Addressing newborn mortality in Nigeria

Dr Nnenna Ihebuzor Director Community Health Services National Primary Health Care Development Agency Abuja, Nigeria Team Nigeria @ Global Newborn Health Conference Johannesburg, South Africa April 16th 2013
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Context and objectives of todays discussion

Objectives
Contextualise the problem, major 1
and underlying causes of newborn mortality inn Nigeria and discuss why the Government can do better to improve the lives of Nigerian newborns and women

Context

Women and children in Nigeria continue to lose their lives in large numbers

Demonstrate some of the results 2

and progress in newborn health

Although Nigeria has made some strides inAlthough Nigeria has made some strides in improving women and childrens health, progress has not been fast enough and Nigeria lags behind other countries in dramatically shifting outcomes, especially for newborns

The current shift in Nigerias response aspires to deliver significant, visible, and immediate results in the lives of Nigerias newborns, women and children

Describe Nigerias efforts to 3

deliver significant, visible, and immediate impact and bend the curve for newborn survival by scaling up access to essential newborn care
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Nigerias Demographics
Map of Nigeria Showing the Six (6) Geo-Political Zones
Niger
Sokoto Katsina Zamfara Kebbi Kano Jigawa Yobe Borno

Chad

Bauchi Kaduna Niger Plateau Kwara Oyo Osun Ogun Lagos Ekiti Ondo Edo Enugu Anambra Ebonyi Delta Cross River ImoAbia Akwa Ibom Bayelsa Rivers Kogi Benue FCT, Abuja Nassarawa Adamawa Gombe

B e n in

am e

ro u

Taraba

Zone

Federation of 36 States Population: 167 million + Large under five population and high birth cohort Five main language groups, 250+ regional languages/dialects Infrastructure and logistics challenges: roads, unstable power, dense and rural populations, poor sanitation West Africas transport and migration hub bordering four countries
Atlantic Ocean

Southsouth Southeast Northcentral Southwest Northeast Northwest

One nation: 167 Million+ People, 250 languages, many cultures

Countries with the highest numbers of newborn deaths are similar to those with high maternal deaths
Ranking for numbers of neonatal deaths 1 1 Ranking for numbers of maternal deaths

India

NIGERIA
3 4 5 6 7 8

2
2.4 million neonatal deaths

2
8 13 3 5 6 7

Pakistan

China

DR Congo

270,000 maternal deaths

Ethiopia

Bangladesh

Indonesia

Approx 67% of global total

Approx 65% of global total

Ref: Lawn JE et al BJOG sept 2009. Data sources: Estimates of maternal (2005) and neonatal (2008) deaths from WHO. Updated June 2010

Afghanistan 9 number of newborn4deaths in Africa Nigeria has the highest Tanzania 10 17th in terms of rates 9 and ranks 5 254,000 deaths in 2010 (NMR of 40)

More mothers and babies die in Nigeria per year than in comparable countries
Ghana2 409 352 306 Uganda2 Sudan2

Nigeria1

545

Maternal mortality Deaths per 100,000 live births

40

31

29

36

Neo-natal mortality Deaths per 1,000 live births

1 MMR Data 2008 NDHS, NMR Data 2008 NDHS 2 MMR Data 2008 IHME, NMR Data 2005 WHO 6

SOURCE: National Demographic Health Survey, World Health Organization, Institute of Health Metrics and Evaluation

Variation in MMR across geopolitical zones

Very high MMR High MMR

Moderate MMR
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A tale of two regions: North and South

Northern States 1025-1549 5.7-7.0 41-75 12-49 40-53 Southern States 165-286 4.1-4.6 83-99 56-88 36-50

Selected socio-demographic statistics

Maternal Mortality Ratios (deaths per 100,000 live births) Total Fertility Rate (children/woman) At least one ANC attendance (%)

Delivery with Skilled Birth Attendant (%)

Neonatal mortality (deaths per 1000 live births)

Neonatal mortality: the rich also cry

The poorest Nigerian women have significantly less access to MNCH services than richer women
MCH service access by the poorest and richest women in Nigeria, 2003 91% 31% +196%

Multiple antenatal care (ANC) visits % of pregnant women 85% 13% +555%

Skilled attendant at birth % of live births

Contraceptive prevalence % of women of reproductive age 4% Poorest 20%

21% Richest 20%

+469%

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SOURCE: World Bank: Socio-economic Differences in Health, Nutrition, and Population within Developing Countries

Nigeria: Health System

Responsibility National policy; Monitoring; Tertiary hospitals Population health in State; Referral State hospitals Primary Health Care Facilities

Government Tier

Federal

State

Local Government

Deconcentration SMoH, SACA, SASCP Delegation NAFDAC, NPHCDA, NASCP Devolution LGAs for PHC Health is on the concurrent list

Some States and LGAs simply do not prioritize health and/or make adequate budgetary allocations resulting in inconsistent health services across states and local government areas

Generally, health services, uptake and indicators in southern States better than in northern States
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Health Worker Population Ratios in Nigeria Cadre of Health Care Workers

Physicians Nurses Midwives

Workforce per 10,000 population 2005 2006 2007 3.0 3.54 3.70 10.0 8.95 9.10 6.8 6.36 6.39

Translates to 20 physicians, nurses and midwives per 10,000 population Much higher than for many SSA countries Closer to WHO benchmark of 25/10,000 population required to provide minimum MNCH services. But main constraint is maldistribution
Source: Health Workforce Profile, Nigeria, 2008
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SBA

13

14

Poor Financial Access to Health Services

Source: Soyibo et al 2009

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Why do Nigerian newborns die?

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When? The first week is the riskiest week of life

Mortality risk by week of life for the first 5 years:

The riskiest week of life

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Birth and first week is key:

yet coverage of care is low for mothers and babies

30

25

20

20

15

10

2.33

0.4

0.17 Age 12-59 months

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Weekly risk of death per 1000 live births (global average)

Early neonatal Late Neonatal Post-neonatal (Day 0-6) (Day 7-28) (1 - 11 months)

JE Lawn based on global ENMR, NMR estimates by WHO, and IMR and U5M by UN child mortality group around the year 2008

Why? Coverage along the continuum of care

Not one key package for MNCH above 60% coverage

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Source: Saving Newborn Lives in Nigeria, 2011. Data from DHS 2008

Progress to MDG4
NDHS U5MR UN U5MR IHME U5MR NDHS NMR UN NMR
160 157

250

200

IHME NMR

150
138

100

50
40

Mortality per 1000 live births

MDG 4 target (71)

0 1995 2000
Year

1990

2005

2010

2015

Source: Saving Newborn Lives in Nigeria, 2nd edition, 2011

Child deaths (<5 years) are declining BUT still little progress for neonatal deaths... Now 29% of under five deaths, up from 24% (in 2008) 18

254,000 newborn deaths each year in Nigeria

What is Nigerias response? A holistic response

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Where will we focus?

Mapping of newborn deaths, newborn care delivery points and strategic state/LGA government and partner support

Geographic areas where newborn deaths are concentrated

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Where will we deliver?

Distribution of births in Nigeria by place of birth Source NDHS 2008
Other/missing 2% Public facilities 20%

At home 62%

Private facilities 15%

Public facilities Private facilities At home Other/missing

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What needs scaling up?

Asphyxia Scaling up neonatal resuscitation training with focus on HBB Infection Promoting clean delivery in facilities Scaling up chlorhexidine access and use in public and private health facilities and in the community Improving community case management of newborn infections

Prematurity Antenatal steroids in health facilities for preterm labour Scaling up KMC

Skilled delivery Expand access to facility deliveries (MSS and SURE-P) Improve training (inservice and preservice) on newborn care within MSS and SURE-P

Community care Family planning Engaging families through Closing the gap for unmet needs for contraception essential newborn care messages (early and exclusive breastfeeding, clean cord care and warmth) Educating families on newborn danger signs Improve and increase access to CBNC - through CHEWS 22 and VHWs

Key interventions - in facilities

Intrapartum injury/Asphyxia

EmONC Neonatal resuscitation and HBB training

Helping Babies Breathe training,

Prematurity

Kangaroo Mother Care

Antenatal steroids

Infection - prevention & treatment

Chlorhexidine (nationwide at all levels) Antibiotics for newborns

prevention

Case management of sepsis

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Key Interventions - in communities

Bringing services close to the home

Community Based Service Delivery (CBSD)

Antenatal and postnatal care Chlorhexidine for cord care in communities Early and exclusive breastfeeding Ambulatory KMC Identification and referral of sick newborns to health facilities

Linking community to facilities Community engagement for improved practices & care seeking Ward health committees Village health workers/ counselors Emergency Transport System
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In Nigeria as in most of Sub-Saharan Africa, the majority of neonatal deaths are at home Reducing delays is critical
Delay 2: Transport to care

Delay 3: Receiving quality care

Delay 1: Recognition and decision to seek care

CEmOC Facility BEmOC Facility

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Lawn JE, Lee AC, et al IJGO 2009

Platforms and Options for Scaling Up Essential New Born Care in Nigeria
The objective of any maternal and newborn health (MNH) program expansion should be to increase ACCESS to and QUALITY of services being provided!

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SBA at Birth: Where are we and where do we want to go?

SBA in Health Facilities

SBA at home CHEWs at home Trained TBA at home (Ineffective)

Untrained TBA/Relatives at home (X)

SBA = Physicians, Midwives, Nurses
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MSS Cluster Model

PHC: Primary Health Centre (1000) to provide BEmOC

GH: General Hospital (250 Locations) for referral

Midwives: 4000 (4 per PHC)

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Community Health Workers: 1000 (North-East, North West Zone)

The Midwives Service Scheme has delivered visible results within two years of implementation
789 584

Maternal mortality ratio Deaths per 100,000 live births

-26%

Neonatal mortality rate Deaths per 1,000 live births

9

11

-22%

Pregnant women with focused ANC % of pregnant women

41%

50% +22%

Skilled attendant at birth % of births 12%

16%

+33%

Use of family planning methods % of reproductive age women

1% 2009

2% 2011

+100%
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SOURCE: Midwives Service Scheme

SBA Productivity: Deliveries per Skilled Birth Attendance Per Annum

# Deliveries Per SBA Per Annum
12 20 27 35 52 56 59 70 85 100 100 115 131 136 139 147 180 226 349 0 50 100 150 200 250 300 350

UCH FMCA FMC Gusau King Fahd WCH Sheikh Mohd Jidda GH Fagwalawa GH Kaura Namoda GH Danbatta GH Gezawa Anka GH MMSH Waziri Shehu Gidado Sir Mohd Sanusi GH Dawakin Tofa Shinkafi Tudun Wada GH Zurmi Tsafe GH Rano GH

Tertiary Hospitals

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The SURE-P MCH programme will build on the impact of MSS through supply and demand-side interventions along the continuum of care
Continuum of care Training Antenatal visit 1 Payment Conditions Demand Inputs Conditional Cash Transfer

Supply Inputs Human Resources for Health

Recruitment

Deploy-ment

Ident-ification

All cadres receive a one-week training Antenatal visit 4 Skilled attendant at birth Postnatal care Women who meet conditions are paid a set incentive value

Midwives and CHWs recruited from school or unemployment database, VHWs from communities

Midwives and CHWs deployed after enrolment, VHWs deployed after training

Women are encour-aged to meet programme conditions (i.e. to access MCH services at PHCs)

Pregnant women in the community identified by VHW, CHW, or midwife

Family Planning

SOURCE: PIU team

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These health workers will reach deeper into target communities with the help of the ward development committees
WDC Midwives PHC referral VHWs CHWs PHC Patient

Patient

Midwives

CHWs

VHWs

PHC referral

Hospital PHC

Midwives Patient

Patient

Midwives WDC

CHWs

VHWs

VHWs

CHWs

WDCs play important roles in this system: Ensure beneficiaries are aware of the programme and receive the benefits Monitor implementation within the community Hospitals key for providing services for complicated births SURE-P to provide health commodities to the PHCs and health workers in each community

SOURCE: PIU team

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The supply-side intervention will dramatically scale up the number of health workers
Scale-up from 2011-15 Thousands of workers
2.0 0.8 0.6 2.0 9.4

Description

Midwives provide care for women

during pregnancy, labour, the postpartum period, and also provide care for newborns
4.0

Midwives

Health workers hired by the

SURE-P MCH programme specifically to offer MNCH services to communities
1.0 1.0 0.4 0.3 1.0 3.7

Community health workers (CHW)

Health workers not hired under the

12.0 12.0 0

12.0

48.0 12.0

Community health workers (CHW), non-MSS & SURE-P MCH

MSS programme who provide a wide range of health services within their community, but to be trained on MNCH by SURE P.

Workers within the community

9.0
0 1.2

3.0 0.9

Village health workers (VHW)

14.1

trained on basic health care services and household practices Primary role is to stimulate demand for health services

2011

12

13

14

2015 Total
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SOURCE: World Health Organization, PIU team

Nigeria DHS 2008 Why Doesn't Skilled Birth Attendance Alone Lower Neonatal Mortality?

100

90

80

70

60 NNM SBA

50

40

30

Percent SBA and NNM/1000

20

10 North East North Central South South South West South East

0
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North West

The focus on human resources and demand stimulation comes from earlier lessons about what drives outcomes
Implications for SURE-P

Insights from 2009 effort

On average, Nigeria does well to provide

Focus on human resources supply and

access components

However, available facilities are distributed

inefficiently, often lack basic equipment and supplies and are underutilized

demand-side intervention using PHCs that already exist appropriate given evidence that building new PHCs is unlikely to dramatically improve outcomes

Additionally, PHC staff does not spend

sufficient time on outreach

Addition of VHWs and scale up of CHWs

will significantly increase outreach efforts and get health resources deeper into communities, mitigating the challenges of PHC-based service delivery

Overall, available access does not

adequately translate into improved outcomes

SOURCE: McKinsey

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Opportunities )

Government

UNCC Nigeria as co chair Saving One Million Lives Initiative Child Survival Call to Action and African Leadership for Child Survival Road Map SURE-P MCH

Global momentum Global Newborn Health Conference

State of the Worlds Mothers 2013 Donors Development agencies Private sector

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Thank you

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