Maternal and child deaths: A battle Gombe State is not winning

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Gombe Women and Children Hospital

Gombe State government used to pride itself as running a free maternal and child health (FMCH) programme. Recently, the government allegedly suspended the programme for reasons that the public, particularly maternal and child survival activists, consider to hold no water. Analysts have expressed shock and dismay over this decision that the public see as insensitive to the plight of the poor. The question has been: why completely remove funding for a programme that was actually not fully addressing the problem because of the insufficiency of funding?

Everyday, Nigeria loses 2,300 under-five year old children and 145 women of child-bearing age, according to the 2013 edition of Nigeria Demographic and Health Survey (NDHS), which puts Nigeria’s maternal mortality ratio (MMR) at 576 deaths per 100,000 live births.

The meaning, according to experts, is that out of every 100,000 live births, 576 women die within 42 days of childbirth of causes related to or aggravated by pregnancy or its management (excluding accidental or incidental causes).

With about 7 million births yearly, Nigeria records 40,000 maternal deaths yearly, and ranks second highest in maternal mortality globally.

According to reports by the United Nations Children’s Fund (UNICEF), the Northeast Zone has the highest maternal mortality ratio of 1,549/100,000 live births, compared to165/100,000 live births in the South West Zone.

The highest neonatal mortality rate (death of infants within the first 28 days of life) is also in the Northeast and North-West regions of the country. Gombe State, in the Northeast region, posts an MMR that is lower than the regional average but uncomplimentary all the same.

With a projected population of 3,022,590, the state’s hospital-based maternal mortality rate is said to be much higher than the national average. For this reason, activists say the state government needs to restore FMCH immediately; otherwise the state’s maternal death ratio would follow the recent national pattern.

According to Dr. Ejike Orji, Chair of the Coalition for Maternal, Newborn, Child and Adolescent Health Accountability in Nigeria (C4MAN), the national ratio, which was brought down to well under 500 by the national Midwives Services Scheme (MSS), shot up to the current level—576—after the abrogation of MSS last year.

Most of the people The Guardian spoke with believe that if re-introduced, Gombe’s FMCH programme would help in reducing the death of pregnant women and children.

It is common knowledge that some of the underlying causes of maternal and child deaths in northern Nigeria are rooted in cultural and religious factors that make proven, effective modern healthcare inaccessible to women. However, poor funding and inappropriate government policies are more directly related factors.

Mr. Musa Abubakar, who describes himself as a maternal and child health stakeholder in the state, says that poor access to quality and affordable healthcare, and lack of emergency obstetric care are factors working against maternal and child health in the state.

Suspension of free access to these services can only make matters worse, he says.

Experts point out that most maternal deaths are preventable, as the health care technologies to prevent or manage complications are well known. Pregnant women only need access to antenatal care, skilled care during childbirth, and care and support in the weeks after childbirth. It is important that skilled health professionals attend all births, as timely management can mean the difference between life and death for both the mother and the baby, Abubakar explains. He adds that unless there is urgent improvement in service access and timely release of funds budgeted for the health sector; the state would continue to record high numbers of maternal death.

Also speaking on funding, the State Chairman of Media Coalition on Neonatal and Child Health (MNCH), Alhassan Yahya, said that the allocation to the health sector is inadequate, and cannot “go round” in terms of providing health coverage for all.

“Looking at the approved budget in our health sector in 2016 and estimates for 2017, allocation to the health sector is grossly inadequate,” he insists.

“From our analysis, the percentage allocated to health was 9.7 per cent in 2016. This was grossly inadequate, looking at the population growth rate of 3.2 per cent and the influx of internally displaced persons.”

The consequence of poor funding and inappropriate policies is wide-ranging, activists say. All the primary health care centres are in poor condition and without adequate numbers of doctors, midwives, nurses and other health workers.

Gombe State has 615 health facilities comprising 592 primary health care centres, 22 secondary facilities, and one tertiary facility. The number of health care workers in the public sector in the state is 4,081. At 1,209, community health extension workers (CHEWs) constitute the majority; nurses and midwives follow with strength of 1,150. Others are junior community health extension workers - 605; doctors - 163; community health officers - 114; environmental health officers, environmental health technicians, and environmental health assistants - 560; and more than 1,000 village health workers.

“Most maternal deaths are due to lack of skilled attendance at delivery, lack of access to obstetric emergency care, and poor access to family planning, among others,” said Mr. Abubakar. He added that some of the maternal deaths occur due to a mix of harmful cultural practices, poor health services, poor health funding, transport difficulties, inadequate infrastructure, and social disorganization. He therefore urges government to improve services in the health facilities, adding that skilled attendance during childbirth will reduce the number of deaths and the number of women who develop obstetric fistula, another major maternal problem.

It is known, however, that facility utilization will not improve simply because access haS improved; there will be need to persuade women to embrace orthodox medical services. He therefore urges government to step up behavior change communications in this regard.

Mrs. Hannatu Luka, a retired midwife, says that many women who live in rural areas have no access to good health facilities, adding that when they go into labour, they have to trek long distances to get to a health facility. This is inimical to maternal health, because delays and unduly prolonged labour lead to birth complications such as obstetric fistula. She said prolonged labour is one of the five major causes of maternal death.

She also said that government needs to implement some of the reproductive health policies that tackle the root causes of maternal death and obstetric fistula—delays in accessing emergency obstetric care—and invest more funds in emergency obstetric services.

“There is also the need to increase awareness about obstetric fistula at the community level; improve the health seeking behaviour of women at the community level; institute girl child education, women empowerment, poverty reduction, road networks, and other infrastructure,” Mrs. Luka said.

Investigations in Gombe State’s central and northern senatorial zones revealed poor amenities in health facilities, and total absence of safe delivery kits. Most of the facilities lack trained health workers such as midwives, nurses, and doctors to handle critical cases and emergencies.

At Nafada General Hospital, the Acting Chief Nurse, Mr. Maruwa Fware said that the maternity ward, which shares the same building with two additional wards—the children’s and women’s wards—has only three midwives, while 17 nurses and two doctors serve the entire hospital. He said there is urgent need for additional midwives, nurses, and professional health workers, as well as delivery kits, manual vacuum aspiration (MVA) sets, emergency drugs like oxytocin and misoprostol to save the lives of women.

At Bajoga General Hospital, Chief Nursing Officer Saleh Gadam, said that the hospital has three midwives, three doctors, and 32 nurses, and that there is need for more health workers in all categories to cover all the units in the hospital. Human resources are required to detect and appropriately manage common life-threatening maternal health issues such as pre-eclampsia before the onset of convulsions (eclampsia), adding that drugs such as magnesium sulphate (for pre-eclampsia) and drugs for otheremergencies should be available in all health facilities to save the lives of women. At the moment, such drugs are rarely available in the required quantities.

Deba General Hospital, which is a 57-bed facility, has three doctors, two midwives, and three nurse-midwives. One of the doctors, who asked for anonymity, said the hospital is in bad shape in terms of manpower, equipment, and other necessities. He explained that a major problem is that primary health centres lack manpower to handle proper care of pregnant women from rural areas, adding that government needs to make health its second priority after education, as an unhealthy population cannot develop meaningfully or adequately exploit the opportunities provided by education.

Currently, he explained, the attention given education makes it the first, second, and third priorities of the government. He also said the government needs to get its priorities right now that development partners – the international donors to the health sector – are pulling out. The assistance of development partners has traditionally helped to make up for financial lapses in the health sector.

Mr. Ibrahim Bako Nafada, Director Primary Health Care in the State Primary Health Care Development Agency, says that primary health care is the first line of service delivery, adding that the agency has concluded plans to recruit more nurses, midwives, community health extension workers, and junior community health extension workers to help address the problem of maternal mortality in the state.

Also speaking on the matter, the state’s Commissioner for Health, Dr. Ishaya Kennedy said that state government is not relenting in its efforts to ensure adequate maternal and child health.

One of the recent efforts of the state government to save the lives of pregnant women and children is the construction of an “ultra-modern” women and children hospital in the state capital. He said the hospital is equipped with modern facilities, and that it can compete favourably with its counterparts in advanced countries. “Governor Ibrahim Dankwambo is passionate about maternal and child health, hence the construction of the N1 billion facility,” he said.