Photo: Mark Tuschman
Nigeria is the most populous and one of the wealthiest nations in Africa. Yet our health statistics are devastating – one in 13 women die during pregnancy or childbirth and one in eight children die before reaching the age of five.
These tragic realities have been of great concern to me and to most Nigerians. I have worked in the field of public health in Nigeria for nearly twenty years, and long ago grew weary of witnessing relatives, friends, neighbors, and loved ones die during childbirth. I was tired of seeing women and girls die because they didn’t have access to basic reproductive health services. I was angry that so many newborns and children die simply because they did not have access to quality healthcare.
My colleagues in public health and I decided to act – we began advocating to ensure passage and signing of the Nigerian National Health Bill.
The “Bill For An Act To Provide A Framework For The Regulation, Development And Management Of A National Health System And Set Standards For Rendering Health Services In The Federation, And Other Matters Connected Therewith, 2014” otherwise called the National Health Bill (NHB), was first drafted in 2004 by 30 reform-minded Nigerians. This Bill was drafted during revision of the National Health Policy as part of the Health Sector Reform Agenda of 2004-2007. (Click here to read more about the NHB’s legislative and political history).
Progress to pass the Bill was painfully slow. It took seven years of intensive advocacy – and major public protests – for the Nigerian Assembly to pass a harmonized version of the Bill in 2011. We were elated. But the President did not sign the Bill for reasons which were never formally communicated to the citizens.
My fellow advocates and I did not relent in our hope for passage, and continued to work with the legislature to reintroduce the Bill in 2012. Based on our previous experience, advocates monitored and closely tracked the numerous legislative stages in both the Senate and the House to ensure that a harmonized version was passed.
During this time, we also engaged the media to educate the public, and held several discussions with health professional groups and religious institutions to reach consensus, especially around contentious provisions of the Bill. Our efforts finally proved successful when the President signed the Bill into law in December 2014. The people of Nigeria can now smile because the new law will entitle underserved families to free, comprehensive healthcare services, and accelerate efforts to reduce the high rates of maternal and infant mortality.
Through my experience advocating for the Bill, I learned about the need to exploit every opportunity, and to remain tenacious in my advocacy endeavors. For example, I took advantage of my early interactions with the Senate Health Committee, while working on a Parliamentary project to finance routine immunization in Nigeria, to better understand the legislative intricacies of the Senate and its select committees. My colleagues and I leveraged this knowledge and our alliances to advance advocacy efforts on the National Health Bill.
We designed our advocacy strategies to ensure the passage of the Bill into law and eventual signing by the President, crafting our efforts to promote buy-in and acceptability. Policymaker education was central in all the efforts. We provided allies and opponents with evidence-based research and data reflecting the state of Nigeria’s maternal, newborn and child health and mortality. We also kept lines of communication open with the legislators and their committee staff, providing them with information they could use to advance our collective agenda.
Stakeholder and media engagements were also key. We met with select civil society leaders and groups to ensure momentum, a shared message platform, and constant communication to exchange updates and challenges. We established relationships with journalists in need of research, data, and information to enhance the quality of reporting on the Bill. We also established platforms for engagement between the media and members of the House to openly discuss the Bill’s benefits and provisions. It was incumbent upon us to provide credible information that would lead to support by all members of the National Assembly.
Once we had support from the Assembly, our focus turned to the Office of the President. Access to the seat of government was critical in the advocacy process. We identified allies who were either advisors and/or confidantes, and we made efforts to engage with them both formally and informally. People involved with decision-making needed appropriate ammunition to make a case each time the Bill was discussed.
With the signing of the Bill into law, and after an exhausting ten-year political and legislative gauntlet, we still cannot yet celebrate. My fellow advocates and I know that implementation of the law and adherence to its tenets will take equally undaunted efforts. The critical challenge now is communicating with geographically and economically marginalized Nigerians who are likely unaware of their new rights to free and comprehensive healthcare services, including reproductive health care for women and girls.
Reaching marginalized populations to ensure that everybody understands the law now requires a new set of strategies: dissemination of the law’s details via diverse communication channels, building new alliances, and designing tracking systems, including information analysis procedures. We must leverage the collective efforts of different segments of Nigerian society, including private sector actors including media and healthcare providers, civil society organizations, government institutions such as the Ministry of Health, and Nigeria’s national health insurance network.
Our advocacy efforts demonstrate that influencing change is not a linear exercise. Rather, advocacy comes with its own ups and downs, and its own distinct challenges. We succeeded by keeping abreast of events, designing and redesigning our strategies, keeping allies adequately informed and educated, and making sure we did not lose any momentum.
Nigeria has taken nearly ten years to codify healthcare for all of its people. And despite the success of our advocacy, the challenge of implementation has only begun.
Kangaroo Mother Care (KMC) has been practiced in many countries like Colombia for decades. The practice of keeping a baby warm and close to her mother – allowing for ease of breastfeeding and exposure to all the “good bacteria” – is seemingly so simple, yet it has failed to gain wide traction. Why is this? Some mothers practicing KMC report discomfort and challenges when performing their daily activities. Other mothers may not have been taught the importance of KMC.
Because KMC is good for all babies but can be lifesaving for preterm babies, we want to find creative ways to make it easier for mothers. Recently the Gates Foundation together with the Boston Consulting Group convened a group of product developers and advisors to explore innovative solutions and to learn from KMC in action. We held this convening in connection with the recent Saving Newborn Lives KMC Acceleration meeting and the 10th International Conference on KMC in Kigali, Rwanda.
While in Kigali, we visited the delivery ward at the Muhima District Hospital to see KMC in action. We met a mother who had recently delivered a preterm baby. She was wearing a blue hospital robe and looked up as we entered her room and smiled as we approached. In her arms was her preterm daughter, asleep. Her hands looked too big to handle such a fragile bundle, but this didn’t seem to faze her. Her smile didn’t fade, her shoulders hunched over slightly as she looked down at her daughter with admiration. She spoke to us through a translator. She told us she was happy because her baby breastfed for the first time just moments before we arrived. It gave her hope that her daughter would survive and begin to grow. The mother stroked the delicate face resting in her arms, breast milk still showing on the corners of the infant’s mouth.
We were led to the next room where two mothers were practicing KMC. This was a darker room lit only by a gentle orange glow from the curtains that were pulled to shield the mothers and babies from hot afternoon sun. Small babies were wrapped against their mothers, skin-to-skin, as they sat peacefully in raised hospital beds. They too were smiling. We knew the mother we saw in the first room would soon join them to continue KMC and give her baby the greatest chance of survival.
Seeing KMC in practice seemed so simple, yet we know there has been very little uptake of this intervention globally (currently, just 5% according to WHO’s Born Too Soon: The Global Action Report on Preterm Birth). How can we make it easier for mothers to continue to practice KMC at home? Can a KMC wrap make it easier for mothers to hold their babies skin-to-skin safely and comfortably? Can KMC buddy groups make it easier for women to practice? We aim to find out through product innovation and implementation research!
We invite you to comment below and share this post on Twitter with a message such as this one: “Saving #EveryNewborn: Finding creative ways to make it easier for mothers to provide KMC”
Prematurity and birth asphyxia still have a devastating impact for newborns and their families in Uganda. In 2011, over 15,000 newborn babies in Uganda did not survive their first day of life. While the neonatal mortality rate declined from 36 to 22 per 1,000 live births from 2000 to 2013, there were still over 212,000 newborns born premature in 2013.
In recent years the government has made new commitments to address care around the time of birth but in many parts of the country, skilled care is not always available. Thankfully, health workers are receiving critical training on the Helping Babies Breathe neonatal resuscitation curriculum and Kangaroo Mother Care (KMC) to help manage preterm babies and ultimately help save newborn lives. Furthermore, this helps to give women the piece of mind to know that their babies can survive despite great odds.
These two stories highlight the impact of trained and equipped health workers on helping reduce the number of babies dying from intra-partum complications and prematurity.
KMC Practice Saves Babies at Lyantonde Hospital
Thirty four-year-old Jacinta Nangonzi of Kaliiro, Lyantonde district, went to Lyantonde Hospital with leaking membranes when she was only 27 weeks pregnant. Jacinta had a poor obstetrical history of three previous miscarriages at 24-28 weeks of amenorrhea. Tragically, all the babies died due to poor obstetrical care.
Photo: Sylvia Nabanoba/Save the Children
New mother Jacinta smiles at her baby as Sister Grace and Harriet Othieno of Save the Children look on.
This fifth pregnancy almost turned out as the previous ones – a preterm female baby born at 27 weeks of gestation with an Apagar score of 10 and low birth weight of 1.5kgs. After birth, Jacinta requested to be referred to Mbarara Regional Referral Hospital, which she knew had incubators.
“I assured Jacinta that her baby would be fine without an incubator,” says Midwife Sister Grace of Lyantonde Hospital. “I shared with her the knowledge and skills on Kangaroo Mother Care, which I had received during a training conducted by Save the Children. I told her that KMC helps to manage preterm babies, and we taught her how to practice it, and how to express breast milk for the baby, who could not breastfeed yet,” Sr. Grace explains.
Photo: Ian P. Hurley/Save the Children
Kangaroo Mother Care signs inform people walking past the Neonatal Intensive Care Unit at Kiwoko Hospital in Uganda about Kangaroo Mother Care.
Jacinta and her baby stayed at the hospital for two weeks, after which they were both discharged in good condition. Sr. Grace reminded her to continue practicing KMC and to breastfeed her baby girl every two hours while at home. Jacinta also had to take the baby back to hospital for review after a week. During the review, the baby weighed 1.65kgs. It was breastfeeding well and had gained some weight.
“I thank you very much Sr. Grace for teaching me KMC that saved my baby at no cost,” Jacinta told the midwife. Sr. Grace is also glad that she was able to help Jacinta’s baby live.
“As a health worker I feel happy towards my success and thank Save the Children for having given us skills, knowledge and the equipment for saving newborns,” she says. Sr. Grace says that the hospital is still following up Jacinta’s baby, who is now nine months old and weights 11kgs.
Helping Babies Breathe Plus at Lujorongole Health Center II Gulu District
At 12am on a dark Monday night, twenty-two-year-old Adongo Paska from Lujorongole village in Gulu district, Northern Uganda, started experiencing labour pains. Her membranes raptured early while still at home but she was not able to go to the health centre because the family could not access any means of transport during the night. Thankfully Adongo made it through the rest of the night and early the next day was able to reach Lujorongole Health Center II (HCII).
Photo: Sylvia Nabanoba/Save the Children
New mother Adongo Paska with her new baby at Lujorongole Health Center II
On-duty Nursing Assistant Onek Regina Apio examined Adongo and helped to conduct a normal delivery at around 11am that morning. However, due to the prolonged labour, the baby failed to breathe at birth and his skin started to turning blue. Apio was one of the participants in a Helping Babies Breathe Plus (HBB+) training, so she knew how to handle babies who present such signs at birth.
Photo: Sylvia Nabanoba/Save the Children
Nursing Assistant Onek Regina Apio narrates her story during HBB+ support supervision at Lujorongole HCII
“I quickly dried and stimulated the baby but it still could not breathe. I sent for the E/M to assist me as I continued with resuscitation,” Apio explains. “I quickly cut the cord and transferred the baby to the resuscitation corner and started suctioning and bagging. After bagging and suctioning for about 20 minutes, the baby started breathing.” Apio was very glad that she had succeeded in helping the baby, but new mother Adongo was even happier.
“I am so very grateful to the staff of this health centre for enabling me to take a live baby home,” exclaimed Adong, looking lovingly at her newborn.
Photo: Lucia Zoro/Save the Children
Rizelle, 17 years old, has a three-week-old baby. She breastfed her baby immediately after birth so that she received the benefits of colostrum. It provides the baby with needed vitamins and important antibodies to help ward off infections. She plans to continue breastfeeding for a year. Rizelle has had a postnatal check up. The baby has received vaccinations and Roselle is planning to go to the health centre for the next dose when she’s six weeks old.
Rizelle lives in a squatted home under a bridge in San Dionisio, Manila, Indonesia where they live with 30 other families. She was shown how to breastfeed her child by local health workers trained by Save the Children.
Even at 17, this young woman looks proud and tough despite having to live in tough conditions and now have the responsibility of raising a newborn baby. I am also really impressed by her attitude and determination to breastfeed her baby exclusively. Let's all hope that she is able to do so, for both her health and her baby's.
Helpful Resources on Breastfeeding
Women walk into the health centre in Dera Murad Jamali, Pakistan.
The recently published recommendations in Lancet Every Newborn series strongly advocate ensuring the quality of care at birth. This is the time when most deaths occur and when most lives can be saved as well as long-term disabilities averted, through higher coverage of effective interventions.
However, since many decades the situation in Pakistan remains dismal. The statistics from Pakistan Demographic and Health Survey indicate that Neonatal Mortality in Pakistan is still high as out of every 1,000 live births 55 newborns die within a month of birth. Among other factors, a point of deep concern is that more than 48pc deliveries are being conducted by traditional birth attendants (TBAs).
According to the Global and National Newborn Health Indicators database (May 2014), Pakistan ranks on top for Still Birth Rate/First day Mortality Rate among South Asian countries. Despite a huge population, many key health indicators are far better in India than in Pakistan.
The traditional birth attendant, or ‘dai’ is an indispensable reality for millions of pregnant Pakistani women. What we need to do is to tap and hone their skills
In our country, a number of programmes and projects are being implemented to improve the overall situation of maternal, neonatal and child care. Two major programmes — the Lady Health Worker Programme (LHWP) and the National Maternal Newborn & Child Health Program (NMNCH) — claim to cover the 65pc of the population.
Community midwives (CMW) working under NMNCH programme are trained to conduct deliveries at community level but unfortunately due to multiple reasons, the programme has not been expanded yet to the level that was expected at the time of its conception.
An important task of the CMWs was to establish linkages with all the health work force working at community level but functional integration cannot yet be witnessed in the field.
Although TBAs are still considered controversial by a number of internal organisations, they probably share a significant burden of more than 47pc of deliveries being conducted by unskilled birth attendants in the rural areas.
Formal and informal links between the traditional birth services in a community and professional health services can facilitate not only the effective use of available resources as well as access to quality.
Since TBAs are from the rural setting, their bonding and relationship building with the rural community runs across generations.
Talk to a mother-in-law at the community level, it is not surprising to find that the TBA conducting the delivery of her daughter-in-law was actually trained by her own mother (TBA). This kind of relationship building is a key factor in convincing and attracting the families of rural areas to consult TBAs in case of emergencies.
The probability of conducting unskilled deliveries by TBAs is higher in areas which are not covered by frontline health workers.
The main reasons due to which Pakistan is not on track for achieving the UN Millennium Development Goals (MDGs) 4 & 5 are practicing multiple strategies, redesigning them repeatedly, implementing both independently and in integration resulting in a failure to achieve results as desired.
This is because the policies implemented till now have mostly been projects created and driven without considering local factors that come into play.
There is a dire need to revisit our policies and strategies and accept ground realities.
We have several evidences in South Asia and in Pakistan that the TBAs have been trained on Safe Motherhood patterns resulting in the betterment of maternal and newborn health indicators but unfortunately those models were not taken up by the government or scaled up due to the absence of any policy guidance for TBAs in our health strategy.
The rate of maternal and neonatal mortality can be lowered specially in the rural settings by improving the capacity building of TBAs through several interventions like antenatal care and identifications of danger signs during pregnancy, management of normal delivery process; detection of obstetrical complications and timely referral to the nearest health care facility and the establishment of linkages with first level health care facilities like equipping them with safe delivery kits to ensure safe motherhood.
Similarly, TBAs can be trained on simple interventions in order to decrease the infant mortality rate as well as immediate care of the newborn, promotion of early and exclusive breastfeeding, cord care, the detection of danger signs (preterm pneumonia/infection, asphyxia) and early referral of newborns to the first level health care facilities, etc. Studies have proved that the level of accessibility and acceptability of TBAs are much higher in our rural settings since they belong to the same vicinities.
The State of World Midwifery Report 2014 report launched two months ago, has also endorsed the importance of TBAs and urged that “TBAs will continue to be part of service delivery models in the coming years, including in those countries where there are severe deficits in the number of professional health workers. In communities where community health workers and TBAs hold a respected position, they can influence women’s use of midwifery care and can provide basic health information about healthy pregnancy, safe birth options, newborn care, nutrition, breastfeeding support, family planning and HIV prevention. Formal and informal links between the traditional birth services in a community and professional health services can facilitate not only the effective use of available resources as well as access to quality. Such links can also open a career pathway for community workers to enter professional midwifery cadre through appropriate education programs.
The government needs to acknowledge the important role of TBAs as a ground reality in Pakistan. Without doing that, long-term planning may be impossible.
Published in Dawn, Sunday Magazine, September 14th, 2014
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