK and other high-income countries, there is limited use in low- and middle-income countries like Nigeria. This PhD research project aims to introduce and evaluate the use of obstetric early warning systems in Nigerian hospitals.


The research is in three phases:

  • Phase one assessed the feasibility of using early warning systems in three purposefully selected health facilities in regions of Nigeria with the highest maternal mortality ratio. Scoping activities undertaken during this phase included observation of maternal monitoring practices, focus group discussions and key informant interviews of midwives and doctors.
  • Phase two covers design and validation of an obstetric early warning chart for use in resource limited settings based on well-established statistical methods. Secondary data consisting of 2440 maternal deaths and near-misses prospectively collected in a country-wide cross-sectional study of 42 tertiary facilities in Nigeria has been secured for this phase.
  • Finally, the designed obstetric early warning chart will be implemented in a quasi-experimental study involving three tertiary facilities in northern Nigeria (phase 3). Effectiveness in reducing adverse maternal outcomes and perceived usefulness among healthcare professionals will be assessed using mixed methodology (quantitative and qualitative methods, respectively).