From the December 2015 issue of The Rotarian
The rainy season in Nigeria varies depending on what part of the country you’re in. In the south, the rains begin in March and end by November, with a short respite known as “the August break.” In the north, the rains arrive in June and continue through September. If you’re a pregnant woman living in a rural area – which most of the country is – you hope your due date falls during the dry season. That way, if you need to get to a hospital, the roads won’t be washed out.
Nigeria’s maternal and newborn mortality rates are among the world’s highest, and bad roads are one of “three delays” contributing to these alarming statistics, according to a health project led by the Rotarian Action Group for Population and Development (RFPD). Another delay occurs in the villages, where prenatal information is scarce and women rely on untrained traditional birth attendants at delivery time.
“The third delay is when you get to the hospital and it doesn’t have the facilities to deal with problems, and some of the equipment is inadequate, and the training of the medical staff is poor,” says Mark Townsend, a retired physician and member of the Rotary Club of The Island & Royal Manor of Portland, England. Townsend recently visited a project site in the southern Nigerian state of Enugu as part of an evaluation for The Rotary Foundation’s Cadre of Technical Advisers.
Only 58 percent of women in Nigeria seek medical care during pregnancy, 35 percent deliver their babies in a medical facility, and 42 percent get checkups after giving birth, researchers reported in a 2011 article in the International Journal of Gynecology and Obstetrics. The country’s maternal mortality ratio – based on data from the World Health Organization, UNICEF, the United Nations Population Fund, and the World Bank – is 560 for every 100,000 women. Data from Nigeria’s National Demographic Health Survey show that for every 1,000 live births, there are 69 deaths. For children under age five, the mortality rate is 128 per 1,000.
NUMBERS LIKE those are the reason RFPD has made maternal and child health one of its priorities. The group traces its beginnings to the 1994 UN International Conference on Population and Development in Cairo, which marked the first time a representative from Rotary International – Past RI Director Umberto Laffi – joined the world body in a discussion on population and development issues. With more than 20,000 members today, RFPD is the largest of Rotary’s 22 Rotarian Action Groups, which aim to connect members with a particular project or service focus. It maintains a database of population and development projects funded by Rotary Foundation Global Grants that clubs can help sponsor.
In Nigeria, RFPD has supported Rotarians working to advance maternal and child health for the better part of 20 years. In May, they achieved a historic first when four states – Kano, Kaduna, Ondo, and the Federal Capital Territory (FCT Abuja) – announced they would adopt Rotary’s quality assurance model for improving maternal and newborn health into their statewide health systems. The decision ensures the sustainability of a program that has sent maternal mortality rates plummeting wherever it has been implemented.
The simplest explanation of the model comes from the International Federation of Gynecology and Obstetrics (FIGO), which calls it a “cycle of continuous improvement via the introduction of standards, collection of data, and discussion of results.” It represents the accumulation of knowledge gained from years of Rotary health projects in Nigeria focused on family planning and the health of mothers and newborn babies – especially a 2005-10 pilot project, which initially centered on obstetric fistula and expanded into a comprehensive strategy to reduce maternal and child mortality. Public and private funders in Germany, Nigeria, and Austria cheered its dramatic results: a 60 percent drop in maternal mortality and a 15 percent drop in infant mortality. FIGO called the effort “a masterpiece.”
“This was a pilot project for the reduction of maternal mortality – and if it’s a pilot, it should be an innovation. And if it’s an innovation, it should be replicable and scalable,” says Robert Zinser, CEO of the action group. “And it was, thanks to the German government, which co-funded the pilot project. They said, ‘Look here, this is a great project you did, don’t you want our funds to scale up?’ If the co-funders want to co-fund again, then you see you are on the right track.”
NONE OF THIS success would have been possible if Zinser and Emmanuel Adedolapo Lufadeju hadn’t met at Rotary’s 1994 International Assembly. Zinser, then incoming governor of District 1860 (Germany), was interested in population issues. Lufadeju, of District 9120 (Nigeria), was concerned about his country’s sky-high birth rate.
Lufadeju told Zinser that Nigeria’s population problem was exacerbated by a scarcity of contraception and family planning resources, underequipped clinics and dilapidated rural hospitals, and limited awareness of the health risks of multiple pregnancies. “There were too many early marriages in my country, and people continued having children after age 35,” he says. “Three, four, five, up to 11 children. There is also a high mortality rate for these children, and a lot of newborns die because of pregnancy-related problems. You have many children because you think, ‘If I have six children, maybe I will lose three.’ So: pregnancies too early, too frequent, and too late in life. When we put this all together, we decided we must do something.”
Zinser and Lufadeju ended up launching a groundbreaking health project in two local government areas in the northern state of Kaduna with a $35,000 Matching Grant from The Rotary Foundation. The effort, which ran from 1995 to 2000, had four goals: to build capacity by training nurses, doctors, midwives, and village health workers; to supply poor hospitals with essential medical equipment; to educate people about the benefits of family planning; and to make contraception more widely available. In pursuit of the last goal, and with a second $100,000 Matching Grant co-funded by the German government, Zinser and Lufadeju sought and won unprecedented permission from local officials to install “contraception distribution cupboards” in 21 clinics. “That was a major achievement,” Lufadeju remembers. “The fact that we were able to integrate the local government and all the stakeholders in contraception – that had never happened before.”
During the five years of the project, contraception use soared from 3 percent to 27 percent. “USAID asked us about it,” Zinser recalls. “They said, ‘We spent millions and never had such a good result.’” Local government officials and civic and religious leaders also were impressed, and wanted to expand the program quickly to 10 states. Zinser had to persuade them to scale back their plans. “You have to go step by step” to replicate the success, he explains. With the help of RFPD, the child spacing and family health program was expanded to six states in Nigeria, funded by The Rotary Foundation, the David and Lucile Packard Foundation, and the European Commission.
With that program off and running, Zinser led a shift in the focus of RFPD in Nigeria, to maternal health. His mantra is, “If you take care of the mother, you take care of the child.” So when health officials asked for help in building a clinic to treat obstetric fistula, he and Lufadeju readily agreed.
Fistula can result from the birth canal tearing during a difficult childbirth. Such births are often fatal for the newborn. For the mother, the fistula causes chronic health problems such as incontinence, which can lead to social shaming and isolation. According to WHO, which calls fistula “the untreated tragedy,” as many as 100,000 women worldwide develop it every year, and more than two million women in Asia and sub-Saharan Africa live with the condition.
The obstetric fistula project in northern Nigeria provided surgeries at two fistula centers, trained doctors, and conducted an education campaign on the need to seek medical attention when labor starts. In addition to medical care, patients also received vocational training and microcredit loans.
Like so many pregnancy-related issues that the developed world addressed long ago but poor countries still confront, fistula is preventable. “Gradually, we learned that fistula is a problem caused by lack of antenatal care,” Zinser says. “So we said, let’s do antenatal care. Let’s start with prevention.”
With that decision, RPFD launched the Quality Assurance in Obstetrics project in 10 rural hospitals. Over two years, beginning in November 2012, the effort expanded from the original 10 hospitals in Kano and Kaduna states to include another five in Ondo State and five in FCT Abuja. A second “scaling-up” stage, from 2013 to 2015, added five hospitals in Enugu State. The protocol is based on Western clinical practices that have proved successful and replicable, and that measure three standards of quality. Lufadeju explains: “Quality of infrastructure comprises the condition of the hospital: the building, water supply, power supply, hygienic conditions, number of personnel, and available treatments – basically asking, what shape is the hospital in? Second, quality of process: This looks at the adequacy of medical personnel’s professional qualification and experience, and measures the performance of their record and data keeping. Quality of outcome looks at the impact of our intervention – the change in maternal and infant morbidity and mortality and improvement in the system.”
Outcome measurements are the most important data, because they indicate how well the rest of your efforts are working. Lufadeju says the Rotary quality assurance model made it possible, for the first time, for Rotarians and health officials to get to the root of the issues they had been grappling with for years. “When you start a project, you start generally and then begin narrowing down to the most important problems,” he says. “By the time we got to this project, we had narrowed down what is causing morbidity and mortality. If you don’t understand what is causing the problem, you will continue, forever and forever, to have to solve the problem.”
FIGO President Sir Sabaratnam Arulkumaran says the program lit a path that allowed Rotary to target its work, providing help where it was most needed. “This process of measurement led to interventions by Rotary: supply of medications and instruments, production of simple guidelines to tackle problems, teaching and training, implementation of the processes, measurement of outcomes continually in a dashboard to close any loopholes. This spiraling audit cycle has led to continuous improvements.”
Zinser traveled to Abuja in early May with a small team to meet with government health officials and present data from the hospitals where the quality assurance project has been implemented. Wapada Balami, director of the Family Health Department of the Federal Ministry of Health, praised the Rotary team’s plan to incorporate its quality assurance model into the WHO Maternal Death Surveillance and Response program, declaring, “This was exactly what Nigeria needed.”
Before he left for Nigeria, Zinser called government adoption of the project his “dream.”
“If they gradually start, step by step, to take this model project into their health system, then other states in Nigeria hear about it and start to take the model into their health system. That is the dream. You have to have a dream sometimes, and sometimes dreams come true.”
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