Nigeria has the second-highest number of neonatal deaths globally. In this report, CHINYERE OKOROAFOR writes that establishing more primary health centres with neonatal facilities, among others, is crucial to ending the scourge.
One Saturday morning, in the Iba New Site area of Ojo, Lagos, Onyemuru Akubueze’s mobile phone interrupted his sleep. The caller was her younger brother, Amaechi. At first, Amaechi spoke in a rush and his garbled words were difficult to understand. Eventually, Akubueze understood that he was trying to say his girlfriend had given birth to a baby boy at a clinic owned by the Sacred Heart Catholic Church’s Hospital, Oguta Imo State. The baby was born prematurely and died 30 minutes later.
The baby was not placed in an incubator because they ran out of time to do so. Two big bottles of water were filled with hot water and wrapped around the newborn while preparation was made to transport the baby to the Federal Medical Centre (FMC) in Owerri, the state capital for proper care.
Akubueze said the newborn’s mother, who never attended antenatal care, had an early labour and was rushed to the hospital early that morning.
“At the hospital, while her stomach was being examined through the scan, the baby’s head was coming out and she was rushed to the birth theatre for delivery. By the time he returned from where he rushed to pick up his friend’s car for a 45-minute drive to the hospital, his baby had died,” he said.
According to Akubueze, it was a shame that her hometown could not boast a good primary healthcare centre where women could attend antenatal care.
“I felt so sorry for the baby to have been unfortunate to be born in the village. His death could have been preventable if the hospital had neonatal care. The government primary healthcare centre I used to know was abandoned for years before the present administration began to renovate it. But the renovation has been ongoing for over a year and they’re still not done. I was so upset. My cousin was crying uncontrollably, it was his first child. He called him Promise,” Akubueze said.
Akubueze’s nephew’s death is one of many such avoidable deaths regularly recorded in the country’s rural areas, because of the non-availability of mechanical assistive devices in primary healthcare centres that could help to save them.
But not all such newborns die. Some can survive through the “first aid” care given to them by health workers before they are taken to a proper hospital. But that also creates another kind of problem.
According to experts, babies that survive through such crude methods or suboptimal use of technology suffer from disability.
The neonatal period is the first 28 days of an infant’s life, whether the baby was carried to term or born prematurely. During this period, medical professionals examine newborns closely in the first few hours of life, particularly in the case of premature births or if there are complications during delivery and intervene where life support is needed. This entails, for instance, the availability of mechanical assistive devices to drive the breathing process and the provision of supplemental oxygen to curtail breathing difficulties and aid adaptation into the new world outside the mother’s womb.
Data outlook
The country’s Infant Mortality Rate (IMR) or Neonatal Mortality Rate (NMR) is not looking good. A new report shows that Nigeria accounts for the second-highest number of maternal and child deaths globally. The report titled: “Improving Maternal and Newborn Health and Survival and Reducing Stillbirth: Progress Report 2023” and released by the World Health Organisation (WHO) showed that Nigeria, Africa’s most populous country, is only behind India in the latest ranking.
The report noted that in 2020, 788 women and children died ‘per thousand’ in India and 540 women and children ‘per thousand’ died in Nigeria.
In the same year, India accounted for 17 per cent of global maternal and neonatal deaths and stillbirths, while Nigeria accounted for 12 per cent.
The country has worse IMR compared with neighbouring West African countries such as Benin, Cameroon, Togo and Ghana, with 57, 48, 44 and 33 deaths per 1,000 live births, respectively.
According to Statista, the mortality rate of infants under one year old in Nigeria as of 2023 was measured at 55.17. This means that there were about 55 deaths of children under the age of one year per 1,000 live births. The report noted that male infant deaths accounted for 60.43 per cent while female infant deaths accounted for 49.6 per cent.
Last year, a United Nations Children’s Fund (UNICEF) report titled “Situation of Women and Children in Nigeria” stated that the country records approximately 262,000 baby deaths at birth every year.
Acknowledging the high rates last year, former Minister of Health, Osagie Ehanire, during a News Agency of Nigeria (NAN) ministerial forum in Abuja last year said it was embarrassing “when you go to conferences and see that your country has some of the worst indices.”
Where infant mortality rate is high in Nigeria
According to Ehanire, lack of access to healthcare is the main factor contributing to high maternal, infant and under-five mortality in the country.
He said: “The area where you see this maternal and infant mortality is mostly in the rural areas where they have zero access to healthcare. There is no hospital there. Most of the women who are delivered of their babies do so without skilled birth attendants. But, once you have skilled birth attendants, maternal mortality reduces drastically.”
WHO data supports the claim that there is a higher rate of neonatal deaths in Nigeria’s rural areas than in urban ones.
According to the organisation, the country’s Neonatal Mortality Rate (NMR) in 2015 was 34 deaths per 1,000 live births. In rural areas, it is 44 deaths per 1,000 live births and 34 deaths per 1,000 live births in urban areas for an urban-to-rural ratio of 0.8.2. Among the poorest households, there are 45 neonatal deaths per 1,000 live births, compared to 30 deaths per 1,000 live births among the richest households.
In the area of skilled attendance at birth, WHO’s maternal and newborn health coverage indicators showed that coverage of skilled attendance at birth is 23 per cent in rural areas, compared to 67 per cent in urban areas. In postnatal care, eight per cent of newborns in rural areas receive postnatal care (PNC) within two days after birth, compared to 25 per cent in urban areas.
The urban health centres, where there is a semblance of health services, are slightly better off.
Similarly, a visiting Professor of Medical Engineering and Technology at Imperial College London, Prof. Hippolite Amadi told The Nation that “Most of the babies dying are not just in cities but more in the rural areas. So that is where the newborn technology care should be taken to the areas if not, Nigeria can’t bring down the numbers.”
Based on his decades of experience as a Medical Engineer and Technologist in state and federal health centres across the country, Prof. Amadi, who won the 2023 Nigeria Liquefied Natural Gas (NLNG) Prize for Science–Innovations, said the structure of Nigeria’s healthcare system for newborns is also part of the problem of the high neonatal mortality rate in the country.
He said until that is changed, the country’s newborn mortality rate will find it difficult to trickle down.
“The Nigerian healthcare system for the newborn; the way it is structured is part of the problem of high neonatal mortality rate. That is, neonatal intervention is tied around the consultants and the professors, because it is a highly specialised aspect of patient intervention.
“The system is fundamentally built around a difficult implementation path and that is why whatever the government has to offer to assist a tiny baby in Oguta, for example, to survive finds it difficult to trickle down.
“We have a primary healthcare centre with no neonatal care because they tell you that neonatal care could only happen at a Tertiary Center. So, in other words, it is difficult, on the premise of how Nigeria is today, to do neonatology in the village, at the primary healthcare level, and secondary healthcare. Every needy neonate is being rushed to tertiary hospitals. It is not even that the tertiary is well-equipped and well-funded. Many of these babies that would travel this journey would either die on the way or by the time they get to the tertiary institutions, they would be moribund. This has been the practice, and it is not changing because people are not looking closely at these salient issues.
“So, when a baby is born, these hospitals use crude methods. What they were doing with the water bottle in the case of the baby you said died in Oguta is only one aspect of the essentials of neonatal care and that is Thermoneutral control, and we can’t do it with a hot water bottle, even for an adult. It is a struggle, let alone tiny babies with partially developed brains to do auto-regulation. So, the baby will find it difficult to survive with that kind of technique; that is a crude old technique,” Prof. Amadi said.
Meanwhile, by 2030, the United Nations (UN) neonatal mortality Agenda aims to end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1, live births.
The big question is: can this be achieved domestically when globally; Nigeria is also not looking good, being garbed with the second highest number of NMR or IMR?
Causes of infant mortality rate in Nigeria
According to the WHO, 75 per cent of most neonatal deaths occur during the first week of life, and in 2019, about 1 million newborns died within the first 24 hours.
It includes preterm birth, childbirth-related complications (birth asphyxia or lack of breathing at birth), infections and birth defects as the leading cause of neonatal deaths in 2019.
From the end of the neonatal period and through the first five years of life, the main causes of death are pneumonia, diarrhoea, birth defects and malaria.
Malnutrition is the underlying contributing factor, making children even more vulnerable to severe diseases.
A 2018 study by the National Library of Medicine showed that lack of access to Antenatal care (ANC) or delayed ANC was a risk factor associated with neonatal mortality. Several individual and community-level determinants were identified as being associated with neonatal mortality in a developing country like Nigeria.
According to the 2018 Nigeria Demographic and Health Survey, 61 per cent of live births do not take place in a health facility.
An estimate report on preterm birth by the WHO, UNICEF, together with with Partnership for Maternal, Newborn and Child Health (PMNCH) revealed that no fewer than 152 million premature babies were born between 2010 and 2020, with an estimated 13.4 million babies born preterm in 2020 and nearly one million died from preterm complications. It said the figure is equivalent to around one in 10 babies born early (before 37 weeks of pregnancy) worldwide. Many survivors face a lifetime of disability, including learning disabilities and visual and hearing problems.
Of every 10 babies born, 1 is preterm – and every 40 seconds, 1 of those babies dies. Preterm birth rates have not changed in the past decade in any region of the world. The impacts of conflict, climate change, and COVID-19 are increasing risks for women and babies everywhere.
In 2010, low birth weight was highlighted as the most common cause of IM accounting for 25% of IM. The study also identified a lack of delivery attendants, home delivery and traditional birth attendants as predictors of IM in Nigeria.
Globally, prematurity is the leading cause of death in children under the age of 5 years. Inequalities in survival rates around the world are stark. In low-income settings, half of the babies born at or below 32 weeks (2 months early) die due to a lack of feasible, cost-effective care such as warmth, breastfeeding support and basic care for infections and breathing difficulties. In high-income countries, almost all these babies survive.
Other contributing factors causing high infant and child mortality rates in Nigeria include the mother’s level of education, environmental conditions, and political and medical infrastructure.
Skilled birth attendants, nurses, and midwives are scarce in Nigeria, and there are few properly equipped birth centres and hospitals. Where available, the costs of medical services are too expensive for the masses.
During the ongoing naira scarcity, several men reported losing their pregnant wives because they had no cash to pay hospital bills.
In droves, skilled medical professional doctors, nurses, laboratory attendants, consultants, and others – are fleeing Nigeria’s broken health system for Europe and North America. PAN estimates one doctor to 3,000 patients in Nigeria; made worse by the 2,000 locally trained doctors that leave the country annually. The Nigerian Medical Association estimates the doctor-to-patient ratio at between 1:5,000 and 1:8,000. The Medical and Dental Consultants Association said 500 of its members left the country for overseas practice in the two years to September 2022.
Economic consequences of high newborn mortality
The WHO said that “improvements in health, such as increases in life expectancy at birth and reduction in child mortality rates have great potential to raise economic growth in such regions.”
Ensuring access to high-quality, affordable newborn health care is critical to building healthier, more equitable communities. This is because good health is an important factor in the economic and social development process in that it enhances the efficiency of labour and increases savings. Thus, there is a bidirectional relationship between health and growth or development. Therefore, wealth and health may be thought of as complementary.
Joint responsibility for government and citizens
Making a success of saving the Nigerian child from neonatal death is a collective responsibility of both the government and its people.
To make amends, all tiers of government must progressively buy into initiatives aimed at eradicating the MMR and IMR scourge, mothers must ensure that they attend Antenatal care (ANC) where doctors can spot health problems early. Also, mothers should ensure that they deliver their babies in hospitals equipped with neonatal care in case there might be a need for it.
Like Amaechi’s girlfriend, who didn’t attend ANC until she had a premature birth, an ANC visit to a doctor would have spotted an early issue and intervened.
Nigeria has implemented several interventions and policies to improve IMR. An example is the Nigeria Midwives Service Scheme (MSS), a public sector collaborative initiative established in December 2009 by the National Primary Health Care Development Agency (NPHCDA). However, these interventions have not helped to reduce the number.
Ensuring access to high-quality, affordable newborn healthcare
During the announcement of the 2023 Nigeria Liquefied Natural Gas (NLNG) Prize for Science – Innovations, a video demonstration of the winning respiratory technologies for newborns by Prof Amadi consists of a solar energy-powered non-invasive Neonatal Ventilator, an Oxygen Delivery Blender System, and an Oxygen Splitter System.
The innovations have been verified by various Nigerian hospitals, having undergone testing, and shown to be cost-effective, when compared to available alternatives.
Amadi’s technology called “PoliteheartCPAP” is an improvement to an existing/imported non-invasive neonatal ventilator model, as it provides access to ventilators and oxygen delivery simultaneously to neonates at an extremely reduced cost of N750,000 as against N6.5million for the existing device with comparable and better efficiency.
In the wake of the win, President Bola Tinubu while congratulating Prof Amadi was delighted and said “Amadi’s innovation has already reduced neonatal care costs significantly and saved lives in verified hospitals that have adopted the use of the solar-powered neonatal ventilator.”
He, therefore, commenced Amadi, “for leveraging his extensive background in medical engineering and technology, with a special focus on affordable medical systems for the betterment, progress and benefit of Nigerians.”
According to Amadi, his newborn technology is the right sustainable frugal technology and procedure for saving newborns’ lives.
It is built in a way that even a trained nurse in a rural health centre can operate it without the presence of a consultant or specialist.
“The best way to solve the problem of neonatology in Nigeria – knowing that over 66% of the needy babies seeking intervention are located around primary and secondary centres was to create what I call a ‘newsroom’.
“I created it in a local centre, which doesn’t require a professor or a big consultant. It just requires a basic knowledgeable nurse, medical officer and assistant, to operate. So, the devices I create would be devices that could be easily used. These devices are like the PoliteheartCPAP machine. Ventilating a baby or doing proper scientific-grade respiratory support is a high-class medicine. But I have brought it to the lowest state, where a basic nurse would be able to treat a baby with such a machine and deliver life to that baby. Therefore, it is necessary to create devices that would enable them to manage neonates in faraway hinterlands.
“In my practice, I have identified all the contributors to the high neonatal mortality rate in Nigeria, including dysfunctional buildings in the context of neonatal safety. I have published extensively because I have identified and studied all the problems. I have discussed the aetiology of so many of the problems and I have created solutions. So, it is either this generation of Nigerians would look into what I have provided and solve the problem, or the next generation would do it. My happiness is that I have published everything and it is in the public domain,” Prof Amadi said.
QUOTE
Improvements in health, such as increases in life expectancy at birth and reduction in child mortality rates have great potential to raise economic growth in such regions. Ensuring access to high-quality, affordable newborn health care is critical to building healthier, more equitable communities. This is because good health is an important factor in the economic and social development process in that it enhances the efficiency of labour and increases savings
