Lead Writers: Ugonna Ofonagoro, Michael Atima and McHenry Igwe
It was a long drive to get to Odenigbo community in Ikwo Local Government Area (LGA), Ebonyi State. The untarred road was bumpy, full of potholes, and wound through thick vegetation on both sides, with only sparse signs of development the further we travelled. Odenigbo is a relatively small community and having experienced the roads, one couldn’t help but wonder how tasking it must be for community members to get to the capital city, Abakaliki, an estimated one-hour drive from the community.
This is especially worrying for healthcare delivery, especially when pregnant women need to access maternal care and other health services. Pregnancy and delivery are some of the most vulnerable moments in a woman’s life in Nigeria. Nigeria represents 2.4% of the world’s total population, but 19% of maternal deaths globally occur in Nigeria. One Nigerian woman dies every 13 minutes — that is 109 women dying every day — from preventable causes related to pregnancy and childbirth. These are only recorded deaths. Nigeria is yet to have a system that allows it to record maternal deaths that happen in the communities, where women do not go to a health facility to give birth.
In May 2019, a baseline survey was carried out across six states, one per geopolitical zone, to gather evidence on the prevailing factors responsible for maternal mortality in rural communities across Nigeria. The survey is part of an 18-month project being implemented by a consortium consisting of Africare, EpiAFRIC and Nigeria Health Watch, called the “Giving Birth In Nigeria (GBIN)” Project, and commissioned by MSD for Mothers. The goal of the GBIN project is to catalyse accountability for maternal deaths in Nigeria.
Ebonyi was the state selected in the South East, and Odenigbo was the selected community. A study to determine the causes, trends, and level of maternal mortality rate in a teaching hospital in Abakaliki, Ebonyi State, was published in 2013. It reviewed the records of all maternal deaths related to pregnancy over a ten‑year period, January 1999 to December 2008. During the study period, there were 12,587 deliveries and 171 maternal deaths. The maternal mortality ratio (MMR) was 1,359 per 100,000 live births. The trend over the period was lowest in 2008 with an MMR of 757 per 100,000 live births, and highest in 1999 at 4,000 per 100,000 live births. The progressive decline in maternal mortality corresponded with the time that free maternal services were introduced in Ebonyi State. Hemorrhage was the most common cause of maternal death, accounting for 23.0% maternal deaths, according to the study.
Given the distance of Odenigbo from the state capital, Abakaliki and the state of the roads leading to the community, the Nigeria Health Watch team was expecting to hear numerous stories of women who had died trying to give life. It came then as an incredibly pleasant surprise to learn that the community had recorded no maternal deaths this year. Instead, there is a health facility in the community and pregnant women are encouraged by community members and health workers to attend antenatal classes and give birth at the facility, fostering a positive health-seeking culture despite the remoteness of the community.
Extending primary health care to remote communities
The encouraging maternal health ecosystem in Odenigbo is made possible by an organisation committed to extending primary healthcare services to remote areas in Ebonyi State, with a particular focus on safe motherhood, maternal and newborn health.
Ananda Marga Universal Relief Team (AMURT) is a private international voluntary organisation founded in India. AMURT came to Nigeria in 2010 and started a pioneer project in Ebonyi because of the state’s high maternal mortality rates. Director Dala Tul Biernsen said their aim is to reduce maternal and child mortality to the barest minimum. The project is run in collaboration with the Ebonyi State government. In Ebonyi, AMURT is currently in five LGAs; Abakaliki, Ikwo, Ohaukwu, Onicha and Ebonyi. They currently partner with nine primary health facilities in the five LGAs in Ebonyi State. Each facility caters to a project area that encompasses about 20 villages. “Our role here is basically to decrease mortality and morbidity to the barest minimum,” Ikechukwu Obinna, a medical doctor with AMURT, said.
Three of the facilities operate as Comprehensive Maternal and Child Care (CMCC) centres. These centres are different from the other six because they conduct surgeries. Doctors are resident in these communities in case of emergencies. AMURT upgraded the three centres to CMCCs and located doctors in those communities where they could handle caesarian sections after they noticed that there were delays before women were taken to the referral facilities, where surgeries could take place.
A community-driven primary health care model
All the health centres AMURT have helped to open in Ebonyi State are community/government owned and community managed. The community is involved in the building of the facilities, contributing labor and local materials like sand and sometimes wood, while AMURT provides the major building materials. When the health centre is built, community members have a sense of ownership. This fosters sustainability because the community takes responsibility when maintenance issues arise at the facilities.
AMURT put in place a revenue system that ensures funds generated at the health centre is used for basic operating supplies, cleaning supplies, casual staff salaries, maintenance and fuel. They also encourage their health centres to save some money to contribute towards expansion and upgrading the health centres.
AMURT recruited maternal health promoters who were formerly Traditional Birth Attendants (TBAs) in the community. These are women who are respected and trusted by their community. The women are trained on the danger signs of pregnancy, then divided into support groups, which also include a health facility staff member. Pregnant women in the community register and join the support group monthly meetings. The maternal health promoters identify pregnant women in the community, encourage them to go for antenatal checkups, encourage them to give birth at the facility, monitor live births for those who choose not to give birth at the facility and report on those who deliver at home. These reports are used together with the health facility’s database to track the rate at which women are giving birth either at home or in the facility, Dr. Obinna said.
Human resource development: A critical game-changer in maternal care
In each project area, AMURT created management committees that take charge of managing the day-to-day activities in the health centre.
One of the biggest challenges in government-owned health facilities is that staff who do not reside in the community usually come to work late and leave early, which means they are usually unavailable at night and during the weekends.
AMURT tackled this challenge by having the management committees mobilise community members and recruit auxiliary and additional staff from project areas. As a result, 80% of staff at the health facility are from the project areas. This ensures that those at the facility speak the same dialect and understand the cultural and religious beliefs of the community. This helps to build the trust and confidence of community members in the health facility.
The health centre in Odenigbo, as well as other AMURT centres, operate a shift model for their health facility staff. Each of the teams that run a shift, work one week on and one week off. Each team comprises of a doctor, a laboratory scientist and 1 or 2 midwives. This ensures that staff are available to tend to women who attend the facility, and also ensures that health workers are not overworked and can provide their best service when they are on duty.
In addition to adequate staffing, AMURT sends its staff for periodical training, through various partnerships. Partners include the Maternal and Child Surveillance Program (MCSP), which trains on obstetric emergency, and USAID which trained on special procedures like tubal ligations. AMURT also provides scholarships for auxiliary nurses to pursue a formal education after they have worked at the health centre for three years, Director Biernsen said.
AMURT also signed a Memorandum of Understanding (MoU) with the Ebonyi State government in 2012 and renewed it in 2017. It outlines a board partnership-style operational model for the health facilities under its care. The partnership involves AMURT, the government, the communities, and the private sector. The government posts the Officer-In-Charge (OIC) to the health facility as well as provides five government health workers to each facility. The MoU allows the facilities to attract aid from international organizations, who provide commodities for malaria, family planning, maternal health or other issues, as well as training.
Some of the challenges they face include the government’s inability to provide the five health workers it committed to under the MoU, and the long process of behavioural change and building trust in the health facility.
Still, as a result of the inputs by AMURT, the community of Odenigbo has recorded a high number of safe deliveries, with up to 90–100 births every month, Dr. Ikenna said. “We have a ratio of 85% deliveries in the facility to 15% deliveries at home,” he said, a huge improvement from previous years. The data is possible because of their unique community-driven tracking system, which tracks births both in the health facility and in the community. The safe deliveries are possible because of community-focused revenue generation and human resource recruitment and training. These are models that can be replicated in every community, to prevent women from dying during pregnancy and childbirth.
Do you know of a unique primary health care model that is saving the lives of pregnant women? Share with us on social media! Use the hashtag #GivingBirthInNigeria
Reductions in maternal mortality in Ebonyi State cannot be ascribed to AMURT. The organization definitely made contributions but there are others who worked/working towards the same goal, including the USAID-funded Maternal and Child Survival Program – a 4 year project that only just ended in 2018. USG finds were used to provide the technical assistance needed to improve the quality of maternal and newborn health services in all LGAs in Ebonyi (and Kogi) states. It also donated equipment to secondary and tertiary facilities for quality CeMONC care and newborn resuscitation.
Yes, Malaikah has a Primary health care model for saving lives of pregnant women that has been tested in India and Uganda and has been p proven to be very effective.
Malaikah Medical Center a Community Centered health and referral health Center, set up to provide quality accessible and affordable health care services with a mandate to develop a supportive medical research and health education environment. It provides specialized clinical services in the areas of gynecology, pediatrics and Non-communicable Diseases.
Contact Malaikah for a collaboration
This is very commendable. The approach is simple and can easily be scaled; a lesson for any group interested in high impact MNCH inervention.