ALARMING RATE AND CAUSES OF INFANT MOTALITY IN NIGERIA CALL FOR GOVERNMENT INTERVENTION
Infant mortality is the death of young children under the age of 1.This death toll is measured by the infant mortality rate (IMR), which is the probability of deaths of children under one year of age per 1000 live births.The under-five mortality rate, which is referred to as the child mortality rate, is also an important statistic, considering the infant mortality rate focuses only on children under one year of age.
World map of infant mortality rates in 2017, the leading cause of infant mortality in the United States was birth defects.Other leading causes of infant mortality include birth asphyxia, pneumonia, congenital malformations, term birth complications such as abnormal presentation of the fetus umbilical cord prolapse, or prolonged labor, neonatal infection, diarrhea, malaria, measles and malnutrition. One of the most common preventable causes of infant mortality is smoking during pregnancy.
Lack of prenatal care, alcohol consumption during pregnancy, and drug use also cause complications which may result in infant mortality.[failed verification] Many environmental factors contribute to infant mortality, such as the mother's level of education, environmental conditions, and political and medical infrastructure. Improving sanitation, access to clean drinking water, immunization against infectious diseases, and other public health measures can help reduce high rates of infant mortality.
In 1990, 8.8 million infants younger than 1 year died globally. Until 2015, this number has almost halved to 4.6 million infant deaths.Over the same period, the infant mortality rate declined from 65 deaths per 1,000 live births to 29 deaths per 1,000.
Globally, 5.4 million children died before their fifth birthday in 2017. In 1990, the number of child deaths was 12.6 million.
More than 60% of these deaths are seen as being avoidable with low-cost measures such as continuous breast-feeding, vaccinations and improved nutrition.
The child mortality rate, but not the infant mortality rate, was an indicator used to monitor progress towards the Fourth Goal of the Millennium Development Goals of the United Nations for the year 2015.
However, considering our dear country, Nigeria, the World Health Organisation ( WHO) in collaboration with Federal Government of Nigeria put up a concerted effort to reduce the rate and causes of infant mortality to bearest minimum if not eradicating it.
On 17th October 2019 - In Njediko community of Niger state, Mrs Aishatu Usman says, “Without this care, where would we go to when our children are sick since there is no hospital nearby?”.
Mrs Usman is one of the caregivers that benefited from the WHO-Federal Government integrated Community Case Management (iCCM) project that scales up provision of essential packages for child survival in communities. “We are grateful to WHO, and the Government for this community based intervention. Without this project, it would have been tough for us and our children”, she added.
In line with Mrs Usman’s plea, despite recent improvements, maternal and child mortality remain critical public health issues in Nigeria with unacceptably high health outcomes indicators.
According to the Nigeria Demographic Health Survey (NDHS, 2018), the under-five mortality rate in Nigeria is 132 per 1,000 live births meaning that 1 in 8 Nigerian children never reach the age of 5. Infant deaths, which account for half of child mortality have declined from 87 per 1000 live births in 1990 to 67 in 2018. One (1) Nigerian woman dies in childbirth every 10 minutes, and 1 Nigerian child under-5 years of age dies every minute.
It is apparent through the elevated mortality rates that the lack of access to quality delivery services is an issue of immense importance in Nigeria. Problems such as cost for treatment, deplorable state of the health facilities, distance to health facility lack of awareness and knowledge for informed decisions and referral are some of the many difficulties stated by caregivers in describing difficulty with accessing healthcare.
Integrated Management of Childhood Illness (IMCI) and iCCM are the key child survival thrust being used by the Nigerian Government to address the unacceptably high under-5 morbidity and mortality indices.
Dr Bose Adeniran, Head of Child Health Department, Federal Ministry of Health (FMoH) stated that “Child mortality has been a long pending issue in Nigeria and a lot of mothers are not aware of the causes and prevention.”
She added that “iCCM is a complete package focusing on prevention and also on curative and I think that is what our children need. In Abia and Niger States, we now have local evidence that this (iCCM) is the way to go as it relates to addressing the unacceptably high under-five mortality rate in Nigeria”
Substantial global progress has been made in reducing child deaths since 1990. The total number of under-5 deaths worldwide has declined from 12.6 million in 1990 to 5.3 million in 2018. On average, 15 000 children under-5 die each day compared with 34 000 in 1990. Since 1990, the global under-5 mortality rate has dropped by 58%, from 93 deaths per 1,000 live births in 1990 to 39 in 2017 This is equivalent to 1 in 11 children dying before reaching age 5 in 1990, compared to 1 in 26 in 2018.
“With numerous World Health Organization’s (WHO) supports to Nigeria, many caregivers, especially in the rural areas are now aware of the available essential package of interventions for child survival along the continuum of care”, says Dr Joy Ufere, WHO, Family and Reproductive Health Cluster.
She added that “WHO will continue to provide leadership role to monitor the implementation of these interventions towards reducing Under-5 morbidity and mortality across Nigeria.”
According to UNICEF, Nigeria becomes world’s highest contributor to Under-5 deaths, this was the assertion as at September 11, 2020.
Nigeria has become the world’s number one contributor to deaths of children under the age of five.
Nigeria overtook India last year to secure the unenviable position, according to a report released by UNICEF, the UN children’s agency.
The development which comes two years earlier than estimated by the World Bank, paints a worrying picture for child mortality and survival in the country, further exposing a lack of plan and ambition in tackling diseases causing the deaths of children, which are usually curable.
In 2018, the World Bank had said Nigeria would take over from India as the world capital for deaths of children under the age of five by 2021.
According to World Bank figures, India recorded an estimated 989,000 under-five deaths in 2017 compared to 714,000 deaths by Nigeria in the same year.
Nigeria’s population is about 200 million, while India’s is over 1 billion.
In the latest report titled Levels and Trends in Child Mortality, UNICEF said Nigeria recorded an estimated average of 858,000 under-five deaths in 2019 against India’s 824,000 deaths out of 5.2 million under-five deaths globally.
The numbers from both countries are almost a third of all deaths before age five globally.
The data, which covered a period of three decades –1990 to 2019 – showed that 49 per cent of all under-five deaths in 2019 occurred in just five countries: Nigeria, India, Pakistan, the Democratic Republic of Congo and Ethiopia.
“Nigeria and India alone account for almost a third,” it said.
The UN agency also warned that the COVID-19 incursion is capable of derailing decades of progress toward eliminating preventable child deaths.
“While the extent and severity of the mortality impact of COVID-19 on children and youth is still unknown, the potential of a mortality crisis in 2020 threatens years of remarkable improvement in child and adolescent survival from 1990 to 2019, the period covered in this report,” the agency said.
“While current evidence indicates the direct impact of COVID-19 on child and youth mortality is limited, indirect effects stemming from strained and under-resourced health systems; limitations on care-seeking and preventative measures like vaccination and nutrition supplements; socioeconomic strain on parents and households resulting from job loss or economic downturns; and stress to children and parents associated with abrupt societal shifts maybe substantial and widespread,” it read.
Nigeria becomes world’s highest contributor to Under-5 deaths
“Moreover, many of these indirect effects may not be apparent for some time after the pandemic recedes and may reverberate for an extended period following the pandemic.”
The UNICEF data lends urgency to the calls by health advocates on Nigeria to show commitment and prioritise management of certain diseases causing deaths of children under five.
Health experts have continued to decry the neglect and poor funding of health interventions by successive governments that would have cut down the yearly losses of lives of children in the country.
One of such is the poor funding of nutrition, especially admist inflation.
Nutrition experts are lamenting the removal of about N800 million budgetary allocation for Ready-to-Use Therapeutic Food (RUTF) from the 2020 budget.
The ICIR reported how the government in 2019 cut funding for the nutritional programme designed to save thousands of lives among an estimated 2.5 million children suffering from severe acute malnutrition.
Even before the cut, Nigeria was spending far less than needed to address its nutrition crisis. The World Bank estimates that Nigeria would have to spend N301 billion ($837 million) annually to combat malnutrition effectively.
According to Beatrice Eluaka, the Executive Secretary of Civil Society Scaling-up Nutrition in Nigeria (CS-SUNN), Nigeria has the second-highest number of stunted children in the world with two million children battling with Severe Acute Malnutrition (SAM).
While most deaths resulting from Pneumonia occur in developing countries and about three-quarters takes place in just 15 countries, more than half of the world’s annual incident cases occur in Nigeria and four other countries.
According to Save the Children, Nigeria has the highest number of pneumonia deaths globally, as the disease claimed the lives of 162,000 Nigerian children under the age of five in 2018.
This means, in every three minutes, a Nigerian child dies from the infectious disease.
It also means the disease now snuffs lives out of under-five children in Nigeria more than other child killers like HIV/AIDS, Malaria, Measles, Tuberculosis put together.
There are eight health indicators used to track health performance of countries – infant and child health, infant mortality, nutrition, reproductive health, maternal mortality, life expectancy rate among others – and Nigeria has not fared well in any.
Worst still, Nigeria’s poor data collation culture makes it even more difficult to get a clear picture of the situation.
Nigeria still remains one of the worst places in the world to raise a child, infant, or mother.
Asides UNICEF data, a 2018 report by the World Health Organization (WHO) showed that one in eleven children who die in the world before their fifth birthday are Nigerians.
The 54-page UNICEF report marshalled several key facts and figures involved in child survival across the world.
It said despite dramatic reductions in child and youth mortality over the last 30 years— under-five mortality has dropped by almost 60 per cent since 1990—the global burden of child and youth deaths remains immense.
The report found that in 2019 alone, about 7.4 million children, adolescents and youth died mostly of preventable or treatable causes.
Same year globally, 70 per cent of deaths among children and youth under 25 years of age occurred among children under 5 years of age, accounting for 5.2 million deaths.
Among under-five deaths, 2.4 million (47 per cent) occurred in the first month of life, 1.5 million (28 per cent) at age 1–11 months, and 1.3 million (25 per cent) at age 1−4 years.
An additional 2.2 million deaths occurred among children and young people aged 5−24 years in 2019, 43 per cent of which occurred during the adolescent period, ages 10−19.
If all countries reach the SDG (Sustainable Development Goals) child survival targets by 2030, 11 million lives under age 5 will be saved—more than half of them in sub-Saharan Africa, the report stated.
At this juncture, there is need for us to delve into the survivals
Fertility, Family Planning, and Child Survival .Available data show a relationship between birth rates and infant deaths in developing
countries. Certain patterns of reproductive behaviours are associated with poor child health.
Infant and childhood mortality is higher for “high-risk” births. High-risk births are those occurring to women who are too young (before age 18) or too old (after age 34) or who have too many births (birth order four and above) as well as births that occur and too close
together (less than 24 months apart). Comparing birth intervals (BI) of 24 months or more with those less than 24 months, the 1999 NDHS notes lower IMR (59) and U5MR (126) for longer birth intervals and higher IMR (104) and U5MR (174) for shorter birth intervals.
Presently, fertility rates are high in Nigeria as indicated by a TFR of 5.2 births per woman and a crude birth rate of 41.
The 1999 NDHS data assessment on fertility suggests an under-
reporting of births, such that the true TFR for the five years preceding the survey is probably closer to 5.9 or 6.0 than the reported rate of 5.2.3
Childbearing begins early in Nigeria, with nearly one-half of women of the
reproductive age becoming mothers before age 20. Teenage childbearing is higher in rural than in urban areas and has negative demographic, socio-economic, and socio-cultural
consequences. These young mothers are more likely to suffer from severe complications during delivery, resulting in higher morbidity and mortality for both themselves and their children.
With an unmet need for family planning of 18 percent (13% for spacing, 5% for
limiting births) and a contraceptive prevalence rate (CPR) of 9 percent, Nigerians are still having more children than planned and at shorter than desired birth intervals. A recently concluded multivariate cross-country analysis on effect of birth intervals on childhood
morbidity and mortality reports that Nigerian mothers had short birth intervals and that these
intervals posed substantial mortality and nutritional risks for children (Rutstein, 2001).
The study also reveals that intervals of at least 36 months are associated with the lowest mortality and morbidity levels, with the IMR dropping by about 28 percent and the U5MR declining by
23 percent. Other benefits include a reduction in the annual number of deaths of children less than five years by 165,000 and a drop in the TFR of longer birth intervals of 8 percent.
Apart from poor budgetary allocations for FP/RH activities, there is also a marked level of resistance to family planning use in Nigeria because of socio-cultural and economicfactors, particularly religious beliefs, low educational levels, poverty, misinformation, and poor spousal communication.
Although this problem is widespread nationally, data from the 1999 NDHS show that approval of use of modern contraceptive methods is higher among urban residents than those in rural areas, higher among older than among younger respondents, and higher in the southwest, southeast, and central regions than in the northeast
and northwest regions. In addition, females with at least secondary education are more likely
to approve of modern contraceptive use than those with lower levels of education. Other barriers to family planning use include opposition by religious and traditional rulers,
particularly in the northern regions due more to suspicion and misinformation than the tenets of Islam. In the southeast, the Catholic Church, which has a large following, insists on the
use of natural family planning methods; this, together with suspicions arising from misinformation, poses many problems. There is therefore a need for more advocacy and social mobilisation, since ample data exist to suggest that high-risk births are linked to reduced child survival.
Maternal Morbidity/Mortality and Child Survival .Maternal mortality in Nigeria is high, varying between 700 and 800 deaths per100,000 live births with wide geographical disparity ranging from 166 per 100,000 live births in the southeast to 1,549 per 100,000 live births in the northeast (1999 NDHS). Nigeria
contributes to 10 percent of the world’s maternal deaths with an average of seven for every 1,000 births. With about 2.4 million live births annually, about 17,000 Nigerian women die annually. Or to put it another way, one woman dies every 30 minutes from complications of
pregnancy and childbirth (NPC/UNICEF, 2001). These indicators have a negative impact on child survival, since children who lose their mothers experience an increased risk of death or other complications, such as malnutrition. Studies have shown that children who lose their mothers during childbirth, particularly female children, are 10 times more likely to die than those whose mothers survive (Strong, 1992). For each woman who dies, approximately 20–
30 others suffer short- and long-term disabilities from complications of pregnancy and childbirth. Major causes of maternal morbidity and mortality are haemorrhage, infection, unsafe abortion, hypertensive disease of pregnancy, and obstructed labour.
Apart from malaria, diarrhoeal illnesses, ARI, and VPD, a large proportion (30–40%) of infant morbidity and mortality globally and within Nigeria can be attributed to preventable factors during pregnancy and delivery (WHO, 1996; Owa et al., 1995; Lawoyin, 2000).
Low-birth weight, which underlies a significant percentage of early deaths in infancy, is largely due to poor maternal weight gain during pregnancy, arising from maternal morbidity (malaria) and HIV/AIDS, among others (Njokanma and Olarewaju, 1994; Akpala, 1993). In
addition, asphyxia and birth trauma, which also contribute to high infant mortality, occur in conditions of obstructed labour (from cephalo-pelvic disproportion) due to lack of essential
obstetric care.
Lack of adequate ANC in most parts of the country, particularly the northern regions and rural areas, has resulted in low TT immunisation rates and consequently high prevalence
of neonatal tetanus. The 1999 NDHS reports that about two-thirds (64%) of women with births in the three years preceding the survey had received ANC from a health professional.
However, marked urban/rural and zonal differences exist. The proportion of pregnant women who had no ANC in rural areas was almost four times that in urban areas (37% vs. 10%).
Comparing zones, 28 percent of women received ANC in the northeast, in contrast to 82 and 89 percent in the southeast and southwest, respectively. Poor ANC coverage is reflected in the level TT.
HIV/AIDS and Child Survival
Since it was first reported in 1986, the prevalence of HIV/AIDS in Nigeria has
steadily risen. The rate among women attending antenatal clinics has increased from 1.8 percent in 1991 to 5.8 percent in 2001 (FMOH, 2001). Among teenagers and young adults, the prevalence rate is 6 to 6.5 percent. It is estimated that about 3.4 million people in Nigeria
are presently HIV-positive and that this number will rise to more than 4 million in 2005 if nothing is done to stem the scourge (POLICY/Nigeria, 2002).
Implications of these data on child survival are manifold and grievous, since they threaten to reverse the modest gains made in reducing infant and under-five mortality through immunisation and other child survival strategies. First, because of the 30-percent risk of
MTCT of HIV, infants born to HIV-positive mothers are at risk of becoming HIV infected.
MTCT of HIV can occur either during pregnancy (10–30%), delivery (40–60%), or through breastfeeding (15–20%). Globally, the rate of MTCT of HIV is estimated to vary from 15–35
percent, with a range of 15–20 percent in developed countries where most infants are formula-fed, however increasing to as high as 39 percent in developing countries such as Nigeria because of the practice of mixed feeding. By the end of 2000, an estimated 200,000 children under five had died from HIV/AIDS acquired through MTCT. Unless action is
taken, this number is projected to reach 700,000 by 2010 (NPC/UNICEF, 2001).
Second, because of the possibility of transmitting the virus via breast milk, breastfeeding, which had hitherto been shown to be the single most important measure in preventing infant deaths from diarrhoea, malnutrition, and respiratory infections, is now threatened. Thus, in resource-poor settings such as Nigeria, where alternatives are not easily affordable, providing adequate
infant nutrition is difficult.
Third, as a result of deaths occurring from AIDS, about 1.4 million children (about 700,000 under the age of 10), have lost both parents or their mothers. In addition, there are children who because of their circumstances have become adversely vulnerable, such as those who have lost one or both parents in armed conflicts or through natural or man-made disasters. Examples of these circumstances include the Benue/Nassarawa boundary/ethnic
conflicts, the Plateau religious/ethnic conflict, Ife/Modakeke, and the Urhobo, Ijaw and Itsekiri conflicts, which have left a host of abandoned and orphaned children. Also, the recent Lagos bomb explosion and the Yoruba/Hausa communities armed conflict has recently produced orphaned children.
These orphans and vulnerable children (OVC) are left to fend for themselves and in many cases take up parental responsibilities, thus becoming victims of family impoverishment that is the inevitable consequence of the impact of AIDS and the armed conflicts on the most productive age groups. The process of family pauperisation will adversely affect children’s nutrition and health, diminishing their access to health services, education, and other social services.
Availability/Accessibility of Health Services and Child Survival
Nigeria’s National Health Policy, launched in 1989 and revised in 1996, one year before the WSC, has a goal of attaining a “level of health that will enable all Nigerians to achieve socially and economically productive lives” with a “national health system that is based on Primary Health Care (PHC).” By 1990, only 17 percent of the population had access to modern health facilities; thus, a revitalised PHC system under the National Health Policy was expected to correct the unsatisfactory coverage level.
PHC facilities are supposed to provide basic preventive and health promotion services that include immunisation, health education, and promotion of adequate nutrition as well as management of simple malaria, diarrhoea, ARI, and other common illnesses. PHC also provides ANC, FP services, and basic surgical services. In spite of the laudable goal of its health policies, Nigeria continues to spend below the WHO-stipulated 5 percent (less than $5 per capita) of its annual budget on health care. During the years of military rule, the health budget fell to 1.4 percent; however, the return to democracy has made an improvement (4.4% in 2000), although still short of the recommended 5 percent.
In terms of health infrastructure, Nigeria is well covered, having about 18,258 PHC facilities, 3,275 secondary facilities, and 29 tertiary facilities (NHMIS). Although these numbers seem adequate, the 1999 NDHS reports that 9 percent of households surveyed had
no access to any health facility, 34 percent had no private doctor, and 24 percent had no access to a pharmacy. These data show regional variations with the northeast and north–central regions being the worst served. In addition, timely access to secondary and tertiary services is more problematic than facilities on the ground may suggest.
The health system has been plagued by problems of service quality, including
unfriendly staff, inadequate skills, insufficient numbers of skilled workers as a result of a “brain drain,” decaying infrastructure, unavailable equipment, as well as a chronic drug shortage. Other factors include a financial barrier to access from poorly designed cost-recovery mechanisms; lack of effective community participation or real decentralisation; weak referral systems among primary, secondary, and tertiary care; overlapping vertical programmes; reduced national funding; and weak information systems.
In addition, the majority of the population regards public health services poorly; 26 percent of people surveyed in Lagos state using the Core Welfare Indicator Questionnaire Survey of 1999, conducted by the Federal Office of Statistics as part of the National Integrated Survey of Households, reported dissatisfaction with public health services because of cost (56%), unavailability of drugs (33%), and long waiting periods (33%).
In this dearth of adequate and accessible health services, immunisation is the most affected child survival intervention. A study conducted on available services in public sector health facilities in the relatively well-served southwest zone reports that no PHC service was available in more than 50 percent of the facilities surveyed. Although immunisation was the most widely available service, it only existed in about 45 percent of surveyed facilities.
Factors in health service delivery that led to the previous successes achieved in immunisation coverage in the late 1980s and early 1990s included adequate funding, proper logistics, availability of power generators, information and education (IEC) materials, and training packages for health staff. The snag at that time, and a lesson to be learned, is that all these activities were overwhelmingly donor-funded and managed, and depended on massive and costly single-antigen mobile campaigns. Thus, when donor funding was withdrawn, coverage rates plummeted.
Non-health Factors Influencing Child Survival Female Literacy. Women’s education has been reported as a key factor in reducing infant and child mortality. The higher a woman’s level of education, the more likely it is that she will marry later, play a greater role in decision making, and exercise her reproductive rights.Her children will tend to be better nourished and enjoy better health. Data from both the 1999 NDHS and the 1999 MICS reveal that lower educational levels among females was related to higher infant and under-five mortality. Both surveys highlighted female illiteracy and under-five mortality being twice as high in the northern zones than in the south.
Similarly, rural areas had lower levels of female literacy and consequently higher under-five mortality than urban areas. The relationship between female literacy and child survival is also clearly demonstrated when looking at immunisation coverage rates and treatment of diarrhoeal illnesses. Timely and appropriate use of ORT in the treatment of diarrhoeal illnesses (the second main cause of under-five mortality after malaria) reduces mortality outcomes. The 1999 NDHS reports that the proportion of caregivers that use ORT progressively rises with levels of education. The same survey data also show that the proportion of children not immunised at all decreases from 60 percent among illiterate mothers to 24 percent among mothers with primary education, before dropping to 10 percent among mothers with secondary education.
Access to Safe Water and Adequate Sanitation. Many of the diseases that lead to increased morbidity and mortality of children under five are largely related to the unavailability of safe water, unhygienic behaviours, poor sanitary facilities, and poor housing conditions. ARI, a major killer of children under five, along with VPD such as measles, diphtheria, and tuberculosis, are easily spread in poor overcrowded houses. Also, increased prevalence of diarrhoeal diseases, cholera, and typhoid is seen in situations of unsanitary refuse, excreta disposal, and use of unsafe drinking water. In addition, inadequate drainage and accumulated wastewater encourage breeding of mosquitoes with increased malaria attacks (the single most significant cause of death among children). The 1999 MICS reports that 54 percent of the population had access to safe drinking water (71% and 48% in urban and rural areas, respectively). The southeast is the worst hit region; only 39 percent of the population get their drinking water from safe sources. Just over one-half (53%) of the population live in households with a sanitary means of excreta disposal (1999 MICS), a situation which varies from 40 percent in the northeast to 58 percent in the southwest, and from 44 percent in rural areas to 75 percent in urban areas. A comparison of data from the 1990 and 1999 NDHS shows improvement in access to safe water; the proportion of the population collecting water from surface sources declined from 52 to 38 percent, while the proportion of obtaining water from ground sources such as boreholes and wells rose from 35 to 44 percent between the two surveys.
Poor access to safe drinking water encourages the spread of certain vector-borne illnesses: onchocerciasis (river blindness) and dracunliasis (guinea worm), which are transmitted by vectors associated with water, causing more debilitating illnesses than those listed above. In the 1990s, remarkable progress was made in reducing guinea worm cases from 394,082 in 1990 to 13,237 in 1999, representing a 97 percent reduction from efforts of the Nigeria Guinea Worm Eradication Programme (NIGEP). In 1999, only about eight states were reporting significant numbers of cases. Poor coverage for water supply and sanitation is linked with insufficient funding of operations and maintenance, lack of capital to complete and initiate water projects, and inadequacy of skilled labour and management capacity. Other
problems are inefficient billing and collection of water revenue needed for operation and maintenance, and inadequate monitoring and evaluation of performance.
Compounding the lack of safe water is the lack of awareness of the health
consequences of unhygienic behaviours, such as defecating and urinating in bushes outside houses, poor refuse disposal, and infrequent hand washing. Another problem is the use of the same water source for bathing, washing, and feeding of cattle.
Poverty. There is a synergistic interrelationship between poverty, ignorance, poor health, malnutrition, and reduced child survival, which is worsened by social exclusion and political marginalisation. A child born to a financially deprived and less educated family is at risk of dying perinatally or within the first month of life, since the mother was probably poorly nourished during pregnancy, had little or no ANC, and is unlikely to have delivered at a health facility. On surviving the first month of life, the child is then exposed to increased risks of illnesses, such as malaria and diarrhoea, due to poor living conditions, limited access to safe water and inadequate sanitation, malnutrition from household food insecurity, or
ignorance about good child feeding practices. Large family size (from ignorance of and lack of access to family planning) puts pressure on the mother to work in order to provide for the
family, thus leaving the child quite possibly inadequately cared for. All these factors are further aggravated by limited access to health services due to poor income and low levels of maternal education, often leading to the non-immunisation of the child.
A World Bank analysis (Table 3), based on 1990 NDHS data and subdividing the
surveyed households into quintiles, found a significant relationship between poverty and increased infant and child mortality, low immunisation coverage rates, reduced access to health services, and malnutrition.
Table 3. Relationship Between Poverty and Child Survival Indicators
Child Survival Indicators Poorest Richest Poor/Rich Ratio
IMR 102.0 68.6 1.5
U5MR 239.6 119.8 2.0
TFR 6.6 4.7 1.4
Children stunted (%) 48.5 32.1 1.5
Children underweight (% moderate) 40.2 22.2 1.8
Children underweight (% severe) 16.4 4.9 3.3
Children 12–23months (% immunised) 14.0 51.0 3.6
Source: World Bank, 2002 .
The relationship between poverty and child survival is pertinent, since economic and development data published by the World Bank suggest deepening poverty in the past two decades. Recent estimates place about 70 percent of the Nigerian population below the poverty line (UNDP, 2001). In a localised study conducted in southwest Nigeria (ITN–Oriade Study), persons earning less than $1 a day were 9 percent less likely to use ITNs, less able to perceive malaria as a preventable disease, and less likely to have adequate drug treatment than those with a higher income. This study also reported a strong association between poverty (income less than $1 a day) and access to safe water and adequate sanitation
(refuse disposal).
Cultural Factors and Gender Bias. There are deeply rooted cultural beliefs and attitudes that sometimes result in practices harmful to the survival of children and women. These include food taboos, gender-related practices such as early marriage and lower levels of education among females, and the attendant risks of maternal morbidity and mortality.
Also, the inability of women to exercise their reproductive rights due to culturally based limitations brings about higher levels of maternal, infant, and child mortality. Some cultural factors lead to poor childcare practices in Nigeria; for instance, widespread beliefs about the aetiology of illnesses being attributed to evil spirits and use of traditional medicine as the first line of treatment for illnesses. To some extent, infant feeding practices have a cultural bias—in some tribes, colostrum is not fed to newborn babies because it is believed to be dirty and thusbreastfeeding is delayed and not sustained. The tendency is to withhold protein-rich foods, such as meat, chicken, and eggs, from infants because of the misconception that feeding children those foods may encourage them to steal later on in life.
Intervention Programmes
An assessment of interventions aimed at improving child survival should use a rights-based approach against the backdrop of the goals of the WSC as outlined earlier.
Provision of Child Health Services
Nigeria’s National Health Policy’s objective is health care delivery through the provision and expansion of PHC, which was adopted in 1987. The PHC approach is basically similar to the Basic Health Services Scheme (BHSS), which had been Nigeria’s strategy for provision of health to all her citizens prior to the adoption of PHC in 1987, except for a new emphasis on intersectoral linkages and greater community participation.
In addition to increasing the proportion of the population with access to adequate and affordable health care through expansion and greater decentralisation, the prevention of untimely deaths and illnesses among children and high-risk mothers is an essential part of this health care delivery system. Strengthening and sustaining the PHC system within the National Health Policy has been the focus since the early 1990s, which resulted in the creation of the National Primary Health Care Development Agency (NPHCDA). The NPHCDA is expected to strengthen PHC implementation through supervision and technical assistance to the LGAs.
Under the three-tier system for organising health services, local governments provide MCH services with some input at the secondary and tertiary levels by the state and federal governments, respectively. However, government efforts at making adequate MCH services easily accessible and available in Nigeria are still limited (as illustrated in the section on health services and child survival). Also, health expenditure in Nigeria is largely borne by the private sector, which accounts for 72 percent of expenditures in contrast to the public sector, which accounts for 28 percent. Recognising the inherent problems that exist in the health system, the World Bank, ADB, and DFID are assisting the Nigerian government (principally the FMOH) in health sector reforms with a particular emphasis on improving immunisation services. The World Bank facility for health system reforms goes directly to participating states, while the government of Nigeria stands as guarantor.
As part of its effort to revitalise PHC, which is the basis for improved child health, the present administration through NPHCDA is constructing 200 model health centres in 200 LGAs nationwide.
In addition, Professor Olikoye Ransome-Kuti (Chairman of the NPHCDA) states that “provision of necessary skills, management techniques, and capacity building through the active involvement, participation, and sense of ownership by
communities at village and district levels remain the most enduring process left to us to institutionalise PHC in the country.”
Also, the NPHCDA is revitalising the Bamako Initiative in its model LGAs. The initiative was adopted in the 1990s to strengthen PHC through the adequate supply of basic drugs, community involvement in the management of
health care, and improved financing.
Presently, routine immunisation is implemented by LGAs with state governments and NPHCDA providing supervision, monitoring, and evaluation with technical assistance in
capacity building and training. The NPI has the task of providing vaccines, strengthening the cold chain system as well as giving technical support to the LGAs, monitoring and evaluating
routine immunisation and polio eradication activities.
The Epidemiology Unit of the Public Health Division of the FMOH has the task of collating information on VPD as well as other notifiable diseases. With the duplicity of activities outlined in the tasks of these federal agencies, their grossly over-centralised management styles and top-down structures operating across all three tiers of government, the communication channels and specific roles of thelocal government in implementing what are largely vertical programmes is becoming increasingly unclear. There is, therefore, a need to ensure integration of closely related health care services to encourage better planning and implementation and avoid wastage of scarce resources.
Combating Diseases and Malnutrition
Government responses in this area aim at reducing morbidity and mortality from
malaria, VPD, diarrhoea, and ARI. Efforts are being made to ensure food security at the household level and reduce micronutrient deficiencies through the fortification of foods and supplementation.
Malaria. Malaria control is identified as a priority programme within the framework of the National Health Policy. Nigeria has adopted the RBM Initiative in its effort to combat malaria.
The RBM Initiative, founded by a global partnership of WHO, UNICEF, World Bank, and UNDP in 1998, has a goal of halving the malaria burden worldwide by 2010 through six core strategies: dynamic global movement, well-coordinated actions, evidence-based decisions, multiple prevention, rapid diagnosis, and treatment and focused research.
The Nigerian government demonstrated its political commitment to this initiative by hosting the African Summit on the RBM Initiative in Abuja in 2000, which resulted in the signing of the Abuja Declaration by the presidents and head of states of the governments in Africa.
At this summit, the Strategic Plan for RBM in Nigeria (2001–2005) was launched.
The declaration has three main goals: correct treatment, preventive measures, and presumptive intermittent treatment. The government heads resolved to commence immediate and sustainable actions to strengthen basic health services to ensure that by 2005:
• At least 60 percent of those suffering from malaria have prompt access to and are able to use correct and affordable treatment within 24 hours of the onset of symptoms;
• At least 60 percent of those at risk of malaria (particularly children under five and pregnant women) benefit from the use of ITNs; and
• At least 60 percent of women in their first pregnancies have access to recommended preventive treatment for malaria.
To effectively achieve these goals, several structures have been developed in line with the RBM principles, such as the establishment of a National Malaria Program at national, state, and LGA levels. The government has adopted the ITN massive promotion and awareness campaign (IMPAC) initiative, which is receiving support from the RBM partners via the WHO, UNICEF, UNDP, World Bank, and other development partners, such as DFID, USAID, BASICS, and the POLICY Project. Integrated Management of Childhood Illnesses (IMCI). Mortality and morbidity in children under five in Nigeria are largely due to five major childhood illnesses, chief of which is malaria. The other illnesses are ARI (pneumonia), diarrhoea, measles, and malnutrition. The IMCI strategy was developed by the WHO and UNICEF in 1995 in response to the challenges of providing quality health care for children, since prior to the strategy’s conception most efforts were limited to vertical programmes, such as Control of Diarrhoeal Diseases (CDD), ARI Control, and others.
These programmes were not very successful in reducing mortality in developing countries, partly because most of these activities were donor-driven in Nigeria as in most other developing nations. This strategy is asector-wide health approach that has proven effective, cost-beneficial, and which has the greatest potential to reduce the burden of childhood diseases in Nigeria (World Bank, 2002).
IMCI ensures accurate identification and treatment of childhood illnesses, prompt
referral of severe cases, a strengthening of preventive and promotive activities in the home, communities, and health facilities (such as routine immunisation and growth monitoring).
Its three main components are
• Improvement of case management skills of health workers;
• Health systems improvement to support IMCI; and
• Improvement of family and community practices that support child survival.
The Nigerian government, with support from the WHO and UNICEF, began
implementing IMCI in 1997 following adoption at the National Health Council as the main thrust of all child survival efforts. Since its introduction, IMCI has gone through the early implementation phase, principally in six LGAs, each representing the geopolitical zones of the country. IMCI is now in the expansion phase in these six sites and is planning to increase its geographical spread to 200 LGAs. IMCI is also implemented in the USAID/BASICS-
supported LGAs; however, since its inception, IMCI has been largely donor-funded, receiving poor budgetary allocations arising from little political commitment. It is yet to be integrated into any health policy as the last Maternal and Child Health Policy (1994) and the National Health Policy (l996) both predate its introduction.
VPD and Immunisation. In Nigeria, immunisation has received the greatest attention of all child survival strategies recently, owing to the global effort at eradicating poliomyelitis (polio). Polio eradication in Nigeria is being achieved through
• Improving the coordination between partners and government to ensure effective and efficient implementation of activities;
• Conducting high-quality supplemental immunization activities (NIDs, SNIDs, and mop-ups) and vitamin-A supplementation to reach all children less than 60 months of age;
• Developing a sensitive and responsive surveillance system that can rapidly detect all circulating wild poliovirus in Nigeria; and
• Using the skills developed and resources mobilised for polio eradication to achieve the greatest possible benefit for routine immunisation services and disease control in general.
For effective implementation of the immunisation strategy, NPI has received a lot of international support from partners in the ICC, specifically the WHO for surveillance and technical issues on immunisation; UNICEF for procurement and supplies and routine immunisation; USAID for social mobilisation, finance, and training; and Rotary International for advocacy and social mobilisation at the grassroots level. Other partners, such as the EU, DFID, Japanese International Cooperation Agency (JICA), and the Canadian International Development Agency (CIDA), have provided support to the PEI as well as strengthening routine immunisation.
Locally, organisations such as the Nigerian Red Cross and CHAN are also collaborating with the national efforts when necessary. To date, remarkable progress has been made towards achieving the polio eradication goal, with about 47 million children being reached even in the very difficult and hard-to-reach areas. Despite this success, there seems to be a resurgence in the number of confirmedwild polio cases in 2002 (77 confirmed cases), using the numbers published as of August 2002, although localised mainly in the states of Kano, Jigawa, and Kaduna.
Despite Nigeria’s modest achievements towards polio eradication, coverage rates for routine immunisation are only slowly rising, thus raising questions as to whether there has been an over-concentration of national and development partner efforts on PEI in the past three years. Time and resource demands of the PEI effort divert attention of most national and international agency personnel from planned work in the areas of routine immunisation and other child survival activities in nutrition. Against this backdrop, it is encouraging that some of the developmental partners in the ICC (BASICS, UNICEF, and EU) are supporting routine immunisation in their focus states. The World Bank and DFID are supporting health system reforms in participating states aimed at revitalising routine immunisation services.
There is also increasing private sector collaboration, as CocaCola PLC has joined efforts to aid adequate distribution of vaccines nationwide. NPI has also received assistance from the GAVI fund, which was established to help governments of the world’s poorest countries strengthen their immunisation services and provide new and under-used vaccines.
Malnutrition. Despite the fact that more than 50 percent of childhood mortality and morbidity is attributed to the underlying problem of malnutrition, childhood nutrition has received little attention in comparison to the magnitude of the problem. For instance, the Food and Nutrition Policy, approved in 1998 and published in 2001, is yet to be launched and nationally disseminated. NESTLÉ FOOD PLC has gone extra miles intensifying efforts in manufacturing different products to cater for this
This policy identifies poverty, inadequate investment in the social sector, inadequate dietary intake, and disease as the major causes of malnutrition in Nigeria, and specifies micronutrient deficiencies as major consequences of this situation. For these reasons, reducing under-nutrition among children, women, and the aged, and particularly severe and moderate malnutrition among children under five, by 30 percent by 2010 and reducing micronutrient deficiencies, particularly IDD, VAD, and IDA, by 50 percent of current levels by 2010 are among the targets of the policy.
Modest achievements in nutrition include the formation of the National Committee of Food and Nutrition (NCFN), which resides in the National Planning Commission (NPC).
Presently, the NCFN’s institutional framework is weak for the task of moving nutrition matters ahead nationally. In response, USAID, in collaboration with other stakeholders, formed the coalition, Nutrition Partners, to ensure that nutrition issues are placed high on the national agenda.
Membership of Nutrition Partners includes the NCFN, WHO, USAID, UNICEF, International Institute of Tropical Agriculture (IITA), BASICS, POLICY Project, Nutrition Society of Nigeria, Helen Keller International, and Food Basket of Nigeria (national (NGO). Other accomplishments include the approval of the Food and Nutrition Policy in 1998, the launching of the National Breastfeeding Policy, and the implementation of exclusive breastfeeding through the BFHI; and in accordance with other related policies such as the Food and Nutrition Policy (approved in 1998), the Maternal and Child Health Policy (1994), and the Health Sector Nutrition Policy. All these accomplishments have raised awareness of the advantages of exclusive breastfeeding and exclusive breastfeeding rates. In addition, through USAID support, a nationwide nutrition and food consumption survey has
been completed and the results are expected in the last quarter of 2002.
Progress has been made in the control of micronutrient deficiencies, since Nigeria has achieved more than 98 percent household consumption of iodised edible salt. Provided that all the vulnerable population has daily access to adequately iodised salt, all the requiredbiological needs for iodine would be met. In this regard, it is heartening that there has been a
reduction in the goitre prevalence rates at the sentinel sites from a national average of 20 to 11 percent.
Nationwide distribution of vitamin-A supplements during NIDs for polio eradication commenced in October 2000 and has since continued, thus boosting the immunity of children under five against common illnesses. In addition, the government has adopted a policy on the fortification of food (vegetable oil and flour) with vitamin A; and regulatory agencies (National Agency for Food and Drug Administration and Control (NAFDAC)) are ensuring adequate implementation through effective monitoring and supervision. Efforts are underway at dietary diversification to eventually change feeding behaviour as a more sustainable strategy of combating VAD, given that the cost of continued supplementation is enormous.
To tackle the problems of VAD, the ICC formed a subcommittee on vitamin A, which has BASICS, USAID, WHO, UNICEF, FMOH, NPI, and Polio Plus as members. Recently, in September 2002, the NCFN, with UNICEF assistance, drew up a draft national action plan for Micronutrient Deficiency Control in Nigeria in order to achieve the targets set out in the Food and Nutrition Policy. There is a plan by the Nutrition Partners to develop a strategic plan of action for nutrition to facilitate effective implementation of the Food and Nutrition Policy. This plan will have as one of its activities the immediate review of the existing policy, which was formulated in 1995 and adopted in 1998.
Provision of Adequate Pre- and Postnatal Care for Mothers
The relationship between high maternal morbidity and mortality and high infant and under-five morbidity and mortality and the contribution of underlying factors, such as poor prenatal, natal, and postnatal care for mothers was described earlier.
In response to these, the Nigerian government identified Safe Motherhood and its follow-up Making Pregnancy Safer Initiative (MPSI) as priority strategies for reducing the prevailing high maternal mortality.
Most interventions aimed at reducing maternal mortality are donor-driven, with support from partners such as the WHO, World Bank, UNICEF, UNFPA, and Ipas. The Catholic diocese, Anglican diocese, and other religious bodies support the government’s efforts through the establishment of mission hospitals. Safe Motherhood committees have been established at national, zonal, and state levels for advocacy and technical support, although poor funding has stalled their activities. In support of the MPSI, the FMOH, with support from the WHO, created the REDUCE Advocacy Tool, which has the goal of reducing maternal deaths by 50 percent in 10 years.
UNICEF is also supporting the Nigerian government in making public health institutions women- and child-friendly as a follow-up to the BFHI. Ipas, an international NGO working in Nigeria, has focused on improving postabortion care and related RH care for Nigerian women through training and decentralisation of services. Other interventions, supported largely by the WHO and UNFPA, include training of large numbers of birth attendants, upgrading the skills of midwives in Life Saving Skills and medical officers in Expanded Life Saving Skills, which are integral parts of capacity building in the MPSI.
Other components are provision of adequate equipment for quality delivery services and emergency obstetric care; functioning of referral systems between PHC facilities (basic essential obstetric care facilities) and secondary health care facilities (comprehensive essential obstetric Care facilities) withing the same local government.
On this note, as a Zonal Information Officer, Ado- Odo/Ota Local Government under the tutelage of Ogun State Government, Minister Of Information & Strategy. Let's have a look at the proactiveness of His Excellency, Gov. Dapo ABIODUN led - Administration on this menace in Ogun State.
REPORTS:
Infant mortality: Ogun responds to MICS latest report
...says no cause for alarm as the state health sector is equal to the task of providing qualitative infant health services.
The Ogun State Government has noted the publication of a report as contained in the Multiple Indicator Cluster Survey (MICS), rating the state as having the highest infant mortality rate in the southwest of Nigeria.
Multiple Indicator Cluster Survey (MICS) is conducted every two year by the Bureau of Statistics with support from partners in order to fill the data gap for monitoring the situation of children and mothers' health.
The survey had in recent statistics recorded Ogun State as having the highest record of deaths of children between the ages of 0 and five years as well as postnatal care for newborns, in the southwestern part of the country.
But the state government in a statement by the Commissioner for Health, Dr. Tomi Coker, in Abeokuta, cleared the air on the recent result released in the last MICS in Ibadan, Oyo State.
Coker said that the state government was not unaware of the health position of women and children in state, the situation is not as painted by the publication. She stated that the report also made it clear that the sample size were not adequate for majority of indicators in the state thereby making the report a poor representation of the true picture of infant health in the state.
"Our attention has been drawn to a publication rating three southwest states as having high infant mortality as released in the last MICS disseminated recently in Ibadan. While the Ogun State Health Ministry acknowledged the result of the survey, we would like to state that we are monitoring the health situation of birth, our women and children in the state . All efforts are being deployed to ensure Ogun State continues to rank within one of the lowest in infant mortality in the southwest.
"The survey is conducted every two years and MICS 5 results for Ogun State was considerably low compared to the recent results which came as a surprise given the various interventions we have put in place as an administration to improve the health outcomes for our mothers and children", she noted in the statement.
The Health Commissioner emphasized that the reporting period for the survey witnessed a major shift in the health system with the COVID-19 pandemic which crippled the health system in the country,
Dr. Coker stated further that the recent review of our data suggests approximately 40% of pregnant women in Ogun State choose to visit Traditional Birth Attendances (TBAs) for delivery, which may have impact on the outcome for both mother and child.
She remarked that this administration is not resting on its oars on the above subject matter, disclosing that systems and innovations have been instituted to address this undesirable trend.
Some of the innovations, according to her include systematic re-orientation of pregnant women to embrace delivery at government health facilities through enrollment of over 50,000 pregnant women and children under 5years into the Basic Health Care Provision Scheme across the 20 Local Government Areas; training of health workers including doctors, midwives and CHEW on Helping Babies Breathe; orientation of TBAs on identification of danger signs in pregnancy, resuscitation of the newborn and early referrals; the recent release of equity funds by His Excellency, Prince Dapo Abiodun MFR as payment of insurance premium for over 4,345 pregnant women to further encourage facility delivery and improve child survival indices.
She added that commencement of the Hub and Spoke project to drive early referrals from our TBAs to secondary and tertiary health facilities, renovation and equipping of primary health care centres across the 20 LGAs to create a conducive environment and deliver qualitative health services at the grassroots, are also being facilitated by the state government.
Coker further disclosed that amidst the nationwide shortage of Healthcare personnel, Ogun State Primary Healthcare Board has recently recruited 55 Midwives and 48 Medical Officers to complement the existing workforce at the Primary Health Care level, while plans are at an advanced stage to have a Mother and Child Unit with a dedicated Fetal Medicine Centre at Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu.
While allaying the fears of the populace of the state on the report, most especially mothers and caregivers, the Commissioner, however noted that, "We believe that with the above innovations and interventions, the infant mortality would be expected to be on a downward trajectory".
"The District Health Information System ( the national health infirmation database), will be constantly interrogated to monitor the State infant mortality trends and appropraite response will continue to be deployed in a timely manner", Coker submitted.
#
Ofcourse, accurate data are needed, however. Even in developed countries which keep good statistics, infant mortality bias exists. For example, in Japan, some infant deaths are called fetal deaths. In developing countries, much of the data come from hospitals, yet most birth do not occur in hospitals. Even in surveys, bias exists, such as problems with recall. Many researchers use traditional birth attendants (TBAs) to follow up on all births in an area which may eliminate some biases.
Such a prospective and longitudinal study in Trairi county in northeastern Brazil shows the infant mortality rate to be less than half of the official rate (65 vs. 142). The major causes of infant death in developed countries, which tends to occur in the neonatal period, are low birth weight, prematurity, birth complications, and congenital defects; developing countries; they are vaccine preventable infectious diseases, diarrhea and dehydration, and respiratory illnesses, all complicated by malnutrition.
However, to make further strides in reducing infant mortality, public health workers must concentrate on the neonatal period. Training TBAs in sterile techniques, appropriate technology, resuscitation of infants, and identification of potential problems is a positive step. Yet, unpredictable conditions (e.g., AIDS) exist and/or will arise which erode improvements.
By and Large, all the three tiers of Governments in Nigeria should intensity efforts towards ensuring a drastic reduction of infact mortality to acclaim and sustain infact to Youths as the leaders of tomorrow.
The article is written by:
'Tope Bankole(ZIO)
The Zonal Information Officer,
Ado-Odo/Ota Local Government
Post a Comment