How Midwifery Scheme that Reduced Infant, Maternal Mortality was Jettisoned

While the now defunct midwifery service scheme was adjudged by both local and international health bodies as the right tool for the reduction of maternal and child deaths in the Nigeria, the abandonment of the scheme by the present government has been identified as the reason for rising infant and maternal mortality, writes Martins Ifijeh

When the federal government in 2009 kick started the now defunct Midwifery Service Scheme (MSS), not few Nigerians, especially stakeholders in the health sector jumped to jubilation, as it was clear it would greatly reduce the abysmally high maternal and newborn deaths in the country. Specifically, advocates for maternal and child health saw it as a victory for the poor Nigerian mother, aspiring mother, newborn and the society at large.

The rave and happiness was not only limited to concerned Nigerians. The World Health Organisation (WHO), United Nations Children’s Education Fund (UNICEF), International Maternal and Child Health Foundation (IMCHF), Global Organisation for Maternal and Child Health (Go-MCH), and several other health bodies saw it as the beginning of good things for the Nigerian mother and child, as they were particularly overwhelmed that the scheme would address the high maternal and newborn deaths recorded mostly in rural and sub-urban areas across the country.

Prior to the commencement of the scheme, maternal, newborn and child mortality was in an all-time high across the country. For instance, in Kano State, hospital-based maternal mortality was between 3000 and 4000 per 100,000 live births, while in Lagos State, where everyone would think the mortality rate would be very low, the case was almost as high as in Kano.

Specifically, Island Maternity in Lagos, South-west’s most populous maternity centre, was around 3000 maternal deaths per 100,000 live births, according to statistics quoted from an IPAS survey.

It is even believed that those figures were hospital-based, as maternal death rates at the time were higher outside the hospital setting.

On a general statistics, if the report of the East Africa Medical Journal is to go by, it means, in 2004, Nigeria’s maternal and child mortality rate was about 96 deaths per one thousand live births in rural areas against 75 deaths per a thousand live births in urban areas. That is about 8,000 deaths per 100,000 live births on the average.

Experts say maternal and infant mortality refers to the death of mother or newborn due to pregnancy or childbearing from any cause related to or aggravated by pregnancy or childbirth, but not from accidental or incidental causes.

It is in addressing the very abysmally poor indices that maternal and child advocates convinced the federal government, in partnership with states and local governments to establish the scheme with the aim of tackling all loose ends in relation to maternal and child health across the country.

First, there was the recruitment of over 4,000 unemployed or retired midwives from each state of the federation, who were trained and then distributed to 1,250 health facilities in the 36 states including the Federal Capital Territory (FCT). 1000 of such facilities were Primary Health Centres (PHCs) while the remaining 250 health facilities were general hospitals.

Each midwife was equipped with a ‘mama kit’ containing a stethoscope, essential medicines, weighing scales, razor blade, blood pressure indicator and mobile registration system. And they also perform child immunisations for facility-based births and family planning services.

Various maternal indices from within the past seven years showed that while the scheme was running, maternal and newborn mortality reduced drastically, which led to the applause of the scheme by the WHO and other international organisations, even though the scheme was not running at the desired level due to lack of continuous financial commitments mostly from local and state governments across board.

But the scrapping of SURE-P by the President Muhammadu Buhari-led federal government dealt a final blow to the scheme, as its financing was previously channeled from the SURE-P purse. The thousands of midwives got frustrated and voluntarily disembarked as no one was catering for their allowances anymore, rendering the programme defunct.

How the scheme was conceptualised
When THISDAY Health andLifestyle met the former Country Director, IPAS, and the current Chairman, Coalition for Maternal, Newborn and Child Advocacy Network in Nigeria, Dr. Ejike Oji, who was one of the key players in the introduction of the scheme, he said in a space of time the programme was functional, maternal and newborn deaths reduced all over the country, making him wonder why the present government was not keying into a scheme that was reducing maternal, newborn deaths in the country.

Going down memory lane on how the scheme started and what was achieved within the space of time, Oji said when in 2002 as the Country Director, IPAS, he walked into the maternity section of the Kano State Hospital, which he said was about the biggest hospital in West Africa, he met a large number of patients, with 75 per cent of them having abortion and pregnancy complications.

“But there was only one doctor on ground, who had the skill to perform Dilatation and Curettage, and evacuate/treat women with abortion or pregnancy complications. Women were waiting for several hours before they were being attended to. This was leading to deaths of many. Meanwhile, there were midwives there but not skilled or empowered to assist the doctor.

“When I got to my hotel room, I wept for hours because I had seen what was really killing our women. I then started to think of how this can be changed. First, I looked at the ratio of doctor to midwives in the country. It was one doctor to 24 midwives as at that time. I knew if we needed to save our women, we needed to shift some of the jobs to the midwives.”

He said while he went back to the maternity ward, he learnt there were only 12 midwives and non was skilled in D & C. “This is just one area (induced or spontaneous abortion) where women were dying, other areas are bleeding, eclampsia, obstructive labour and then infection, yet there were either no midwife or facilities on ground to stop these, especially in rural areas.

“We then proposed to the Kano State government to train their midwives, which they accepted. The 22 midwives trained were spread across the state and within six months, maternal and newborn deaths decreased drastically in the state. When we went back to the Kano State Hospital, there was no crowd anymore because the midwives were doing the evacuations,” he added.

According to him, the success was what propelled the team and a group of other maternal and child health advocates to convince the federal government to start the MSS across the nation.

How the scheme design would have brought maternal, newborn deaths to near zero
“The scheme was initially meant to offer large renumeration to the midwives so that they will be motivated to provide the needed service even in the remotest of communities anywhere in the country,” said Oji, who explained how a N75,000 was proposed to the federal government as monthly allowance for each midwife.

A memorandum of understanding was then signed with the state governments and the various local governments, such that the N75,000 was still the agreed monthly allowance for each midwife, but the federal government was to pay N35,000, states to pay N25,000, while the local governments where the midwives were posted to would respectively pay them N20,000 each, summing up the allowance to N75,000 per midwife.

Most states and local governments refused to honour the agreement
Investigations showed that while the administration of former President Goodluck Jonathan was relatively consistent in paying its N35,000 to the midwives, just few states honoured the agreement of paying their N25,000 to each midwife per month for only a while. Local governments did not pay their parts, and this was across board all over the nation, according to various reports.

Despite the midwives receiving only N35,000 as against the N75,000 expected per month, maternal, newborn indices showed that maternal and infant mortality continued to reduce all the while, even with their poor renumeration.

Experts believed if the midwives were consistently paid the recommended amounts, Nigeria would have met Millennium Development Goal (MDG) on Maternal and Child Health which ended in 2015.

When the cookies finally crumbled
Investigations showed that while the initial funding of the scheme was from MDG resources, the closure of the development goal in 2015 forced the federal government to shift its funding to SURE-P towards the winding phase of Jonathan’s administration.

The coming of President Buhari saw to the demise of SURE-P which by extension was funding the scheme.

“Sometime last year, most of us accepted the fact that we have no jobs anymore, because our monthly allowances stopped coming. We did free services for months, then everyone just went back home when there was no longer motivation. Tactically, we lost our jobs. I am presently working in a private hospital in Akure,” said a midwife who was once enlisted into the scheme.

MSS, an orphaned child
While the scheme reduced maternal, newborn deaths during its hey days, experts believed since it was birthed as an executive action and not an Act, the possibility of it being tossed about or folding up was high.

An Obstetrics and Gynaecologist based in Algiers, Dr. Olakunle Saheed, whose first degree was in nursing, said Nigerian midwives and nurses were not being honoured, despite the sacrifices they make.

“The scheme should be made an Act, duly budgeted for, and then allowed to run year in year out, while more midwives should be recruited. This will greatly bring the health indices further down.”

He said the country’s maternal death rates has increased to 578 per 100,000 live births as against the indices in 2014 during the functioning of the scheme which was below 400 deaths per 100,000 live births. “In saner countries, effective approaches and policies are never allowed to die off,” he added.

What next for the scheme
Investigations show that about N1.1 billion was allocated to the midwifery service scheme in the 2016 health budget, but the midwives on the defunct programme have so far not been identified, paid their outstanding or even lured back to their duty posts.

Saheed and Oji believed the government should do all within its powers to revive the scheme so that the growing maternal and child death indices can be reduced back to its rate in 2014, and then further reduced till maternal and child deaths become rare in the country.

All efforts by THISDAY to speak with a former National Coordinator of the scheme, and a Director in the National Primary Health Care Development Agency (NPHCDA) Dr. M.J Abdullahi proved futile. He fixed two meetings in his office in Abuja, which were eventually cancelled.

Request to therefore send questions via email to him were not responded to.