Dr. Luther-King Fasheun: Improving Maternal Health in Nigeria through Partnership

Embedded image permalinkIt is no longer news that Nigeria is a peculiar country, a nation with huge human and natural resources, and whose diversity of peoples and internal geographies is a blessing. Sadly, it is also not news that the country represents at least 10% of the global maternal mortality burden, with a currently estimated maternal mortality ratio (MMR) of 487 per 100,000 livebirths (as at 2011). However, the well thought-out targets of the Ending Preventable Maternal Mortality (EPMM) Working Group present the country with an unprecedented opportunity to change the tide, improve livelihoods for its women and families, and aim to eliminate preventable maternal mortality within a generation, harnessing the right tools and interventions, at the right scale and quality, as well as building on the success factors in the chase for the Millennium Development Goals (MDGs), including the harnessing of a burgeoning private sector and surging political will for improved health outcomes for women, families, and communities.

Based on the EPMM Working Group targets, the proposed MMR target for Nigeria is ‘less than 100 per 100,000 livebirths by 2035, with country-specific milestones, with the expectation that Nigeria will cross one milestone within every 5 year interval.’ For Nigeria, I humbly recommend that the country-specific 5 year interval milestones be context-driven on a State by State basis, given that Nigeria has 36 States, with one Federal Capital Territory (FCT, Abuja). While the federal government provides strategic guidance and robust supportive frameworks for implementation of reproductive, maternal, newborn and child health (RMNCH) interventions for the entire country, the infrastructural and health systems challenges of Nigeria, as well as the resources available to mitigate these challenges, are mainly State-driven. More so, because of the vast population and heterogeneity of Nigeria, as well as the strategic importance of the country to the attainment of global goals, I wish to strongly recommend that the EPMM Working Group sets State-by-State targets, working in partnership with the Nigerian Federal Ministry of Health, and governments of all the 36+1 States.

A State-by-State framework must not shy away from the interconnectedness of States, and the virtual nature of geographic borders, especially because of the very mobile nature of Nigerian women and families, as well as unavoidably shared natural resources, for example. To this end, there should be significant cooperation and sharing of insightful knowledge, under the leadership of the Federal Ministry of Health, and with the assistance of NGOs, CSOs, bilaterals and multilaterals. In this manner, Nigeria presents a window of opportunity to show the world a model that works to eliminate inequities to the last mile, helping to reach global set goals and targets for maternal mortality ratio (MMR) reduction.

The adoption, last year, of the Maternal Death Review (MDR) surveillance mechanism, at the National Council on Health (NCH) meeting, marked a watershed in the history of Nigeria, as it demonstrated a readiness for evidence-based policy frameworks that will mitigate Nigeria’s huge maternal mortality burden. This policy adoption is being followed through with full vigour. Even more recently, the Presidential Summit on Universal Health Coverage promises a new guiding light for the elimination of inequities and barriers to access to healthcare, especially at the primary healthcare level, where the key to unleashing tremendously scaled-up interventions, to save the lives of mothers and children, exists.

Source: Maternal Health Task Force Blog

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Dr. Nathalie Charpak: “Kangaroo Mother Care” and Neurological Development of Premature Babies

Kangaroo mother care is a method of care of preterm infants. The method involves infants being carried, usually by the mother, with skin-to-skin contact.

Kangaroo mothercareKangaroo Mother Care (KMC) according to Dr. Nathalie Charpak, an internationally respected pediatrician and daughter of the Nobel Prize-winning physicist George Charpak, represents a way of humanizing neonatal healthcare. Like other forms of “kangaroo care,” KMC is an incubation method to keep newborns weighing 2000 grams or less at birth and those unable to regulate their own body temperatures warm. Rather than isolating babies in loud, mechanical neonatal intensive care units (NICUs)—which have been shown to cause both psychological stress and adverse physiological changes—KMC positions preterm and low-birth weight babies in direct skin-to-skin contact with a parent or caregiver once stabilized. While KMC was originally conceived in 1978 in response to overcrowding and inadequate resources for NICUs in Colombia, more recent research studies have shown that skin-to-skin contact works as an effective technique not only for thermal control but for breastfeeding, and bonding irrespective of clinical settings, gestational age, or weight. This case study recounts how research evidence has drawn attention to important aspects of neonatal development.

Research to Practice

During an interview with PAHO, Dr. Charpak outlined three types of surrogate benefits emerging from an intervention like KMC. Firstly, from a sociological standpoint, placing babies in direct contact with their parents presents an immediate opportunity to establish a parent-child relationship without delay and avoids separating the neonate from caregivers simply because of illness. She argued that by involving them directly, parents and caregivers are naturally compelled to assume the roles of providers for their preterm babies. For the infant, investigators have observed a stronger tendency for babies to quickly settle down into a deep sleep (lower state of consciousness) or become less fussy before feeding when in KMC position 4. By enhancing the parent-infant bonding, KMC facilitates the psychological bonding process necessary to overcome the initial stress and shock already associated with a premature birth.

kangaroo-father

Secondly, kangaroo care promotes growth and development. Notably, KMC encourages exclusive breastfeeding and lactation which contribute to proper nutrition needed to sustain appropriate growth and weight-gain rates. Dr. Charpak also alludes to neural stimuli: “It’s favorable for the baby to smell his/her mother, hear the heartbeat, and experience tactile stimulation which resembles the comfort experienced in-utero.”

Research done at the Université Laval supports these claims. Comparing the motor cortex of premature adolescents (39 who underwent KMC and 18 who underwent NICU), the investigators discovered that premature infants under KMC had better brain functions in adolescence than their counterparts who underwent incubator care. When comparing brain maturation, the KMC-patients had brain connectivity more similar to patients born at term. This research suggests an association between KMC and optimized neuroplasticity during critical stages of infancy by reproducing intrauterine environments that NICUs cannot simulate.

Thirdly, Kangaroo Mother Care has led to some changes to standard of care that has improved how neonates are treated. The implementation of KMC units is a 24/7 service requiring clinics to operate non-stop. In contrast, in some low and middle income settings babies in NICUs are left alone while attached to monitors, ventilators, and other mechanical contraptions. Further, NICUs are subject to the dangers of outdated equipment or inconsistent electricity grids found in resource-poor hospital settings. However, KMC, by removing the automation, obliges hospital staff to treat newborns like regular patients (e.g. respecting sleep patterns, reducing exposure to stressors such as noise). This has been associated with dramatic reductions in negative physiological responses such as sleep apnea and fluctuations in heart rate, blood pressure, and oxygen saturation. At the same time, they also they lessen the hospital workload by introducing parents as additional caregivers.

In practice, maternity wards, for example in Nicaragua, have shown KMC to be a cost-saving implementation because it decreases the average lengths of stay in hospitals and thus lowers resource consumption. Additionally, for hospital units surrounded by varying road conditions and surface disruptions, KMC position provides a safer form of transportation. While little data about this adaptation exists in the Americas, studies from Belgium show that the mother and her body provides adequate safety and comfort. This data suggest that KMC as an intervention decreases parental stress and increases quality of care for the infant while gaining high satisfaction among hospital staff.

What’s Next

Although KMC originated in response to limitations of resource-poor hospitals, the benefits attributable to this health service has undoubtedly extended beyond its original purposes and generated new knowledge to improve the standards of care for newborns. From discussion with Dr. Charpak, there is the conclusion that KMC is neither a return to ancestral practice nor an alternative to more conventional means of neonatal care; instead, it complements the NICU. By adopting a more holistic form of medicine and introducing an intervention that looks natural despite of not actually being “natural in nature,” research presents one cost-effective, functional care system that improves the way preterm and low birth weight babies are cared for in hospitals.

At the same time, Dr. Charpak cautions that in addition to implementation, “numbers must be published and guidelines must be actualized.” More published observations will be needed to more comprehensively understand the returns of health services like KMC in varying settings. The strength behind this intervention, nevertheless, is that it has been and continues to be extensively researched, thus further pushing the boundaries of knowledge for better health.

Source: Paho.org