|
 
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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 7
| Issue : 2 | Page : 55-71 |
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Improving maternal, newborn and child health care in Nigeria – A medical women's association of Nigeria multi-centre study
Bobola Iyabo Agbonle1, Mininim Ibiere Oseji1, Glory David Essien2, Laadi Terrumun Swende3, Ngozi Emma-Nzekwue4, Ezinwanne Eunice Idih5, Anisah Yahya6, Mosunmola Rafiat Folorunsho7, Mary Esin Dirisu8, Omolara Adenike Olusola-Taiwo9, Vetty Agala10, Fatimah Yalaraba Abdulqadir11
1 Medical Women's Association of Nigeria, National Secretariat, Abuja, Nigeria
2 Medical Women's Association of Nigeria, Akwa-Ibom, Nigeria
3 Medical Women's Association of Nigeria, Benue, Nigeria
4 Medical Women's Association of Nigeria, Delta, Nigeria
5 Medical Women's Association of Nigeria, Imo, Nigeria
6 Medical Women's Association of Nigeria, Kaduna, Nigeria
7 Medical Women's Association of Nigeria, Kwara, Nigeria
8 Medical Women's Association of Nigeria, Niger, Nigeria
9 Medical Women's Association of Nigeria, Oyo, Nigeria
10 Medical Women's Association of Nigeria, Rivers, Nigeria
11 Medical Women's Association of Nigeria, Zamfara, Nigeria
| Date of Submission | 04-Jun-2023 |
| Date of Decision | 26-Jun-2023 |
| Date of Acceptance | 07-Aug-2023 |
| Date of Web Publication | 04-Sep-2023 |
Correspondence Address:
Dr. Bobola Iyabo Agbonle
Delta State University, Abraka, Delta State
Nigeria
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jmwa.jmwa_8_23
BACKGROUND: The adopted health facility pilot demonstration programme was targeted to achieve sustainable development goals 3 and 5. Nigeria is one of the countries with poor maternal, newborn/child health outcomes – over 800 maternal deaths per 100,000; under-5 mortality 113–200/1000 live births; NMR of 36/1000 live births. Improving health indices through clinical monitoring, reducing neonatal tetanus (NT) risk factors and health systems strengthening can improve MNCH indicators. These factors were considered in the program and indicators were related to Medical Women's Association of Nigeria's themes/subthemes.
METHODS: Interested states were given a letter of introduction to their selected health facility, a plaque to mount in the facility and a template for data submission. Data were sent from facility focal persons through the State Presidents to the National Coordinator, collated and analysed from January 2020 to December 2021. Data were used to track MNCH indicators and intervene. Interventions implemented included training on Strengthening Health Systems, supportive supervision, provision of commodities, for example, chlorhexidine gel, flier distribution and airing jingles. Monthly Monitoring/Evaluation Sessions started from January 2021 for dissemination to stakeholders and receiving feedback. A major intervention was sensitisation on family planning (FP), maternal/NT elimination, female genital mutilation, HIV/AIDS during 2021 World Population Day commemoration.
RESULTS: The project involved 16 health facilities in 14 states. The results of 12 health facilities from 10 States are being presented in this article. There was a marked reduction of NT cases from 16 in 2020 to 3 in 2021. After WPD activities, 10 states had increased contraceptive utilisation. Lack of FP commodities, insecurity and COVID-19 negatively affected FP uptake in four facilities. Facilities increased food demonstrations after supportive supervision.
CONCLUSION: This project demonstrates that instituting an efficient all-embracing monitoring/evaluation system in the health sector using objectively verifiable indicators, can contribute to improving health indices of African nations such as Nigeria. Keywords: Adopted facility, maternal health, Nigeria, pilot project, tetanus
How to cite this article:
Agbonle BI, Oseji MI, Essien GD, Swende LT, Emma-Nzekwue N, Idih EE, Yahya A, Folorunsho MR, Dirisu ME, Olusola-Taiwo OA, Agala V, Abdulqadir FY. Improving maternal, newborn and child health care in Nigeria – A medical women's association of Nigeria multi-centre study. J Med Womens Assoc Niger 2022;7:55-71 |
How to cite this URL:
Agbonle BI, Oseji MI, Essien GD, Swende LT, Emma-Nzekwue N, Idih EE, Yahya A, Folorunsho MR, Dirisu ME, Olusola-Taiwo OA, Agala V, Abdulqadir FY. Improving maternal, newborn and child health care in Nigeria – A medical women's association of Nigeria multi-centre study. J Med Womens Assoc Niger [serial online] 2022 [cited 2023 Sep 26];7:55-71. Available from: http://www.jmwan.org/text.asp?2022/7/2/55/385159 |
| Introduction | |  |
Medical Women's Association of Nigeria (MWAN) is a non-political, non-sectarian, non-profit making organisation of qualified and duly registered female Medical and Dental Doctors in Nigeria. The Association is dedicated to the promotion and improvement of health, especially in women and children, improving professional development and personal well-being of her members and increasing the influence of women in all the aspects of the medical profession. The association has been carrying out programmes targeted at achieving the sustainable development goals (SDG) 3 and 5 (good health and well-being and gender equality).[1]
Nigeria as of 2021 had a population of over 200 million people and is multicultural (over 250 ethnic groups and over 500 languages).[2] Nigeria has six geopolitical zones with Muslims more in the Northern zones and Christians in the southern zones.
This project was a pilot programme that spanned 2 years – 2020 and 2021 in 12 facilities in 10 States of Nigeria where the Medical Women's Association of Nigeria had State branches, with the following aims:
- To conduct needs assessment to identify where interventions are required using specific indicators including those of the SDGs
- To create the awareness of the prevention of HIV/AIDS and unwanted pregnancies in the places where facilities are located
- To implement relevant interventions at the facilities, such as training, provision of medical equipment and consumables, provision of fliers for health education, as well as supportive supervision
- To improve the indices of maternal, newborn and child health in 12 health facilities in 10 selected States of Nigeria between January 2020 and December 2021.
| Methodology | | |
A total of 16 health facilities in 14 States were chosen for the project based on the availability of the State President and focal person to access the facility. The results of the 12 health facilities from 10 States are being presented in this article.
A signage plaque bearing the name of the association was mounted in a visible area of the health facility for identification purposes. Letters requesting use of the facilities were duly presented to facility authorities for approval of the program to be carried out in the facility.
Facility focal persons were appointed by State Presidents and were then given a specific format to submit their data monthly. Although not all started the project the same time, they were all required to submit the full data for January 2020 to December 2021 latest by January 2022. Data were submitted by the Facility focal persons to the National Coordinator with the concerned State President and National President being aware of submissions. Data were collated on a monthly basis and then posted online on MWAN WhatsApp group pages to allow members throughout the nation to be informed of the progress, and also disseminated through the monthly Monitoring and Evaluation (M and E) that took place virtually from January 2021 to September 2021 for dissemination of the findings to stakeholders and receiving feedback.
Activities carried out included:
- Trainings and health information
- Provision of medical commodities
- Supportive supervision
- Data accumulated from the reports for informed needs assessment.
Each facility was given the following information, education and communication (IEC) materials:
- FLIERS
- Family planning (FP) and its benefits
- Don't circumcise female children
- How to be free of HIV/AIDS
- About HIV/AIDS
- The Nigerian Urban Reproductive Health Initiative 2 getting it together books
- Facts about tetanus
- Male involvement in maternal and child health
- Gestational diabetes mellitus
- Post-partum cardiomyopathy
- Bagging waste
- Managing medical waste.
- VIDEOS.
- MWAN FGM jingle
- MWAN HIV/AIDS Jingle
- MWAN maternal and newborn tetanus elimination jingle
- MWAN FP jingle.
Data from the pilot programme covered FP activities, tetanus indicators, births and infant and young child feeding practices, maternal and neonatal mortality and advocacy. FP activities included old and new FP users, along with sensitization on FP to the community/clinic/organisations. Births included live births and reports of neonatal deaths. The feeding practices included data on number of babies' breast fed within 1 h of delivery and food demonstrations carried out in the facility [Annexure 1].
Interventions implemented included online training on Strengthening Health Systems for the facility focal persons, provision of commodities, for example, chlorhexidine gel to a State with high neonatal tetanus (NT) cases, provision of fliers to each facility for distribution to clients, provision of health jingles that were aired in facilities, schools and places of worship and also supportive supervision. Advocacy on any of the findings above was also included. A major intervention was a facility wide sensitisation on FP, maternal/NT elimination, female genital mutilation, HIV/AIDS during the July 2021 World Population Day (WDP) commemoration.
Each focal person was supported with N2,000 (Two Thousand Naira) monthly to cover cost of sending information and to encourage them for gathering the data, starting from the month the project commenced in the health facility. All focal persons that attended the online training on Strengthening Health Systems were paid Two Thousand Naira only (N2000) for data usage.
Expedited ethical approval was obtained from the various States Research and Ethics Committees: Research and Ethics committee, Federal Medical Centre (FMC), Gusau, Zamfara State; Health and Research Ethics Committee (HREC), FMC, Owerri, Imo State; HREC, FMC, Markurdi, Benue State; HREC of Kaduna State Ministry of Health, Kaduna State; Oyo State Ethics Review Committee, Department of Planning, Research and Statistics Division, Oyo State Ministry of Health, Ibadan, Oyo State; Akwa-Ibom State HREC, Dept of Planning, Research and Statistics, Akwa-Ibom State Ministry of Health, Uyo, Akwa-Ibom State; Kwara State Ministry of Health ERC, Ilorin, Kwara State; Niger State Ministry of Health ERC, Minna, Niger State; Delta State Ministry of Health RHC, Asaba, Delta State; HREC Rivers State Hospitals Management Board, Port Harcourt, Nigeria.
| Results | | |
All facilities reported 24 months with the exception of Oyo reported 23 months due to inability to get data as the staff in charge was on maternity leave. The facilities included 8 Primary Health Care Centres, 2 Federal Medical Centres and 1 General Hospital. All results, intervention reports and world population activity reports here are from the needs assessments collated from these facilities.
[Table 1] and [Table 2] present the adopted health facilities reports from 2020 January to December 2021. | Table 1: Report of adopted health facilities as at December, 2021 (Part A)
Click here to view |
 | Table 2: Report of adopted health facilities as at December 2021 (Part B)
Click here to view |
Family planning
The grand total for new acceptors was 8,929 and FP revisits were 12,690 in 2020 as compared to 8,516 new acceptors and 13,539 revisits of 2021. For new acceptors that of 2020 was higher with a 4.6% drop in 2021 and 6.6% increase for revisits in 2021. Uptake increased in 9 out of the 12 facilities namely Kwara (36.4%), Delta (Idumuje –Unor) (292%), Oyo (3.8%), Kaduna (7.2%), Benue (12.6%), Rivers (256.3%), Edo (68.1%), Akwa-Ibom (5.6%) and Delta (Utagba-Unor) (24.1%).
Four facilities (Niger [51.5%], Zamfara [14.1%], Imo [16.2%] and Delta (Ubeji) [45.5%]) experienced lower uptake.
FP revisits were increased in 7 centres Delta (Idumuje-Unor), Kaduna, Benue, Rivers, Akwa-Ibom, Imo, Delta (Ubeji).
Kwara, Oyo, Delta (Utagba-Unor), Niger and Zamfara had a drop in revisits.
Sensitization programmes on FP organised for community groups and faith-based organisations monthly.
Kwara had an improvement in the sensitisation as the clinic did sensitisations on a daily bases every week for 11 months in 2021 (totaling 220) as compared to none at all the previous year. Delta (Idumuje-Unor) doubled their sensitisation, while Rivers had 70 as against none the previous year. Akwa-Ibom had a 68.75% increase. A grand total of 122 in 2020 and 401 in 2021, which is an over 300% increase of sensitisation programmes.
Tetanus toxoid vaccination coverage
Almost all states had tetanus toxoid vaccination programmes. The challenge of reporting in disaggregated form (Td1 – Td5) was overcome by the second half of 2020 and all sates reported in disaggregated form by 2021.
Number of secondary school girls from 15 years and above mobilised to take Td1 to Td5 – 6 facilities [Kwara, Delta (Idumuje-Unor), Oyo, Benue, Delta (Utagba-Unor) and Delta (Ubeji)] were involved in giving Tetanus toxoid to secondary school girls. These included mobilisation and some [at Delta (Ubeji)] were given as a result of injuries sustained by the students.
Maternal and neonatal tetanus
A total of 14 NT cases from Zamfara[3] in 2020 with an 86% reduction in 2021-Zamfara.[2] There was one case of maternal tetanus in Zamfara in 2020 none was reported in 2021.
Maternal and neonatal deaths
A total of 48 maternal deaths were seen in Benue, Zamfara and Imo in 2020, while 31 occurred in 2021 this indicated a 35.4% reduction in maternal deaths.
Neonatal deaths totaled 144 in 2020 and 180 in 2021 (25.0% increase).
In 2020, there were 4129 live births recorded, while in 2021, there were 10,521 live births recorded. This gave a neonatal mortality rate (NMR) of 34.9 deaths/1000 live births for 2020 and 17.1 deaths/1000 live births for 2021.
Food demonstrations
Number of food demonstrations done per month increased in 2021. In 2020, the grand total was 1231 while in 2021 it rose to 3790 which was a 208% increase.
States that increased the food demonstrations include Kwara, Oyo, Kaduna, Benue, Zamfara, Rivers and Akwa-Ibom.
States that had the same frequency include Delta (Idumuje-Unor) and Niger.
Reduced number of demonstrations occurred in Cross River and Delta (Utagba-Unor) facilities.
None were done in four facilities-Imo and Delta (Ubeji).
The Kaduna State MWAN leadership taught mothers how to prepare a nutritious meal for weaning babies (young child feeding practices) and made an online video for circulation. The verbal report is that food demonstrations have continued in the Kaduna adopted facility without support of the initiators and mothers attending the centre know how to make nutritious meals for their infants with locally sourced affordable items.
Advocacy
Advocacy was achieved by State representatives in Kwara, Kaduna, Cross River, Benue, Niger, Zamfara, Rivers, Imo, Delta (Utagba-Unor).
Interventions
A series of interventions was carried out based on urgency, cost and schedule.
A virtual training for focal persons of adopted health facilities on Health Systems Strengthening took place on 23rd January 2021 via zoom. Topics included Social Mobilisation for Health and Health Data Management; Mental health; Essential Newborn Care (ENC) and Chlorhexidine, Teething; ICT.
Supply of one thousand tubes of chlorhexidine gel to FMC, Gusau, Zamfara State (Zamfara Adopted health facility). This resulted in collaboration between the PHC Agency (PHCA) Zamfara state and MWAN. The Zamfara State Commissioner of Health, Executive Secretary PHCA and Director Public Health Zamfara State joined to receive the gel. It was distributed to 14 LGAs depending on the cases reporting to the facility.
Monthly M and E also by zoom were carried out from January 2021 to September 2021. Through this means stakeholders in health were provided information on the data received from the adopted facilities.
A breastfeeding support group was initiated in Delta (Idumuje-Unor) facility on 27th August, 2020. It was attended by 16 mothers and 16 babies and facilitated by 2 members of MWAN.
During a supervisory visit by the National President of MWAN, a baby with cleft palate was identified in Delta (Idumuje-Unor) facility and was supported with baby formula. The child was referred to the Smile Train program[4] which provided corrective surgery for the child free of charge.
World Population Day activities
To mark the WDP 2021 all the 12 adopted health facilities participated. Each facility was provided with a banner, between 80 and 100 fliers each on FP and NT elimination (of which some facilities made more copies), 4 jingles – Female Genital Mutilation, HIV/AIDS, FP, elimination of NT (to be played for the participants), a letter of introduction for the school, and house of worship, and the National President's address for the WDP 2021 (to be read out).
All the facilities participated and ran the program in either or all of three places viz: the health facility, a place(s) of worship and a school.
The program held from 12th July 2021 to 29th July 2021 in the different States/facilities. Indigenous languages were used at many of the places to read the letter and explain the purpose of marking the day.
A total of 8 schools, 11 health facilities (including the adopted facilities) and 9 places of worship. Due to religious restrictions, no mosque was visited.
A total of at least 2814 individuals were sensitised and at least 2212 fliers (maternal and NT elimination, FP) were shared.
[Table 3] (WDP activity). | Table 3: World Population Day activity table (arranged according to dates of activities)
Click here to view |
| Discussion | | |
In this discussion, each subheading addresses the needs assessment that was used in this study.
The importance and interest in Maternal Neonatal and Child Health (MNCH) is increasing with Nigeria having 800 maternal deaths per 100,000 live births;[5] an under-5 mortality of 113–200/1000 live births;[6],[7] and a NMR of 36/1000 live births[8] despite efforts at reduction from government, international organizations, professional bodies and non-governmental organizations. The WHO has laid down indicators and strategies which this project focused on, so as to ultimately improve the present Nigerian health indices. The WHO indicators and strategies include global elimination of maternal and NT,[9] SDG 3.1 – reducing the global MMR to <70/100,000 live births, with no country having a maternal mortality rate of more than twice the global average[10] and SGD 3.7 by 2030 ensure universal access to sexual and reproductive healthcare services, including FP, information and education and the integration of reproductive health into national strategies and programmes.[11]
A systemic review by Kana et al.[12] noted that MNCH indicators in Nigeria had been poor in the 1990s and while most interventions took place from 2000 there was not much improvement. The M and E efforts to improve MNCH indices using available data is accepted as an important intervention[13],[14] as well as health system strengthening programs[14]/clinical mentoring.[15] Unfortunately, M and E in most African countries is problematic due to poor data collection and analysis.[3],[11] Friberg et al.[14] estimated that nearly 4 million mothers, neonates and children could be saved by MNCH interventions in sub-Saharan Africa if 90% of families were reached and facility-based interventions could result in 26% decrease in maternal and neonate deaths.[14]
MWAN is dedicated to the improving of lives of women and children and thus the attention to maternal, neonatal and child health was given through this simple but wide reaching project touching on FP, maternal and NT elimination, breast feeding, maternal and neonatal mortality, food demonstrations, data analysis and advocacy.
Family planning
FP is addressed under SDG target 3.7 and indicator 3.7.1 which refer to access to FP, information and education; and FP needs met with modern methods of FP.[11] Better access to modern FP methods reduces the risk of maternal mortality,[14] and the more contraceptive needs are met there are fewer deaths.[11] There is also an inverse relationship between wealth of countries and FP access,[11] inferring that low-income countries tend to have less FP access.
As at 2018 Nigeria had a total demand for FP among married women of 36%,[16] which is still considered low. The data generated from our pilot study give some information about the problems women have accessing FP methods in 4 of the facilities with reduced uptake in 2021. Niger state facility experienced lack of commodities especially the long acting contraceptives which women preferred over other methods, while Imo State experienced insecurity and noted the possible effects of the National Association of Resident Doctors' Strike action. Zamfara also experienced a drop in new cases due to insecurity, COVID-19, and emigration from the State. The facility focal person in Delta (Ubeji) could not proffer reasons for the decline at the time.
The FP data of 2021 improved in 9 of the States (increases ranging from 3.8% to 292%), this was attributed to the facility wide sensitization done in July 2021 to mark WDP and is in agreement with other studies.[17],[18] The WPD activities were an intervention used to improve uptake and spread information on FP and other health issues (understanding of FP, Maternal and NT elimination, Female Genital Mutilation and HIV/AIDS). According to the United Nations Population Fund, about 12 million women experienced disruption in accessing FP in March 2020, and this was mainly due to the COVID-19 pandemic.[19] In the words of the United Nations Secretary-General Antonio Guterres “These gaps in access to health rights are unacceptable. Women cannot be alone in this fight. As we mark WDP, let us pledge to ensure the reproductive rights of everyone, everywhere.”[19]
Marking the international days gives an opportunity to educate on issues of concern, advocate and mobilize political will, as well as to celebrate and reinforce achievements of humanity.[19]
The FP activity in our pilot study was measured by the number of individuals reached, fliers shared and the increase in the uptake of FP at the various facilities.
Though our pilot programme addressing FP did not seek other reasons for reduced uptake in FP from clients, there are known or related factors associated with high uptake such as interests of mothers and that of fathers.[17],[20]
High knowledge, positive perception and education do not have a positive effect on uptake as shown by studies done in Enugu, Lafia, Benin and in sub-Sarahan Africa.[3],[18],[20],[21],[22] This was however not the case in a study in Osogbo, Nigeria where there was a significantly positive relationship between education, media and attitude to FP among facility based participants which was related to the high number of enlightenment programmes.[23]
Other studies cited religion as a major barrier[18],[20],[24] which was noted in our WPD sensitisation programme as female health workers could not go into the Mosques to sensitise congregations (where males are) about FP. Another challenge noted is the lower rural uptake in comparison to urban uptake.[20],[25]
The political will of African nations has been noted as a challenge to the attainment of FP.[14],[24] Although there has been a notable increase in FP uptake as indicated by Aliyu[3] which we also achieved as seen in various levels of increased new acceptors in 10 of the facilities, various authors noted the importance for a continued use of health education and IEC to address social and cultural barriers of FP,[17],[20],[21],[25] male involvement[3],[22],[25] and religious leaders[20],[25] as well as the motivation of users to avoid pregnancy by continued follow-up from providers.[26]
Tetanus
The elimination of NT as a public health problem is defined as having less than one NT case per 1000 live births in every district or similar administrative unit in the country each year.[9] Tetanus is proven to be a vaccine preventable disease, with the administration of at least 2 doses of tetanus toxoid containing vaccine to the pregnant mother with an interval of 4 weeks;[9],[27] or primary infant series and booster doses in adolescence, or 5 doses if vaccinated after 1 year of age/during adolescence/adulthood including during pregnancies.[9] The fourth international target date to eliminate NT was 2020, the process began in 1989 with World Health Assembly calling for the elimination in 59 priority countries by 1995.[9] By the end of 2018, 14 countries remained[9] and as at 2019 only 12 countries remained to eliminate maternal and NT (MNT) of which Nigeria has a partial elimination (elimination in south-east and south-west regions).[28] As indicated in one study, Tetanus was still a major cause of death in a facility.[29] Inability of a country to eliminate MNT means that country has been unable to attain at least 80% coverage for women of reproductive age with respect to five factors (1) at least 2 doses of tetanus toxoid containing vaccine; (2) protection at birth; (3) skilled birth attendance; (4) antenatal care visits and (5) health facility delivery.[28] Worldwide as a result of implementation of these recommended strategies the global estimates declined by 96%.[9] Immunization coverage as at 2018 (including three doses each of DPT-HepBHib) was at 31% for all children 12–23 months of age.[16] Basic vaccination coverage was <10% in Zamfara (7%), Kebbi (6%) and Sokoto (5%) states and highest in Anambra (76%).[16]
Our pilot project noted that all facilities had regular tetanus vaccination for pregnant women but only 6 facilities were also involved in routine vaccination of secondary school girls. Moreover, at that only one (6.25%) facility (Delta – Idumuje-Unor) was consistent, the other 5 carried out vaccinations between one month and 10 months. This is evidence of our inability to get adequate coverage, which also depends on adequate knowledge of health care providers.[9],[28]
A study noted that knowledge of Tetanus vaccination for adolescents among school girls from Ibadan North LGA (where cases of NT had come from 2 years preceding the study) was low.[30] Suggestions have been made for improving Tetanus vaccination uptake by increasing campaigns in Nigerian high schools and primary schools,[30],[31] as the major but wrong reason given by the adolescents for taking the vaccine was injuries.[30] This corroborates with information given by the Delta (Ubeji) facility contact person that adolescents came to the facility to take Tetanus vaccination only for injuries. For adolescents booster doses are recommended to give life-long immunity and also protect their babies.[9] It would also result in fewer pregnant women needing the vaccine, as most would be vaccinated as adolescents.[9]
Tetanus vaccination of pregnant women[7],[31],[32] and a strong NNT surveillance system[32] and improved immunisation coverage in rural areas[31],[32],[33] are all means of reducing the incidence of tetanus in Nigeria. A National report of the National Primary Health Care Development Agency (Nigeria)[34] noted the difficulties in achieving high tetanus toxoid coverage due to low ANC coverage, low post-natal coverage and low facility deliveries. Poor funding to achieve subsequent rounds of Tetanus Toxoid Supplemental Immunisation Activities after that of 2014 was also a setback.[34] There had been a gradual reduction in the number of states reporting NT cases and by 2014 only 17 states reported,[34] although the plan was to meet the global and regional MNT disease elimination target by 2018. This is yet to be achieved. A strong case surveillance for NT was initiated in 2008, but noted under reporting as a constraint.[34]
Our pilot programme demonstrated the importance of these interventions when 14 NT cases in one state (Zamfara) were identified in 2020 and promptly given attention through advocacy to Federal Ministry of Health and necessary stakeholders, and the donation of Chlorhexidine gel by MWAN through the Zamfara Adopted facility and subsequent distribution to the Local Governments in that state. In 2021, only 2 cases were reported, revealing a plunge as a result of implementation of effective interventions. Most of these cases were brought to the facility as deliveries were un-booked cases. Yusuf et al.[28] noted that Zamfara state had only 22% likelihood of being protected against Tetanus which aligns with our project findings.
Chlorhexidine is a broad-spectrum antiseptic used as an adjunct to the 5 basic clean practices for cord care.[35] 7.1% Chlorhexidine digluconate was included in the WHO essential drug list of essential medicines for children in 2013 and introduced by the WHO in 2014.[36] It was introduced in Nigeria through USAIDS in 2012 Targeted States High Impact Project thereafter, Nigeria launched a National Chlorhexidine Scale up Strategy in 2016 to increase its use.[37] It can be safely used in settings where unhygienic applications to the cord are common and it is proven to reduce infant mortality from tetanus.[9],[27],[36],[37] An earlier study in 2015 noted that the introduction of 7.1% Chlorhexidine gel in two Nigerian states was seen to be more successful in health facilities where it replaced methylated spirit for cord care. However, unfortunately, a high percentage of births (75.2% and 83.9%) were home based or by traditional birth attendants who used hot compress, cow dung or local herbs for cord care.[38]
Maternal mortality
Maternal mortality has been a topic of great interest to many researchers for the obvious reason of its importance in reducing the maternal mortality rates in different hospitals, states and geopolitical zones in Nigeria. Although the association did not directly intervene due to limited funds, it is of note that the information gathered gave a picture of what was happening in various facilities.
Maternal mortality worldwide as at 2017 was 211 maternal deaths per 100,000 live births.[39] According to world rankings in 2017 on maternal mortality, Nigeria ranked 179 out of 182 countries, with Chad having the highest values of 1140 and Nigeria 917. Other countries in Sub-Saharan Africa like Mali (576), Niger (509) and Togo (396) were slightly better off. Egypt had 37, Algeria 112 and South Africa 119. Developed countries such as Norway, Italy, Poland had better indices of 2; Iran had 16, USA 19.[40] As at 2015, MMRs were the highest in WHO African region where one woman died for every 185 children born and highest in low-income countries where one woman died for every 202 children born with a 29 times higher chance of maternal mortality occurring in a low income than high income country.[11]
As at 2015 in Nigeria had about 58,000 maternal deaths, accounting for 19% of maternal deaths worldwide.[41] Okaro et al.[42] compared two 10-year periods (1976–1985 and 1991–2000) in a facility and attributed the significantly higher MMR (1406/100,000 live births) of 1991–2000 to institutional delays and diminished standard of living among Nigerians which were also mentioned by Ebeigbe.[43] Abe and Omo-Aghoja[44] had a ten-year review and attributed maternal mortality to low literacy, high poverty, extremes of parity and non-utilisation of antenatal services. Several studies noted various rates in maternal mortality and commonly occurring direct causes of hypertensive disorders (eclampsia and pre-eclampsia), obstetric (including postpartum) haemorrhage, sepsis, unsafe abortions, embolisms, ectopic pregnancies, uterine rupture, obstructed labour[44],[46],[47],[48],[49],[50],[51],[52],[53],[54] and indirect causes included institutional difficulties[44] AIDS, anaemia, anaesthesia, thyrotoxicosis and diabetes mellitus.[48] Other factors influencing maternal death include un-booked cases,[52] poverty, lack of freedom over reproductive health choices, and lack of command of resources, women's educational attainment and economic empowerment.[11] An important factor to reduce maternal mortality is the presence of skilled provider-assisted deliveries,[11] this was measured as low (<30% in the North) to high (>60% in the South) in Nigeria.[14] According to Nigerian Demographic Health Survey (NDHS),[16] the total skilled provider-assisted delivery was at 43% by 2018. Unfortunately, the WHO African region has delivery coverage of only 59% as compared to over 90% seen in the Americas, European and Western Pacific regions.[11]
Nigeria has introduced some interventions to improve maternal health indices. These include State based free maternal health programs,[55] Saving One Million Lives Project (SOML),[56],[57] Basic health care Provision Fund (BHCPF),[58] 2nd National Strategic Health Development Plan,[57] and National Health Insurance Scheme (NHIS) which included Bauchi, Ogun, Cross River, Akwa-Ibom, Rivers, Edo, Taraba, Adamawa, Kaduna, Zamfara, Kebbi, Sokoto, Katsina, Nassarawa, Anambra, Jigawa, Imo, and Kogi as at September 2009.[59]
Neonatal mortality
Our report is facility based and therefore the neonatal deaths covered the first 7 days of life giving values in early neonatal deaths and not late neonatal deaths.
SDG 3 also addresses child mortality in Target 3.2.[11] Though neonatal death rates have declined globally,[11],[39] Sub-Saharan Africa had the highest values in 2020 at 27 deaths per 1,000 live births followed by South Asia with 25 deaths per 1,000 live births.[39] Globally neonatal death rates fell by 41% between 2000 and 2017, but they are still highest in the WHO African region and low-income countries. According to the 2018 NDHS Nigeria had a NMR of 39 deaths per 1,000 live births in 2018, but the rate was considered stagnant between 1990 and 2018.[16]
Food demonstrations
The increase in the number of food demonstrations in 2021 as compared to 2020 is proof of the positive effect of supervision. The increase was notable after the virtual training that took place for the facility focal persons in January 2021. The training generated questions directed at understanding food demonstrations and answers given helped participants understand that food demonstrations were simple, inexpensive ways to teach mothers at facilities to prepare meals for infants and reduce malnutrition. According to Masters et al. programs aimed at altering preferences, programs to alter prices of food and improved access to healthy foods are identified as cost effective ways to promote behavior change, as they are less costly per child. This study agrees with our method of food demonstrations carried out in the Kaduna facility as it altered preferences and its cost-effectiveness. Other methods such as food and cash (resource) transfers were found to be more expensive per child.[60]
Other studies on food demonstrations noted the importance of food demonstrations during Ante-natal visits to introduce dietary sources of energy, iron, vitamin A and folic before and during pregnancy so as to improve maternal and neonatal/child outcomes this is also in line with our pilot study.[16],[61] Lutter et al. agree with our method of food demonstration and its online circulation as an effective way to reach out to large numbers as it is a programme-specific key message using multiple platforms, and it agrees with the use of locally available foods which are important in achieving long-term sustainability.[62] The study also suggests that designs for nutrition programs should be comprehensive, transdisciplinary and with rigorous evaluation, noting this, such aspects of the pilot program can be further looked into to improve its impact as we were unable to do so during the allotted time of two years. Zamfara center had a nutritionist attending to individuals not groups which was to suit the individual challenges, a method which according to Lutter et al. is considered demanding on the part of the health personnel, requiring training and investments in time thus affecting the quality of counselling.[62]
Breast feeding support groups
WHO recommends exclusive breast feeding for the first 6 months of a baby's life.[16] In 2018 Nigeria had a rate of 29%.[16] The aim of starting the breastfeeding support group at the Delta (Idumuje-Unor) facility was to promote proper infant and young child feeding practices including exclusive breast feeding to enable growth, health and development of the newborn to their full potential which was seen in other studies.[63],[64] The study by Flax et al. started with training of health personnel on Baby Friendly Hospital Initiative and the pregnant women received breastfeeding messages through texts, WhatsApp and WhatsApp groups, foldable messages at the facilities, information at the Health facilities through LED screens.[63] Our support group was formed including mothers that had babies coming for immunization and did not get texts or WhatsApp messages, but were given pamphlets and health talks on breastfeeding. The study by Nyati et al. notes that breastfeeding requires a lot of motivation from mothers and clinicians.[64]
Cleft palate child
The baby with the cleft palate was identified during the supervision of the project in Idumuje-Unor (Delta) by the National President. This shows the importance of supervision by a clinical mentor/senior health personnel,[15] who in this case was able to guide the child and parents to a cost effective method of treatment.
Limitations to the study
The study was limited by the fact that not all the 36 States of the Federation and the Federal Capital Territory were represented, as participation was based on the interest of the leaders of the MWAN State Branches. This may affect generalizability of some of the findings.
| Conclusion | | |
This project demonstrates that instituting an efficient all-embracing monitoring/evaluation system in the health sector using objectively verifiable indicators, can contribute to improving health indices of African nations like Nigeria.
Acknowledgement
I wish to acknowledge the focal persons of each Health Facility. Their names are listed below:
- Akwa-Ibom State - Dr. E. Johnson
- Benue State - Dr. P. Okpeh
- Delta State (Idumuje-Unor) - Mrs. E. N. Imafidon
- Delta State (Ubeji) – Mrs. P. Ossaiga
- Delta State (Utagba-Unor) – Mrs. M. Okeh
- Imo State - Dr. J. Nkemdeme
- Kaduna State - Hajiya Adama S. Usama
- Kwara State -Dr. Yusuf Khadija
- Niger State - Hajiya Fatima Saidu
- Oyo State - Dr. Famakin and Matron Fatunmobi
- Rivers State - Dr. Harrison Douglas
- Zamfara State - Dr. Khadija Mohd Kanoma.
The authors also acknowledge the Kwara State Ministry of Health, FMC, Gusau, Zamfara State; FMC, Owerri, Imo State; FMC, Markurdi, Benue State; Kaduna State Ministry of Health, Kaduna State; Oyo State Ministry of Health, Ibadan, Oyo State; Akwa-Ibom State Ministry of Health, Uyo, Akwa-Ibom State; Niger State Ministry of Health, Minna, Niger State; Delta State Ministry of Health, Asaba, Delta State; Rivers State Hospitals Management Board, Port Harcourt, Nigeria.
Financial support and sponsorship
The project was funded by MWAN and development Research and Projects Centre Partnership for Advocacy in Child and Family Health at Scale (dRCP/PAFCaH@SCALE).
Conflicts of interest
There are no conflicts of interest.
| Annexure | | |
Annexure 1
State Adopted Health Facility Report
- Name of Health Facility
- Date that the MWAN 2019 -2021 Biennium Plaque was mounted
- Total number of New Acceptors for Family Planning monthly since facility was adopted
- Total number of Revisits for Family Planning since facility was adopted
- Number of sensitization programmes on family planning organised for Community Groups and Faith-Based Organisations monthly
- Monthly coverage of Td1 –Td5
- Number of Secondary School Girls from 15 years and above mobilised to take Td1 to Td5:
- Number of cases of Maternal and Neonatal Tetanus reported
- Number of babies put to breast in first hour after delivery per month
- Number of food demonstrations done per month
- Number of advocacy activities to major stakeholders including Press Releases.
SDG Indicators
GOAL 3
- Maternal Mortality Ratio for Adopted Health facility
- Neonatal Mortality Rate for Adopted Health facility.
| References | | |
| 1. | United Nations, Department of Economic and Social Affairs. The 17 Goals – Sustainable Development. Available from: https://sdgs.un.org>goals. [Last accessed on 2023 Jun 04].  |
| 2. | |
| 3. | Aliyu A. Family Planning services in Africa: The successes and challenges. In: Amarin ZO, editor. Family Planning. London: IntechOpen; 2018. Available from: https://www.intechopen.com/chapters/58297. [Last accessed on 2022 Jun 08]. |
| 4. | |
| 5. | |
| 6. | |
| 7. | |
| 8. | |
| 9. | World Health Organization. Protecting all Against Tetanus. Guide to Sustaining Maternal and Neonatal Tetanus Elimination (MNTE) and Broadening Tetanus Protection for all Populations. Geneva: World Health Organization; 2019. |
| 10. | World Health Organization. Maternal Mortality Fact Sheet; 19 September, 2019. Available from: https://www.who.int>. [Last accessed on 2023 Jun 04]. |
| 11. | World Health Organization. World Health Statistics 2019: Monitoring Health for the SDGs, Sustainable Development Goals. Geneva: World Health Organization; 2019. |
| 12. | Kana MA, Doctor HV, Peleteiro B, Lunet N, Barros H. Maternal and child health interventions in Nigeria: A systematic review of published studies from 1990 to 2014. BMC Public Health 2015;15:334. |
| 13. | Bhattacharya AA, Umar N, Audu A, Felix H, Allen E, Schellenberg JR, et al. Quality of routine facility data for monitoring priority maternal and newborn indicators in DHIS2: A case study from Gombe State, Nigeria. PLoS One 2019;14:e0211265. |
| 14. | Friberg IK, Kinney MV, Lawn JE, Kerber KJ, Odubanjo MO, Bergh AM, et al. Sub-Saharan Africa's mothers, newborns, and children: How many lives could be saved with targeted health interventions? PLoS Med 2010;7:e1000295. |
| 15. | Okereke E, Tukur J, Aminu A, Butera J, Mohammed B, Tanko M, et al. An innovation for improving maternal, newborn and child health (MNCH) service delivery in Jigawa State, Northern Nigeria: A qualitative study of stakeholders' perceptions about clinical mentoring. BMC Health Serv Res 2015;15:64. |
| 16. | National Population Commission (NPC) [Nigeria] and ICF. 2019. Nigeria Demographic and Health Survey 2018 Key Indicators Report. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF. |
| 17. | Piotrow PT, Rimon JG 2 nd, Winnard K, Kincaid DL, Huntington D, Convisser J. Mass media family planning promotion in three Nigerian cities. Stud Fam Plann 1990;21:265-74. |
| 18. | Onwuzurike BK, Uzochukwu BS. Knowledge, attitude and practice of family planning amongst women in a high density low income urban of Enugu, Nigeria. Afr J Reprod Health 2001;5:83-9. |
| 19. | World Population Day – United Nations Population Fund. Available from: https://www.un.org. [Last accessed on 2022 May 23]. |
| 20. | Mafuyai MJ, Emmanuel A, Gimba SM, Barry AB, Obadiah A. Perception and practice of family planning among rural women in North Central Nigeria. 27 April 2014;8:14-9. Available from: http://www.wiloludjournal.comviewedat researchGate. [Last accessed on 2023 May 16]. |
| 21. | Ehwarieme TA, Iriafen LZ. Knowledge, attitude and practice of family planning among women attending maternal and child health clinic NIFOR Benin, Edo State, Nigeria. J Comput Biol 2016;5:6-18. |
| 22. | |
| 23. | Owolabi EO, Ter Goon D, Seekoe E. Attitude to, and knowledge and practice of family planning among women of child-bearing age attending selected hospitals in Osogbo, Nigeria. Afr J Nurs Midwifery 2017;19:13. Available from: https://journals.co.za/doi/abs/10.25159/2520-5293/1683. [Last accessed on 2023 Jun 04]. |
| 24. | Igbudu U, Okoedion S, Peremene E, Eghafona K. Religious beliefs and family planning practices of married women in zone 5, police barracks in Nigeria. Ozean J Soc Sci 2011;4:55-62. |
| 25. | Ikelegbe OO, Ohwovoriole E. Family planning strategies of rural women in Nigeria: Challenges of implementation and the way forward. 2013;4:34. |
| 26. | Chace Dwyer S, Baruwa S, Okafor E, Daini BO, Ubuane O, Jain A. How do changes in motivation to prevent pregnancy influence contraceptive continuation? Results from a longitudinal study with women who receive family planning services from community pharmacists and patent and proprietary medicine vendors in Nigeria. Reprod Health 2022;19:39. |
| 27. | Blencowe H, Lawn J, Vandelaer J, Roper M, Cousens S. Tetanus toxoid immunization to reduce mortality from neonatal tetanus. Int J Epidemiol 2010;39 Suppl 1:i102-9. |
| 28. | Yusuf N, Raza AA, Chang-Blanc D, Ahmed B, Hailegebriel T, Luce RR, et al. Progress and barriers towards maternal and neonatal tetanus elimination in the remaining 12 countries: A systematic review. Lancet Glob Health 2021;9:e1610-7. |
| 29. | |
| 30. | Orimadegun AE, Adepoju AA, Akinyinka OO. Adolescent girls' understanding of tetanus infection and prevention: Implications for the disease control in Western Nigeria. Front Public Health 2014;2:24. |
| 31. | Alhaji MA, Bello MA, Elechi HA, Akuhwa RT, Bukar FL, Ibrahim HA. A review of neonatal tetanus in university of Maiduguri teaching hospital, North-Eastern Nigeria. Niger Med J 2013;54:398-401. [ PUBMED] [Full text] |
| 32. | Nass SS, Danawi H, Cain L, Sharma M. Predictors of neonatal tetanus mortality in Katsina State, Northwestern Nigeria. Health Serv Res Manag Epidemiol 2017;4:2333392817723970. |
| 33. | Chukwuka JO, Ezeudu CE, Nnamani KO. Neonatal and post-neonatal tetanus in Nnamdi Azikiwe university teaching hospital, Nnewi, South-East, Nigeria: A 10-year review. Trop J Med Res 2015;18:30-3. [Full text] |
| 34. | National Primary Health Care Development Agency. Comprehensive EPI Multi-Year Plan; 2016-2020. Available from: http://www.fricanchildforum.org>. [Last accessed on 2023 Jun 04]. |
| 35. | Blencowe H, Cousens S, MullanyLC, LeeAC, Kerber K, Wall S, et al. Clean birth and postnatal care practices to reduce neonatal deaths from sepsis and tetanus: Asystematic review and Delphi estimation of mortality effect. BMC Public Health 2011;11:1-9. Available from: http://www.biomedcentral.com/1471-2458/11/S3/S11. [Last accessed on 2023 Jun 04]. |
| 36. | |
| 37. | |
| 38. | Abegunde D, Orobaton N, Beal K, Bassi A, Bamidele M, Akomolafe T, et al. 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 quality assurance sampling survey. BMC Pregnancy Childbirth 2017;17:368. |
| 39. | |
| 40. | |
| 41. | World Health Organization. Trends in Maternal Mortality: 1990 to 2015: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2015. Available from: https://www.afro.who.int>files. [Last accessed on 2023 Jun 04]. |
| 42. | Okaro JM, Umezulike AC, Onah HE, Chukwuali LI, Ezugwu OF, Nweke PC. Maternal mortality at the University of Nigeria teaching hospital, Enugu, before and after Kenya. Afr J Reprod Health 2001;5:90-7. |
| 43. | Ebeigbe PN. Reducing maternal mortality in Nigeria: The need for urgent changes in financing for maternal health in the Nigerian health system. Niger Postgrad Med J 2013;20:148-53. [Full text] |
| 44. | Abe E, Omo-Aghoja LO. Maternal mortality at the central hospital, Benin City Nigeria: A ten year review. Afr J Reprod Health 2008;12:17-26. |
| 45. | Olopade FE, Lawoyin TO. Maternal mortality in a Nigerian maternity hospital. Afr J Biomed Res 2008;11:267-73. |
| 46. | Ntoimo LF, Okonofua FE, Ogu RN, Galadanci HS, Gana M, Okike ON, et al. Prevalence and risk factors for maternal mortality in referral hospitals in Nigeria: A multicenter study. Int J Womens Health 2018;10:69-76. |
| 47. | Obiechina Nj, Okolie V, Okechukwu Z, Oguejiofor C, Udegbunam O, Nwajiaku L, et al. Maternal mortality at Nnamdi Azikiwe university teaching hospital, Southeast Nigeria: A 10-year review (2003-2012). Int J Womens Health 2013;5:431-6. |
| 48. | Ngwan SD, Swende TZ. Maternal mortality in Jos Nigeria: A facility based prospective review. Int J Biol Med Res 2011;2:565-8. |
| 49. | Gulumbe U, Alabi O, Omisakin OA, Omoleke S. Maternal mortality ratio in selected rural communities in Kebbi State, Northwest Nigeria. BMC Pregnancy Childbirth 2018;18:503. |
| 50. | Audu BM, Takai UI, Bukar M. Trends in maternal mortality at university of Maiduguri teaching hospital, Maiduguri, Nigeria-A five year review. Niger Med J 2010;51:147. |
| 51. | Bukar M, Kunmanda V, Moruppa J, Ehalaiye B, Takai U, Ndonya D. Maternal mortality at federal medical Centre Yola, Adamawa State: A five-year review. Ann Med Health Sci Res 2013;3:568-71. [ PUBMED] [Full text] |
| 52. | Oyeneyin L, van den Akker T, Durojaiye O, Obaado O, Akanbiemu F, Olagbuji Y, et al. Confidential enquiries into maternal deaths in Ondo State, Nigeria – A comparative analysis. BMC Pregnancy Childbirth 2019;19:514. |
| 53. | Anastasi E, Ekanem E, Hill O, Adebayo Oluwakemi A, Abayomi O, Bernasconi A. Unmasking inequalities: Sub-national maternal and child mortality data from two urban slums in Lagos, Nigeria tells the story. PLoS One 2017;12:e0177190. |
| 54. | Awoyesuku PA, MacPepple DA, Altraide BO. Magnitude, trends and causes of maternal mortality: A 7 year review at a tertiary hospital in river state, Nigeria. JAMMR 2020;32:103-9. |
| 55. | Oseji M, Ogu R. Community based interventions for the reduction of maternal mortality – The role of professional health associations, non-governmental organisations and community-based organisations in delta state, Nigeria. Niger Postgrad Med J 2014;21:343-9. |
| 56. | Saving one Million Lives in Nigeria | Results for Development. @2009-2022 Results for Development. [Last accessed on 2023 Jun 04]. |
| 57. | |
| 58. | BHCPF-NPHCDA. Copyright 2022 National Primary Health Care Development Agency. Available from: https://nphcda.gov.ng>bhcpf. [Last accessed on 2023 Jun 04]. |
| 59. | Agba AM, Ushie EM, Osuchukwu NC. National health insurance scheme (NHIS) and employees' access to healthcare services in cross river state, Nigeria. Glob J Hum Soc Sci 2010;10:9-16. |
| 60. | Masters WA, Rosettie KL, Kranz S, Danaei G, Webb P, Mozaffarian D, et al. Designing programs to improve diets for maternal and child health: Estimating costs and potential dietary impacts of nutrition-sensitive programs in Ethiopia, Nigeria, and India. Health Policy Plan 2018;33:564-73. |
| 61. | Ojofeitimi EO, Ogunjuyigbe PO, Sanusi RA, Orji EO, Akinlo A, Liasu SA, et al. Poor dietary intake of energy and retinol among pregnant women: Implications for pregnancy outcome in Southwest Nigeria. Pak J Nutr 2008;7:480. |
| 62. | Lutter CK, Iannotti L, Creed-Kanashiro H, Guyon A, Daelmans B, Robert R, et al. Key principles to improve programmes and interventions in complementary feeding. Matern Child Nutr 2013;9 Suppl 2:101-15. |
| 63. | Flax VL, Ipadeola A, Schnefke CH, Ralph-Opara U, Adeola O, Edwards S, et al. Breastfeeding interpersonal communication, mobile phone support, and mass media messaging increase exclusive breastfeeding at 6 and 24 weeks among clients of private health facilities in Lagos, Nigeria. J Nutr 2022;152:1316-26. |
| 64. | Nyati M, Kim HY, Goga A, Violari A, Kuhn L, Gray G. Support for relactation among mothers of HIV-infected children: A pilot study in Soweto. Breastfeed Med 2014;9:450-7. |
[Table 1], [Table 2], [Table 3]
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