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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
[email protected] 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