Arresting escalating maternal, infant mortality with life–saving drugs
RASHEEDA Bello is not the regular Hausa-Fulani woman you may have come across in your everyday life. Petit and vivacious, everyone who have come across the woman, who is in her early 20s, will certainly agreethat she is not only beautiful but also intelligent.
It is difficult to tell which is more magnetic between her ebony skin and her sonorous voice.
For many years since she got married to Bello, a security guard from Sokoto, she found it difficult to have a child. Her case was not an issue of infertility, for she had been pregnant for at least two times. But for the two times, Rasheeda lost the pregnancies.
In fact, Rasheeda who live at Kauraren Tsara, Bodinga Local Council in Sokoto, said but for the quick intervention of medical personnel, she would have been a forgotten story, while she was delivering her third child alone at home. She never envisaged any trouble lurking while embarking on the dangerous game. She had been in labour for days, but would not go to hospital.
According to her cultural beliefs, ‘real women’ do not deliver in hospital; they deliver at home. But that costly misconception nearly claimed her life. On the day she was to deliver, there was no one around, except her shadow. In fact, she was in purdah. In Sokoto of her time, that was not strange. Unaided and unattended to, Rasheeda pushed with all her strength to deliver the baby in the dingy room where she had been.
The process was not without complications though. The baby ‘died’, so Rasheeda thought.‘Not again’, she cried. It did not end there, like a mid-August rainfall, Rasheeda started bleeding profusely, experiencing what medical experts often called postpartum haemorrhage, one of the leading causes of death for women of child bearing age in Nigeria.
Rasheeda needed no one to tell that she was in trouble.Without wasting time, she raised her voice with the strength left in her by that harrowing experience. And the voice drew the attention of her neighbours and Community Based Health volunteers (CBHVs), who rushed in with a life–saving drug, misoprostol, to stop the bleeding. In a twinkle of an eye, the CBHVs faced the ‘dead baby’, applied Helping Babies Breathe (HBB) technique to bring the baby to life, and chlorhexidine, an antibacterial used as an antiseptic gel, to care for its umbilical cord.
That was in 2013. But today, Rasheeda and her baby, Musa, are not only alive but are bubbling, thanks to the assistance that came on that fateful day through the United States Agency for International Development (USAID)-funded Targeted States High Impact Project (TSHIP).
Those particular CBHVs, who saved Rasheeda and her baby, were earlier trained on various life-saving drugs and techniques in Sokoto State by TSHIP.
But how does CBHVs operate in Sokoto healthcare system?
With support from USAID/TSHIP, Sokoto worked with ward development committees to identify, train, and support 2,440 CBHVs—10 each from the state’s 244 wards—to promote positive health-seeking behaviours and extend basic health services in resource-poor areas of the state. These trusted CBHVs, all of whom are women, are the only ones who can treat women of reproductive age who observe purdah, which secludes women from public glare.
After training, each CBHV received job aids for a range of topics that include counseling, antenatal care, nutrition, birth preparedness, danger signs in pregnancy, preventing postpartum haemorrhage, umbilical cord care, exclusive breastfeeding, growth monitoring, common childhood illness management, hygiene, birth spacing, and referrals. Every month, CBHVs, who basically take healthcare services to homes, report to their supervisors, who are facility-based service providers.
Launched in 2009, TSHIP is USAID flagship project on health, population and nutrition matters being implemented by consortium led by John Snow Incorporated (JSI).
Dr Nosakhare Orobaton is USAID/TSHIP Chief of Party. Orobaton, a public health physician with a background in business management and 30 years experience in programme execution, was the Director of Operations for The Global Fund to Fight AIDS, TB and Malaria. He had managed $7.5 billion portfolio of grants to 145 countries in Africa, Asia, South and Central America, and the Caribbean before his new assignment.
Orobaton said misoprostol, chlorhexidine and HBB have been among some of the most successful culturally appropriate, low-tech and high impact intervention campaigns pioneered by USAID/TSHIP in Sokoto state.
HBB is an evidence-based neonatal resuscitation technique in resource-limited areas. The World Health Organisation (WHO) estimates that one million babies die each year from birth asphyxia- inability to breathe immediately after delivery. Such babies are often termed by the lame man as stillbirth, and where there is no expert around, such children have been declared dead (even when they have not started breathing) and buried within a twinkle of an eye. But an HBB expert can make a lot of difference to help such babies breath and live.
Orobaton said aside pushing for HBB, USAID/THSIP has been at the forefront for women’s health. He explained that with the support of USAID/TSHIP, the Sokoto government in 2013 launched the use of the two life-saving drugs, chlorhexidine and misoprostol tablets, to save newborns and mothers, thereby making Sokoto state the first government in Africa to launch the use of chlorhexidine, a gel use in umbilical cord care.
According to a study led by researchers at the Johns Hopkins Bloomberg School of Public Health in 2012,cleansing a newborn’s umbilical cord with chlorhexidine can reduce an infant’s risk of infection and death during the first weeks of life.
Misoprostol, a drug for treating postpartum bleeding, has been variously described as a miracle drug in curbing maternal deaths, a nightmare and deadly condition for women in Nigeria.
“We successfully advocated that these medicines be purchased by state governments as a demonstration of commitment to governance. We secured the trust of community who in turn found these medicines acceptable for use. We assisted the states to develop a revitalised ward development committee, which oversaw the work of supervising the distribution at the ward level. We worked with the states to train community-based health volunteers who got the medicines directly to households at the time of need. A data tracking system was also put in place and operated by community based health volunteers with support from the nearby health center in each ward,” Orobaton said.
Before the USAID/TSHIP project, Orobaton said 95 per cent of all births in Sokoto took place at home, underlying the importance of making these life-saving, low-cost drugs available to women in their homes.
Orobaton said the role of traditional rulers in the project cannot be overemphasised. “Traditional ruler, the Sultanate Council in Sokoto, Emirs in Bauchi State and district heads were critical to programme success. In both states, they were engaged very early in the programme. They helped to ensure that proper consultations were done with citizens and leaders ahead of time, to secure community trust, before the other parts of the programme commenced. District heads also played a critical role in regularly monitoring negative sentiments possibly driven by inadequate or misinformation, and proactively corrected them. Traditional rulers also worked to ensure the technical/programme grasped and were responsive to community concerns and expectations.”
The project also boasts of boosting the number of deliveries with a skilled birth attendant by 172 per cent, just as it has assisted 273,758 newborns to receive essential newborns care in Sokoto State alone.
The success of Sokoto state has been replicated byUSAID/TSHIP in Bauchi. Why Sokoto and Bauchi? You may ask.
According to Orobaton, the two states have similar health indices, including high maternal, infant, and child mortality rates. He added that in Northeast, where Bauchi is located, maternal death stands at 260 per 1,000 live births. And in Northwest, where Sokoto is, the maternal death is 269 per 1,000 live births. Moreover, skilled assisted delivery in Bauchi is 15.7 per cent, just as skilled assisted delivery Sokoto is at 5 per cent.
That is the not the end of it . About 95.3 per cent of women in Sokoto deliver at home, while 87 per cent of women deliver at home in Bauchi.
Moreover, in Sokoto, under-five mortality rate stands at 166 per 1000 live births in comparison with 100 per 1000 live births in Bauchi.The two states had one of the worst maternal and infant deaths across the federation.
But Orobaton said USAID/TSHIP is changing the negatives in both states into positives. “For misoprostol, among women who got them in both states, there has been a significant reduction in the percentage of women who reported heavy bleedings. The maternal mortality ratio is much lower than the published ratio for the state as a whole. Similarly, for chlorhexidine, we witnessed a dramatic reduction in neonatal mortality among newborns that received chlorhexidine,” Orobaton said.
Orobaton, a member of the Technical Advisory Group of the Routine Health Information Network (RHINO), is of the opinion that other states of the federation needs to use Sokoto and Bauchi model to reduce maternal and newborns death in Nigeria.
The public health physician is worried for Nigeria’s maternal and under-five mortality rates. Orobaton’s concerns are not unfounded, considering Nigeria’s bad rating in the international arena for maternal and newborns death. With only about 2 per cent of the world’s population, Nigeria ranks as the second highest in the world for maternal deaths, accounting for about 14 per cent of the global maternal burden. For instance, the 35,000 Nigerian women who died in childbirth in 2014 alone accounted for 13 per cent of the global maternal deaths that year. Health experts like Orobaton are not happy because almost all the maternal deaths in Nigeria could have been prevented.
The glooming statistics goes beyond maternal deaths. According to the United Nations Children’s Fund (UNICEF), every single day, Nigeria loses about 2,300 under-five and 145 women of childbearing age.
The UN body added that this ugly scenario “makes the country the second largest contributor to the under–five and maternal mortality rate in the world.”
Equally troubling, according to UNICEF, is that “the deaths of newborn babies in Nigeria represent a quarter of the total number of deaths of children under-five.”
USAID/TSHIP believes that the ugly scenario of maternal and newborns deaths need to be brought to an end. Orobaton said that is why USAID/TSHIP has been working to strengthen healthcare delivery in Bauchi and Sokoto States. Ultimately, the project, he said, is establishing durable bonds between community institutions and the healthcare delivery system to improve household health practices and increase people’s use of health services.
Orobaton said apart reducing maternal deaths, the USAID/TSHIP project has gone ahead to put the issue of No One Present (NOP) in the global arena. NOP practice is when a woman delivers all alone by herself without the assistance of anyone. It is a worrisome phenomenon because not only are Nigerian women predominantly using unskilled attendants, statistics have shown that one in five births are delivered with NOP. Various studies have shown that NOP is highest in the northern part of Nigeria.
Orobaton said aside increasing the use of high-impact integrated maternal, newborn, and child health (MNCH), and family planning and reproductive health (FP/RH) interventions in the Sokoto and Bauchi states, USAID/TSHIP is showing other states in the federation how to use high-impact, but low-cost strategies to reduce maternal and newborn deaths in Nigeria.
The thinking is that if any strategy can work in Sokoto and Bauchi States, the two leading states with maternal and under-five mortality rates, such strategy can work in any state of the federation. But Nigeria needs political capital to be able to do so, Orobaton said.
Deputy Chief of Party for Bauchi State, Dr Hamila Mukaddas, threw light on how government buy-in into the project made a lot of difference in Bauchi. “The government of Bauchi State clearly demonstrated leadership at the start off of the programme, not just by accepting the programme. Bauchi State Government is the second state in Nigeria that used its own funds to procure and distribute 75,000 doses of misoprostol and chlorhexidine each across the state. The state has included misoprostol and chlorhexidine in its essential drug list,”she said.
Mukaddas is a gynaecologist with more than 14 years post-graduation experience in the field of reproductive health, maternal and child health.
Excited with the success of USAID/TSHIP in Bauchi though, the public health expert said the programme and success did not come without some hiccups. One of such challenges that greeted the programme, according to Mukaddas, was the challenge of non-acceptance by the medical community. “Bauchi State was the second state after Sokoto to start such a programme. There were no local evidence to make reference to and thus the scientific world was a bit skeptical,” Mukaddas said. “Moreover, there was no community platform to deliver the intervention to the beneficiaries at the household.”
Mukaddas, who has experience in capacity building for healthcare professionals in maternal, neonatal and child health interventions, said such development did not deter the project. “We presented sufficient evidences from other developing countries to introduce the chlorhexidine cord cleansing in place of dry cord care. There were documented experiences from Nepal, Bangladesh and Pakistan. We also made references to World Health Organisation (WHO)’s recommendation for cord care when it said: daily chlorhexidine application to the umbilical cord stump during the first week of life is recommended for newborns who are born at home in settings with high neonatal mortality (30 or more neonatal deaths per 1000 live births).”
After winning the side of the medical community, “we had to strategise on how to reach every household in 323 wards of Bauchi State, ” Mukaddas said. “We assisted the state and the communities established a more vibrant community network of volunteers to assist in delivering health message at home as well as the delivery of essential commodities like misoprostol, chlorhexidine and oral rehydration salts (ORS). We encouraged the communities to select 10 reliable volunteers per ward and thus the state established 3230 Community Based Health volunteers (CBHV) responsible for delivering health messages to their respective communities. The CBHVs are linked and supervised by the health facility personnel (who serve as technical supervisors) in that community and also linked to the ward development communities (who are serving as administrative supervisors),” the health intervention expert said, adding that there have been successful stories from the intervention mechanisms. “There has been a significant reduction in incidence of postpartum haemorrhage-the major cause of maternal mortality-with the use of misoprostol, and there is improved neonatal survival following the reduction in umbilical cord sepsis (infection) with the use of chlorhexidine.”
According to Orobaton, the Sokoto state model has not gone unnoticed, for delegations from 33 states of the federation have visited the two states to see how this ground-breaking strategy works, and can be implemented in their states to reduce maternal and newborns deaths. “Part of the aspiration of working in these two states was that lessons gained would be shared with other states. This has indeed happened with 33 state government delegations having visited Sokoto State as of May 2015, to learn about the maternal and newborn efforts there.”
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