E2A Newsletter, November and December 2015
Nigeria: Saving Mothers, Giving Life stakeholders meeting and assessment results
In Nigeria, resources for health vary dramatically by state and region—a testament to the fragmented nature of the government, including the public health system. To ensure the sustainability of E2A’s approach to the Saving Mothers, Giving Life initiative it is applying in Cross River State, Nigeria, E2A has therefore joined all necessary stakeholders, from communities and primary healthcare up through the state and federal governments, in an effort to garner wide support and leadership for the initiative and to identify additional areas of collaboration.
During the Saving Mothers Giving Life stakeholders meeting held by E2A in Nigeria, on November 17, 2015, at the Gomora Hotel in Cross River State, participants became familiar with the approach that will be applied and how the interventions will contribute to Cross River State health goals.
Saving Mothers, Giving Life in Nigeria will replicate a package of evidence-based, comprehensive maternal and newborn health interventions successfully piloted in Uganda and Zambia that resulted in a 35 percent decline in mothers dying as a result of childbirth at participating facilities. In Nigeria, the interventions are expected to lead to a 15 percent reduction in maternal mortality and a 10 percent reduction in newborn mortalities in the 18 Local Government Areas (LGAs) of Cross River State where the initiative is operating. According to the 2013 Nigeria Demographic Health Survey, maternal and newborn death statistics translate into approximately 241,000 newborns and 33,000 women dying from largely preventable causes each year.
At the stakeholders meeting, participants drafted action plans to address the shortfalls and weaknesses of service delivery in each of the nine northern LGAs. They also heard about results of a baseline health facility assessment conducted by E2A in the 18 intervention LGAs.
Health facility assessment
E2A conducted two separate baselines: one for the nine northern LGAs discussed at the recent meeting and another for the nine southern LGAs. Assessment results will inform how the Saving Mothers, Giving Life model will be adapted in both regions of Cross River State.
E2A assessed the quality of care and coverage of services in both regions, including the functions of basic and comprehensive maternal and newborn care performed, human resources available, supplies and basic amenities available, as well as the causes of maternal and newborn mortalities and morbidities. The assessment spanned 812 health facilities in Cross River State (268 in the southern LGAs and 544 in the northern LGAs) and included public hospitals, primary health centers and health posts, and private hospitals and primary health centers. All facilities selected for the assessment had conducted at least 1 delivery in the previous 12 months.
All health centers in Nigeria are expected to provide the 7 functions of basic emergency obstetric and newborn care services (BEmONC): antibiotics, anticonvulsants, uterotonics, manual removal of the placenta, assisted vaginal delivery, removal of retained products, and newborn resuscitation. All hospitals are expected to provide the 9 functions of comprehensive emergency obstetric and newborn care services (CEmONC), which includes the 7 basic functions as well as caesarian deliveries and blood transfusions related to labor and delivery.
Just 16 out of the 71 hospitals surveyed reported to provide the 9 functions of CEmONC. The majority of those providing CEmONC are private hospitals in the South. Only 4 out of the 369 health centers surveyed reported to provide the 7 functions of BeMONC.
Many health facilities lack basic amenities. Just 148 out of the 812 total health facilities surveyed had functioning water in their delivery rooms at the time of the survey. Only 6 health facilities in the northern LGAs and 13 in the southern LGAs had a functioning toilet for clients to use.
Just over half of private and public hospitals in the northern LGAs and the vast majority of hospitals in the southern LGAs had functioning electricity at the time of the survey, however, only a small number of health centers had power—just 32 percent of public health centers and 10 percent of private health centers in the North and 56 percent of public health centers and 40 percent of private health centers in the South.
The survey showed that essential equipment and supplies were not available in some health facilities, including magnesium sulfate, oxytocin and misoprostol—drugs necessary for safe motherhood interventions. Other equipment shortages include rectal thermometers for newborns, neonatal resuscitation packs, adult and newborn ventilator bags, and partographs, implying that huge investments must be made before many facilities can adequately perform expected functions.
Democratic Republic of the Congo: The beginning of a strong community-based distribution network
E2A’s community-based family planning program in Democratic Republic of the Congo’s Kasai Central, Lomami, and Lualaba provinces—now in operation almost six months—has formed the foundation for a strong community-based distribution network that is supported by community leaders, trained providers, and the three provincial health systems.
E2A has trained 400 community-based distributors and 100 health facility providers to offer integrated family planning and maternal and child health services, and 981 community leaders and champions, of which more than 300 are young people, to generate demand for these services in their communities. This community-based distribution network reaches a population of more than 575,000 people, which includes more than 120,000 women of reproductive age, and almost 109,000 children younger than five. Nurses from health facilities accompany the community-based distributors once a month, and soon twice monthly in some areas, to support them with their outreach work.
Despite continued stock-outs of some commodities including female condoms, progestin-only pills, injectables, and implants, family planning uptake is on the rise and community-based distributors remain motivated to do their work. Among the contraceptives provided, most women have a preference for implants, but stock-outs have hindered the widespread provision of this long-acting method. Providers and community-based distributors, in the first five months of the project implementation, distributed 209,362 male condoms, and 6,938 oral contraceptive and progestin-only pill packs, 6,731 female condoms, 5,828 Cyclebeads, 919 injectable contraceptives (DMPA), and 604 Jadelle implants.
The project is working with local implementing partners and the USAID mission in Democratic Republic of the Congo to address the stock-outs, including a long-term mitigation plan for all supported health centers.
Facility-based providers play a large part in sustaining community-based distributors’ motivation through monthly meetings and outreach sessions with them. The project has also given the community-based distributors bikes. They express pride in having access to transport, which allows them to cover distances further than they had in the past, given the vast terrain and widely dispersed villages.
In addition to bikes for community-based distributors, which have expanded the coverage of services, checklists adapted into local languages that health providers and community-based distributors use to counsel clients on family planning have helped to improve the quality of the information offered.
“Before we were afraid to tell our clients about side effects,” said a nurse working at a project-supported health facility in Lomami province. “We thought that they would be scared and not accept the contraceptive. We found that when we used the checklist and described the side effects to the clients now they are prepared and not scared when it happens and they don’t discontinue.”
Plans for task-shifting and youth engagement
In the three provinces, there is high demand for long-acting reversible contraceptive methods. Providers at health facilities currently offer Jadelle implants and a select set of community-based distributors in the three provinces will soon be trained to offer Nexplanon. The Government of the Democratic Republic of the Congo has a task-shifting policy in place for trained community-based distributors to provide Nexplanon, and the project will ensure that community-based distributors receive adequate supportive supervision for distribution of this method.
In the coming months, E2A will also focus on strengthening the work of youth leaders who target married and unmarried youth in their communities to give them information about family planning and the child health services offered by the community-based distributors (oral rehydration salts/zinc and water purifiers) and refer them to the community-based distributors and health facilities in their communities. These youth leaders will continue to attend regular meetings with providers and other community-based actors, and will be continually supported to document and report on their outreach and referral work.