Unexplored success route to Nigeria’s MDG4 target on

neonatal mortality

Hippolite O AmadiJonathan C Azubuike, Akin O Osibogun, Mohammed B Kawuwa,

Peter Alabi, Angela C Uwakwem

Research Funded in part by

A division of The Mastermind Group Nigeria

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C C E F T H ICommittee of Chief Executives of

Federal Tertiary Hospitals of Nigeria

Background

• In 1990 WHO set off for MDG

targets

– deadline 2015

• MDG4

– targets 67% reduction in U5MR

Background

• In 1990 WHO set off for MDG

targets

– deadline 2015

• MDG4

– targets 67% reduction in U5MR

• For Nigeria

– to save extra 520 babies/day

from 778-daily

– huge task that required

proactive thinking and

implementation

• All kinds of money gosling

programmes set up

• Various donor agencies

– Identified with need

– donated monies

– Various aspects of child

health targeted

Background

• All kinds of money gosling

programmes set up

• Various donor agencies

– Identified with need

– donated monies

– Various aspects of child

health targeted

• Outcome

– Large money spent little

progress made

– Private pockets made richer

– false statistics reported to

enable the next ‘cash-kill’

– Yet U5MR remained high

Background

• Neonatal mortality (NNMR)

– accounts 40% of U5MR in Nigeria

• by simple maths

– any efforts to improve newborn care would

contribute towards MDG4 target

– if neonatal mortality is not reduced, MDG4

target may not be realised

• Many years on

– Nigeria could not demonstrate significant

MDG4 progress

• From: Ibe’s (1993) ‘increasing admission

delivery’

• To: Ogunlesi et al’s (2008) ‘worsening

hypothermia risks’

Introduction

Introduction

• KMC may scarcely work for big

neonates

• Extreme

– preterm babies (<31weeks-GA)

– low-birth weight babies (<1500g)

would die without incubator care.

• A typical Nigeria SCBU

– Up to 45 neonates on admission

– 20 could be preterm

• This implies a basic requirement of

– over 20 incubators in a centre

Introduction

• Sadly no centre could demonstrate

availability of up to 4 functional

incubators for two years

• One could rather see

– large number of dysfunctional and

obsolete incubators

• littering the walkways

• in workshops

• dump sites.

– whilst SCBUs remain empty

• Any inside SCBU

– Can also kill

• Incubator scarcity well-understood

– Modern incubators are expensive

– excess of £25,000

– Maintenance experts, unavailable

– Spare parts supply chain, unavailable

– Local power supply, erratic & unstable

– Operating environment, harsh for

incubators to survive (↑IMR)

Introduction

• Incubator scarcity well-understood

– Modern incubators are expensive

– excess of £25,000

– Maintenance experts, unavailable

– Spare parts supply chain, unavailable

– Local power supply, erratic & unstable

– Operating environment, harsh for

incubators to survive (↑IMR)

• Hypothesis:

– Low-cost,

– Technology-simplified,

– Culturally-adaptable

model must be synthesised if neonatal aspect

of MDG4 must not be compromised

Introduction

Methods

• Neonatal Concerns outreach:

– 2003 private research initiative

– Gradually become popular

RIVERS

KANO

SOKOTO

YOBE

GOMBE

PLATEAU

F C T KWARA

OGUN

LAGOS

EDO ENUGU

EBONYI

CROSS RIVER

AKWA

IBOM

ABIA IMO

OYO

KATSINA

NIGER

BAUCHI

Neonatal Concerns

outreach locations

Methods

• Neonatal Concerns outreach:

– 2003 private research initiative

– Gradually become popular

• Concern-1: RIT Devised

– Generic components plus Incubator

carcasses,

– New low-cost systems

• capable of 10 years of life

• Easily maintained by locals

• Presently applied in 20 Nigerian

referral hospitals

• Concern-2: Teaching

– Incubator care exposed other deficiencies

– 2 elective course modules developed

– instruct practitioners on correct

techniques of incubator care

– Over 1550 passed through level 1 course

– Over 100 been on level 2 course

(advanced)

Methods

• Concern-2: Teaching

– Incubator care exposed other deficiencies

– 2 elective course modules developed

– instruct practitioners on correct

techniques of incubator care

– Over 550 passed through level 1 course

– Over 100 been on level 2 course

(advanced)

• Concern-3: Expansion

– Carcasses used up

– External help called to assist

• freely donate carcasses to hospitals for

recycling.

• Brondek, Atlanta based organisation

currently helping

Methods

UBTH Benin RIT-fleet

casings from the USA

thro’ BRONDEK partnership

• Concern-4: Research Groups

– Centre-based research groups set up

• To investigate local phenomena

• Assess impact on practice outcome

• submit results for peer reviews

• Apply to improve outcome

Methods

• Concern-4: Research Groups

– Centre-based research groups set up

• To investigate local phenomena

• Assess impact on practice outcome

• submit results for peer reviews

• Apply to improve outcome

• Concern-5: Local system fabrications

– Local independent artisans recruited

– Trained to produce spare parts

– Individually being harnessed to fabricate a

serviceable local model.

Methods

• Concern-4: Research Groups

– Centre-based research groups set up

• To investigate local phenomena

• Assess impact on practice outcome

• submit results for peer reviews

• Apply to improve outcome

• Concern-5: Local system fabrications

– Local independent artisans recruited

– Trained to produce spare parts

– Individually being harnessed to fabricate a

serviceable local model.

• Concern-6: Further death reduction

– installation of power-banking

– apnoea monitoring systems

Methods

Apnoea-monitor

• Concern-7: Preventive maintenance

– Half-yearly failure-preventive

– and auditing of all set up

– collaboration w hospital management

• enforcement and

• implementation of recommendations of

audit results

• Concern-8: Performance challenge

– Annual national performance assessment

– each assessed and scored twice yearly,

– Best hospital centre and best performing

ward matron given National Award

– worst performing centre notified too

– has brought out the best of centres

Methods

• A 6 year follow up study in 2010

declared that outreach has led to:

– neonatal mortality reduction by 25%,

– morale/survival confidence of

clinicians/nurses boosted by 79%,

– accelerated discharge of survivors by 19%,

– boosted patient influx by 27%

• Last 2 yrs,

– figures since appreciated further,

– doubling in some centres,

– more hospitals expands in incubator

capacity beyond 15-units

– up to 38-units in a single centre

– All funded within hospital internal budget

Results

Results

• Total capacity (Base & Transport) Incubators

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38

UBTH

FMCnguru

FMCowerri

LUTH

UNTH

Number Functional Incubators

Neo

nata

l C

en

tre

Base Transport

• RIT & associated techniques

have demonstrated a

significant capability for

newborn survival

– Availability

– Sustainability

– Affordability

– Overall growth in incubator

capacity

– Clinical, Nursing & Scholarly

prowess (over 10 publications)

• Fully implemented in 8

centres ONLY

• Great opportunity LOST

Conclusions

Your Attention

is Appreciated

Please feel free for

your questions and

comments

Hippolite O Amadi

h.amadi@imperial.ac.ukResearch Funded

in part by

A division of The Mastermind Group Nigeria

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Committee of Chief Executives of

Federal Tertiary Hospitals of Nigeria

Unexplored success route to Nigeria’s MDG4 target on

neonatal mortality