Governance Power, Newborn and Maternal Lives in Nigeria

This blog was originally published in the Weekly Trust. Written by Nosa Orobaton.

It was Sunday, April 22, 2013. The starless, breezeless night sky pregnant with rain clouds was aglow with the moon waxing in Gagi suburb of Sokoto town in northwestern Nigeria. It was in a house 300 meters off the main road that public health history was made in Nigeria; and in sub-Saharan Africa. Silently made, it was, save for the piercing, heartwarming first cry of a newborn baby that ushered his arrival alive, into his world, and into our world as we know it. Much of the country’s aspirations are now riding on the expectation that the history making events will mark the beginning of the end of a world of indefensible and avoidable deaths of neonates in their first month of life; as well as the death of mothers during the seven million annually occurring childbirths in Nigeria. For now, he goes by the name Baby Nasiru. 

On this Sunday night, the temperature is slightly less than the 45 degrees Celsius which held sway most of the day.  Gagi is in transition. Old mud houses are slowly giving way to those built with cement blocks, a sign of growing prosperity. The scatterings of neem trees around the community appear to affirm the community’s unyielding resilience and resolve to challenge the insatiable embrace of the ever-expanding frontiers of the Sahara Desert. It also hints to a touch of community defiance to outside forces, for better or for worse. Much of the community is quiet by night.    ?

Nasiru is the man of the house, the husband of Suwaiba and father of the newborn. He is an unabashed tinkerer and a self-taught electronics engineer. He makes his living cobbling working TVs out of carcasses of abandoned TV sets that presently form a rising three-foot high pyramid on his lot. His electronics laboratory which doubles as his showroom is located in the front of his cement house, which opens into the street. Armed with secondary education, and his deep faith in the practice of Islam, Nasiru passionately brings the world to the community through the television. Over a decade ago, he even briefly set up his own now defunct, private FM radio station that broadcasted to Gagi community. His showroom is also adjacent to the private rooms and courtyard where Suwaiba, his newest and second wife, is confined to a life of purdah. ?

Suwaiba reads and writes Arabic, and her education was limited to Koranic school. She does not leave the compound. She does not go to the market. Suwaiba has never attended a clinic for prenatal visits, although she has delivered babies five times since she got married at the age of 16 years. Suwaiba is 25 years old. She has never delivered a child in a health facility. Her one source of information is what Nasiru tells her. Another is word of mouth brought in by other women, whom Nasiru approves of. No one can get to Suwaiba without his consent. Similarly, Suwaiba cannot reach out to people and institutions outside her home without Nasiru’s express consent.  ?

It was on this Sunday night that Suwaiba went into labor. She did not go to the nearby health center that was recently upgraded with support from the state and Federal Governments and their partners. It is unlikely she even asked to go to the health center. Less than 1,000 minutes later, her son will be safely delivered at dawn on Monday, just before the call to Fajr prayers. It will be her fifth delivery, and this one produced her first son.

Baby Nasiru is the first newborn to benefit from the Sokoto State government-sponsored community-based distribution programme to deliver to every child, Chlorhexidine 4% gel to prevent cord infections. Also, a part of this program, Suwaiba received and ingested Misoprostol tablets to prevent bleeding associated with childbirth.

It is also the first time that these medicines are being offered to all political wards in a state, in any state in Nigeria, or elsewhere in Africa. It is also the first time that Chlorhexidine 4% is being used for cord care at population level. Only Nepal has a more developed programme. Government statistics estimate that in Sokoto State alone, with the introduction of Chlorhexidine, would save 2,000 newborns from death in the first month of life each year. When applied across Nigeria, 60,000 deaths could be averted. In the case of Misoprostol, 1,000 women will be saved from dying each year in Sokoto State and 10,000 women nationally. ?

Elsewhere in Abuja, New York, Seattle, Oslo and Geneva, where this event is being closely watched, one lingering question is how this bridgehead of an intervention can be leveraged at national scale to accelerate Nigeria’s quest for results in the final 1,000 day push to meet the UN Millennium Development Goals of 2015. A number of things must happen if what is happening in Sokoto is to spread to other states in Nigeria. The first is that other state governments must launch and agree to finance similar programmes in their respective jurisdictions, and do so with a sense of urgency. Second, these medicines need to be locally available on a predictable and continuous basis. Misoprostol is already available locally. Chlorhexidine gel is only available in Nepal. Fortunately, Dr. Muhammad Ali Pate, Minister of State for Health in Nigeria publicly issued a call-to-action on March 13, 2013. He beseeched all state governors to emulate Sokoto State government, so that there are enough local buyers of Chlorhexidine 4%. In return, the increased and sustained demand for Chlorhexidine 4% will serve as a strong signal for prospective, local manufacturers.

This is a renewed call to all state governors to commit to the Chlorhexidine 4% intervention for cord care. This is a call to civil society organizations to lobby state governors and states lawmakers to commit to the local production of Chlorhexidine 4% gel for cord care. This is a call to local pharmaceuticals to locally manufacture Chlorhexidine 4% gel for cord care.      ?

So on that night, Suwaiba’s husband contacted Halima, the local traditional birth attendant, and trusted woman in the community, who also doubles as a community-based health volunteer. Halima is one of the over 2000 trained community health volunteers in the state. Ten of them are in Gagi. Sokoto State government and USAID worked in tandem to train these volunteers who are now a vital source of information to women and men in communities across Sokoto state. In the last three months alone, largely as a result of these volunteers’ efforts, the average number of prenatal visits per woman has doubled from one to two. Halima contacted a community designated and trained drug keeper who dispenses these medicines when labor is confirmed to have begun. 

Halima took the delivery of the baby, gave Suwaiba the recommended three tablets of Misoprostol to swallow, cut the umbilical cord with a clean razor, tied the cord appropriately, applied Chlorhexidine on the cord stump and delivered the placenta. Halima is a critical part of the health system that makes the household level distribution of knowledge, information and medicines possible. She is also a fountain for the nurturing and growth of local trust, the oxygen of this program. 

Nasiru allowed information about these two life-saving medicines to penetrate his household. He agreed for the medicines to be used for his wife. He also has consented for his son to be immunized. He did not have to. Yet, he did. It is the spirit of the tinkerer at work. Consenting parents need the backing and support of state governments to ensure that these low cost, high impact lifesaving medicines are available on a predictable basis. Nigeria has the market and industrial capacity to manufacture Chlorhexidine 4% gel. As an act of good governance, elected officials owe it to new, annual seven million newborns in Nigeria, who are us in our most vulnerable time. ?

Baby Nasiru was brought out to meet visitors when he turned 5 days old. He was very well and very active.  His cord stump was dry and clean. In a few days, he will be seven days old. He will get his own name. Suwaiba did not reveal anything. “I thank the Almighty and the government for making this program available. It must be continued for all other women.” Nasiru agreed. No need to tinker with what they now know works. A new dawn may well have arrived. What remains is to sustain it through the power of governance. It rests with state governors to do the right thing.

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