By Gabriel Olawale
PROFESSOR Oluwarotimi Ireti Akinola, is a Professor of Obstetrics & Gynaecology and current National President, Society of Gynaecology and Obstetrics of Nigeria, SOGON.
During the Annual General Meeting of the Society in Sokoto, Akinola spoke to Good Health Weekly about fortunes of SOGON while stressing the need for repositioning of policies that would bring about better maternal and child health in Nigeria. Excerpts:
Plans for next three years as President of SOGON
Basically one cannot run through all the plans that you have but I will just tell you what flagship programmes we have currently. One of the flagship programmes is called volunteer obstetrician scheme which means that, we take in obstetrician down to address the human resource component of the chain to the baseline local governments so that each obstetrician adopts a Primary Healthcare Center where there are no obstetrician, normally you don’t have them at that level, so you can have medical officers, midwives, nurses, Community Health Extension Workers (CHEWS).
So we can mentor them and we know what it is, we need to improve the statistics. So the plan is actually to avail them of those services through those interventions.
Major problems in health sector
One of the major problems in the sector is the lack of political will to drive policies.
For instance, Nigeria has not devoted 5 percent budget to health. The Abuja declaration which was done in Nigeria for African nations actually specified 15 percent of the budget so there is paucity of fund but even with the available resources you still find out, for example policies are often not well orchestrated towards addressing the issue of maternal and new-born health.
As specialists, we are custodians of women’s health. What do we want to do? We feel that we need to broaden our partnership particularly with the media in terms of advocacy, we can’t get to the people, the people do not know, so if we can increase awareness of health issues we are sure that maternal and child health will be a battle half won.
There is need for Nigerians to prevail on the President, Governors, Local government Chairmen, and other political authorities to implement those policies that will be favorable.
Talking about universal health coverage, we are talking about the health Act that has been signed. None of these things has been put into practice not even budgeted for in most states.
The National Health Act was signed in 2014 but it has not yet been implemented. It is not budgeted for in the budget line. That is why I specify that you should do something with your budget but we are not looking at it.
The other aspect is the percent of consolidated revenue that is supposed to be put in health, if that is done you have finance for universal health coverage.
I cannot see the prospect in the 2018 budget presented by the President, even when it is passed perhaps it might still be before appropriations and all that in the assemblies and senates but the figure is not better certainly. Allocation to health is even lower, I think it is about 4.9 percent or something, we have done 5 before.
Equipping hospitals to resolve maternal death
We have lots of equipment but sometimes because it is not the people who are going to use the equipment that buy them so we have equipment that are bought not according to specification. Here in Nigeria, equipment are bought for contract purposes and not for service purposes.
Like now, very few centres in Nigeria can adequately manage cancer. It is not for lack of knowledge but for lack of equipment, those are some of the problems.
If the hospital is equipped with the right equipment even the doctors that are migrating will come back and work in a centre where you have everything because the fulfilment is being able to perform and work in an environment that is conducive.
Recommendations on reduction of maternal deaths in Nigeria
Everything we’ve been talking about is reducing rate of maternal death, if you don’t get pregnant at all you will not die. In Nigeria today we have just about 15 percent contraceptive prevalence rate so you will know that people who ought to be using contraceptive are not using it and they get pregnant and if they get pregnant too frequently or too often their health is depleted, they have shortage of blood, shortage of the resources and other things so they die.
So if for example, studies have shown that increasing contraceptive prevalence rate alone reduces maternal mortality. So basically, providing skilled birth attendance that is the most important factor that has been identified is present at the time of delivery, sometimes is small cheap things that can be applied to prevent them from dying. A woman who is in labour is a step away from intensive care.
Often times when we talk about emergency obstetrics care being available, it means you are able to transfuse blood, you are able to do these and all that, so these are facilities that will prevent maternal death. Our job is to create awareness, sensitise them, help improve the health seeking behavior and again that is another advocacy that is why I said the media has a big role to play.
obstetrician and gynecologists in Nigeria
The problem really is that you don’t need just obstetrician and gynecologists to reduce maternal mortality. When we say skilled birth attendance we are talking about trained midwives and doctors, 80 percent or there about of normal deliveries should be taken by midwives. If they run into trouble, a doctor comes. It is only when it gets to high -end that a gynaecologist or obstetrician comes in, but the role of the obstetrician is to enhance the quality of care. He trains those people so that they do the proper thing. It is not just the number, it’s interesting when you say we are under served by the number of obstetricians and gynaecologists we have in the country.
You also found out that for example there are states where you have two or three obstetricians and gynaecologists in this country and there are states where you have well over four-five hundred, again you also have that geographical inequality in the distribution. But that is not the problem. The problem is being able to identify thar you have a compressive health care system and that you have clusters, that is what we are trying to do with the volunteer of obstetricians scheme so a lots of satellite places are responsible to the obstetrician so it monitors what is happening in those places and then intervenes when necessary.
Implication of migration of medical practitioners
The truth is that they are living. I will tell you for example that in the last 6 months I know about four obstetricians and gynaecologists that migrated from Nigeria and where in the world did they go? They went to Rwanda. So those are the kind of things that is happening but why do they go there! This is because they are better taken care of, they are well appreciated, they have resources that they need. If you fold your hands and a woman is dying but there is nothing you can use to help. You don’t know how hurtful, how painful it can be to the practitioners.
Ways to stop migration of practitioners
We’ve had it, we have what is called brain drain and then its improved, people came back and then people are going again because we are having trained professionals who are not getting employed, there is no employment, we have gynaecologists who are looking for employment in this country so by the time they look for employment for six to one year and they don’t get placement then they go outside, they go where they are needed. Is interesting.
Population of Britain that is probably about 40 million or thereabout absorbs all the people they trained and all the people also we can donate, meanwhile the cost of training each of us is so enormous. In America, for example an average medical student raises about $50,000-60,000 per annum and trains for about four-five years.
What happens in Nigeria is that we now have supernumerary residency. When I say supernumerary those are people working 24 hours for government free of charge just because they want to attain knowledge. So we have turned them into students again, that doesn’t happen anywhere else in the world. Addressing exodus is for all of us, we must all appreciate that there is a problem. I know for example that almost about 30 to 40 percent of the students we train in all honesty migrate to developed countries.
Controversy over Ceaseran Section
The truth is that a lot of things are based on misconception. The World Health Organization prescribes a minimum of an average of about 15 percent Ceasarean Section rate. If you do not provide that to an obstetric population it means that you are under serving them.
Worldwide, CS rate has been on the rise and will probably continue to go up even in Nigeria because of several reasons. Fear of litigation makes people practice defensive medicine. Caesarean Section sometimes is as a result of defensive medicine.
Rise in CS and obstetric fistula
I most disabuse your mind that CS rarely contributes to the increase in obstetruc fistula. it is actually vaginal delivery where you have what we call pressure necrosis, prolonged obstructed labour that will make the head of the baby press on the tissues and slough off of the bladder and everything and the vagina.
That increases the CS rates. So there is no doubt about it. If you have girls getting married early who are not developed, if you allow them to go through labour then certainly you will have cases of fistula. There is need to empower them, give them education so that they don’t get pregnant when they are 15-16, they don’t fall in labour then you will not need to do CS for them, so all thee are intertwined. Elimination of poverty, increasing girl child education is necessary in reducing maternal deaths.
Malnutrition and childbirth
When a child that is malnourished gets stunted, so if you lower the standard of living because of recession and you don’t feed the children, you are actually implanting something that in the next 10-15 years when they get to child-bearing age they are not going to be able to successfully have normal deliveries.