………Pregnant women, children bear the brunt
Ebonyi State has grim health statistics. In 2018 and 2019, it was one of the three high burdened states with frequent occurrences of Lassa Fever. In February this year, 17 people died of cholera in Ezza South Local Government Area of the state.
However, the state’s biggest challenge is maternal and infant mortality. In 2019, the National Population Commission (NPC) conducted the National Demographic Health Survey (NDHS) and identified Ebonyi as state with highest fertility rate in southeastern Nigeria.
According to the survey, the state also had the highest case of under-five mortality in the region with 91 deaths from 1,000 live births. In 2021, the State Manager of the United States Agency for International Development-Integrated Health Programme (USAID-IHP) in Ebonyi, Ms Gladys Olisaeke, disclosed that Ebonyi was a special interest state on infant and maternal mortality.
“The mortality and morbidity for mothers and children is higher in Ebonyi State compared to other eastern states. When you compare the statistics for women, for children, for adolescents, it is not as good as other states,” she noted.
In 2022, Ebonyi reported 7,014 maternal deaths from 40 healthcare centres. According to a new State Manager, USAID-IHP, Ms Augustina Otu, the deaths occurred between January and June, 2022.
“The record has it that Nigeria is among the worst hit in maternal mortality in the world and Ebonyi State is among the leading states that contributed to this record,” she said.
“We recorded 7,014 deaths in just 40 health facilities. Imagine if we had gathered reports from other health centres in the state,” she further said.
How the journey began
Armed with the gloomy data, the reporter moved to Ebonyi State to investigate why it ranks high in maternal and infant mortality. Focus was on rural communities where higher mortality rates were often reported. From Abakiliki, the state capital, the reporter moved 22 kilometres to Iboko, the headquarters of Izzi Local Government Area. This local government shares a boundary with Cross River and Benue – two states in South-South and North-Central regions of Nigeria.
Moving from Iboko to communities in Izzi local council was challenging. A long stretch of road connected communities, including Igbeagu, Okpoduma, Ndiukwa, Ndieze, Ndingele, Ndinwekwe, Amoda, Ohuruekpe, Mgbala Ukwu, among others. However, its muddy surface made movement of vehicles and motorcycles awkward and laborious.
The road was lonely and sometimes deserted. It had not been rehabilitated by the Federal Government since 1999 when Nigeria returned to democratic rule, the reporter learnt. It was early August, and it rained cats and dogs.
After sitting for an hour, the cyclist tipped his motorcycle to the side in an agrarian community named Ndiukwa. People were seen shouting in apprehension. A few minutes later, the reporter saw a man helping a pregnant woman on a motorcycle. It was obvious she was bleeding and was being rushed to the hospital.
Five minutes later, the motorcyclist, the pregnant woman and her husband zoomed off. Their destination was Iboko, one hour from Ndiukwa. It was a race against time to save the life of the 36-year-old woman and her unborn child. Due to issues relating to traditions, the reporter was not allowed to take the bleeding woman’s photographs. However, a man who was at that scene was interviewed.
“It is a regular occurrence,” said a prominent member of the community, Mr Sunday Aleke, who was at the scene. “There is neither a hospital nor a primary health centre in Ndiukwa here. Any woman in labour or bleeding like Esther Uguru (referring to the bleeding woman) is driven to Iboko for medical care,” he said.
“We have lost several children and pregnant women here due to the absence of medical care. In one particular week, we lost two pregnant women. Several women are giving birth at home due to lack of a health centre in this community,” he remarked.
“Older people are suffering and neglected too. I suffer from rheumatism but visit medicines stores popularly known as “chemists” because of lack of a government health centre. Pregnant women do their antenatal care at those chemist stores,” he disclosed.
A chemist is a “shop where medicinal drugs are dispensed and sold,” according to the Oxford Dictionary. In Africa’s most populous nation, chemists are mostly managed by traders and people with little or no medical qualifications. This often results in wrong drug prescriptions and avoidable health problems, experts say.
“So, these explain why we lose several pregnant women and children here. We visit chemists for virtually everything. And when we have emergencies or complications, we travel an hour on this terrible road to seek medical care,” he added.
Drinking poison
In a neighbouring community named Ndiokeawo, the reporter was taken to a small river which serves an entire village. Women would collect water from that source for cooking and doing other house chores. Based on hindsight, the water was dirty and heavy with metals, yet some villagers used it for cooking.
“It is used by a number of people,” said a secondary school teacher, Mr Nwankwoagu Benjamin Nwibo, explaining that the community “is suffering from neglect.”
He said the nature of water used by the community could harm everybody, especially pregnant women, children and older people who were vulnerable.
Drinking or using contaminated water is dangerous for pregnant women and their babies, according to a new research by Princeton, New Jersey, the United States, as reported by Sarah Jerome of wateronline.com. The study found that “exposure to drinking water contaminants such as lead, nitrates, pesticides and even the byproducts of processes that disinfect water supplies can harm a baby by retarding growth, stunting mental development and causing birth defects.”
Another research paper said that drinking contaminated water could “lead to cardiac defects, small for gestational age, low birth weight, preterm delivery, spontaneous abortion, oral clefts, and neural tube defects.”
Nwibo said apart from drinking contaminated water, women were not being given proper medical attention during pregnancies, thus increasing their chances of death or complications.
“The closest health centre to this community is located at Ndingele, which is another community entirely. Over there, laboratory tests are taken to Abakiliki for analysis. Imagine how long it takes to bring back the test to the health facility. What they do at Ndingele is the rapid test analysis for malaria, nothing else. There are only ‘applicant nurses’ there and there are no facilities,” he claimed.
Ndingele Health Centre in chaos
The reporter moved to Ndingele Primary Healthcare Centre to confirm or refute Nwibo’s comments. Only one bed was seen at the delivery room, meaning that it could not handle more than one pregnant woman due for child delivery at the same time.
Only one nurse was on duty. The nurse, Ms Ruth Uguru, told the reporter that gloves were lacking, stressing that she and her senior colleague, Ms Ogbangba Grace (absent at that time), were doing their best to ensure that no life would be lost.
The reporter found that basic facilities for childbirth, including ambu bags used in resuscitating babies, were lacking. Important drugs like Oxytocin, used in bringing on contraction in pregnant mothers during labour, were absent.
“There is no water here. We do not have borehole, so it is a major problem,” Ms Uguru said. The nurse was sympathetic and diligent to duty. Her detailed analysis of what she would do in the case of an emergency betrayed that. However, it was obvious that she was being let down by the state of facilities and lack of support from both government and non-governmental organisations.
Ms Uguru and her colleague, Ms Ogbangba, were both nurses and doctors at the same time. They both performed the roles of both due to the absence of a qualified doctor. It was found that the health centre was abandoned for many years and only started operations a year earlier.
However, one woman who visited the health centre after its return to life was not lucky. Ms Esther Omire said she did not receive proper medical attention required of a pregnant woman from the health centre.
According to her, she had the premonition of the situation and visited the health centre for drugs, but the staff could not do anything about it due to lack of medicines.
“Unfortunately, a child in my womb did not survive. I had bleeding after three months. It was so painful, but what can my husband and I do?” she asked, rhetorically.
Same issues at Iboko township
When anyone hears that patients are referred to public health centres or hospitals at Iboko, the local government headquarters, it may seem that all is well there. However, things are as bad as they are at Ndingele. At Iboko Primary Healthcare Centre, the reporter found that critical facilities were lacking. Only one bed was found in the general hall. There was, however, one other room with two small beds for patients, but their mattresses/foams were old and dirty. Another room had only one bed with an old mattress. Two other rooms were locked and unused. Water was also visibly a challenge as there was neither a borehole nor a tap water.
Guarded by their mother, a child was seen in the main hall waiting for immunisation. Despite that, critical facilities such as blood pressure and weighing scales for adults were absent. Women sometimes gave birth at the open hall. A private doctor, however, often came for pregnant women’s surgery and charged about N80,000.
“We need clean water here and hospital beds,” said Assistant Officer-in-Charge, Ms Precious Nkwo. “Please get us as much help as you,” she begged the reporter, who did not disclose his identity for security reasons.
Leaky roofs, stranded staff
At Ohaukwu, one of the local government areas in Ebonyi, the reporter visited Amananta Primary Healthcare Centre located at Ishi-Iziah community. Lack of care for both the facility and the staff was written all over the health centre.
The leaky roofs and broken windows betrayed lack of maintenance of the facility. Doors were always ajar due to damage. There was an acute lack of water as well as facilities for blood pressure and malarial tests. Staff would often buy basic drugs such as Paracetamol and Flagyl for use by patients. Antenatal activities went on every Wednesday but without a doctor.
The reporter found that the health centre was neither getting drugs from the local government nor the state. As of early August when the reporter visited, staff salaries had not been paid for three months. The reporter was told by an Ebonyi State government official that it was due to the transition in government, which started on May 29.
A child patient was seen on the floor. On enquiry, the reporter was told that “he prefers to lie on the floor.” Staff quarters were as decrepit as the health centre -with leaky roofs.
“The government is doing its best, but we need drugs, water, weighing scale, electricity,” Officer-in-Charge, Ms Ngozi Agbo, said. “We want rehabilitation of our roofs. We need beds, chairs and table,” she added.
Like Ndingele Health Centre, no doctor was attached to the Amananta facility. Nurses were totally in charge, even of emergency cases. Ms Agbo, however, said she often referred complicated cases to general or tertiary hospitals.
Ezza North was worse
The reporter moved to Umuoghara-Ogharaugo Primary Healthcare Centre in Ezza North Local Government and saw that patients were going through a hellish condition. Rooms were unventilated and a man whose leg was amputated, Mr Simon Nkome, sat on the bed hoping for the best. Nkome’s little son was on a mat enjoying a meal. By Nkome’s countenance, it was easy to decipher his despondency.
Not knowing that he was in a room with a journalist, Nkome bemoaned the state of the facilities but expressed satisfaction with the staff who he said were doing their best.
A helpless woman was also seen lying in bed in a one of the rooms at the facility. Ventilation was a major problem, and mosquito bites could be felt even in a hot afternoon while the reporter was there. The floors were without carpets, rugs or any other covering, betraying the extent of neglect of the centre.
Nurse Rosemary told the reporter that she and her colleagues were always attending to children and pregnant women and there had been no record of maternal mortality there. It was easy to believe her until anyone began to ask for certain drugs or items. No serious item used by pregnant mothers or even children was available when a skeptical pregnant woman enquired. From folic acid to anti-hypertensive drugs, none was available. Basic drugs for children such as paracetamol, antimalarial drugs and cough syrup were absent.
Nurse Rosemary, however, assured the woman that a doctor often visited the facility with drugs with which the staff attended to the patients, including pregnant women and children.
Connecting the dots
Is there any link between poor state of primary healthcare centres and maternal/ infant deaths?
An Ebonyi State-based healthcare expert, Dr Okechukwu Egboluche, answered in the affirmative. He said the state of health centres had a correlation with maternal and child mortalities, noting that “if the healthcare centres are absent or not equipped, a pregnant mother who is bleeding or has complications may not survive it. This is worse if the distance between the health centres and communities is long.”
Talking about distance, one phenomenon witnessed particularly at Izzi Local Governments was the distance between primary health centres and the communities they were meant to serve. For instance, while there were no health centres at Ndiukwa and Ndiokeawo, there was one at Ndingele – 10 to 20 kilometres from the two communities.
Communities such as Amoda, Akataka, Ndinwekwe, and Okpoduma had none. Patients must travel between 10 and 30 kilometres to Abarigwe to meet a nurse at a health centre. Also, communities such as Onyiriukpo, Ndieze and Agu had no health facility and relied on one at Ijokuma – 20 kilometres away. Even in places with health centres, facilities were lacking.
Dr Egboluche said there was a need to bring health centres closer to the people. “What happens if there are emergencies? But this is not only the responsibility of the government but also other stakeholders such as non-governmental organisations,” he noted.
On other reasons for high maternal and infant mortalities in Ebonyi, he said, “Secondly, several Ebonyi women marry quite in their teens. This exposes mother and child to danger. Also, the state is still regarded as educationally less advanced, which is also a major setback. Lack of awareness makes mortality quite high.” He added that high level of poverty witnessed in some parts of the state would only drive mothers to poorly equipped facilities.
Another public health practitioner, Dr Jeffrey Ajoko, said the high child and maternal mortality rates were not unconnected with the state of medicare in the communities.
“Yes, if you do not invest in primary health centres, you will have high child maternal mortality rates. Underdevelopment and lack of education in Ebonyi are issues driving infant and maternal mortality rates because the state is still poorly developed. If you do not build primary health centres in rural communities, pregnant women may have bleeding and die in the process,” he noted.
Ebonyi State inconsistent health budgets
Ebonyi State health budgets have fluctuated in the last four years. From 7.22 percent share of the state’s total budget in 2019, it rose to 8.6 percent in 2020 and to a surprisingly high rate of 15.23 percent in 2021. It, however, fell to 5.72 percent in 2022.
The state has 417 primary health centres, according to its Ministry of Health. The Basic Health Care Provision Fund (BFCPF) was enacted in 2014 and mandated that one percent of the consolidated revenue of the federation should be dedicated to health. In 2020, the state paid N25 million to support the BFCPF and also access the Direct Facility Fund (DFF) meant for medicare. The N25 million paid by the state was targeted at revamping primary healthcare centres in the state, but the amount was only a drop in the pan.
“It is obvious that the attention of the immediate past government was on infrastructure and it achieved it, though to the detriment of other sectors,” said a medical doctor in a private hospital in Abakiliki, Mr Sam Ibie.
In 2022, Ebonyi State Ministry of Works and Transport got 16.74 percent of the N145 billion budget, while health received only 5.72 percent. In 2020, works and infrastructure got 30.8 percent of the N178 billion budget, whereas health got 8.6 percent. In the previous year, infrastructure got 28 percent of the N188 billion total budget whereas health received 7.22 percent share.
The NGOs and Ebonyi health crisis
Non-governmental organisations (NGOs) in Ebonyi are in bed with the state government. Based on information gathered by the reporter, their activities are mostly in Abakiliki and other semi-urban areas, not in rural communities where the need is high. At Izzi Local Government communities, residents begged the reporter to bring succour to them “as everybody has abandoned us.” Social critics blame NGOs’ ineffectiveness on lack of funding and petty politics, noting that “NGOs are just extensions of the government in Ebonyi.”
However, Ananda Marga Universal Relief Team (AMURT), an international NGO, said it was different. AMURT was launched in Nigeria in 2010. It selected Ebonyi State as its first project area because of its high rates of maternal and infant mortality. The project is run in collaboration with the Ebonyi State government.
Country Director of AMURT, Mr Dada Daneshananda, acknowledged the inefficiencies of primary health centres in Ebonyi State, noting that most of them were not providing 24-hour services. He noted that there was one health centre in one ward, stressing, however, that lack of doctors at the centres from time to time was also a big issue.
“We are in 10 local centres already. The new government has decided to make health and education its priority, and we are working together. There is a need in the state, especially in rural communities such as Izzi. We are receiving applications from local governments regarding their needs and we are working on them,” he told the reporter.
On his part, the Director of Essential Health Network for Rural Dwellers in Ebonyi State, an NGO, Prof Henry Chukwuemeka Uro-Chukwu, refuted the report that Ebonyi was worse-off in health. According to the professor of medicine, successive governments in the state had done practical things to improve healthcare in the state.
“I have been practically part of several health sector in the state for a long time. There has been free maternal healthcare in the past, such that if a woman wanted to have a child, she could do it free of charge. A lot of things have been put in place to improve healthcare. Also, I do not think that Ebonyi is worse than Yobe, Borno and several other states on maternal and infant mortality based on recent data,” he said, stressing that there had been so much development on health infrastructure in the last 16 years.
Nigeria’s unimpressive doctors per 1,000 people
Nigeria ranks very low in terms of number of doctors to 1,000 persons. The World Bank 2020 data showed that Nigeria’s ratio was 0.37 as against South Africa’s 0.79 and Egypt’s 0.75. Only Kenya ranked below Nigeria (0.2) on the list of 10 emerging nations, with Brazil posting 2.05 and Pakistan, 1.12.
Vietnam, one of the fastest growing nations, posted 0.83 whereas Bangladesh had 0.67 while China’s was estimated at 1.98.
We are touring facilities, says commissioner
Newly appointed Commissioner of Health in Ebonyi State, Dr Daniel Umezuruike, told the reporter that he was touring all the health centres in the state to ascertain their strength and level of facilities.
“We are just touring those facilities to ascertain the extent of things in those places. At this stage, we are assessing the extend of things,” Umezuruike, who was appointed commissioner in June this year, said.
“One of the things we have found is that manpower is a problem. Some people have just been posted to the facilities and they are just new. We are at a stage where we write to the governor for the employment of qualified personnel,” he added. He did not, however, say what he planned to do about the facilities and the rehabilitation of health centres in the state.
What is the way out of crisis?
In spite of the high infant and maternal mortality in Ebonyi, experts have not lost hope. They, however, believe that certain steps must be taken to improve the situation. According to Dr Ajoko, earlier cited, the state government must begin to invest heavily in primary health centres.
“There is a need for the government to build more health centres in places where there are none. They need to spend money to rehabilitate, resuscitate and equip health centres that are sited in rural communities. This is very important because you cannot have a significant reduction in infant and maternal mortality if you are not investing in primary health centres,” he explained.
A lawyer and associate at an NGO named Centre for Health, Ethics, Law and Development (CHELD), Ms Chioma Ejimofor, said there was a need for primary health centres to have good synergy with tertiary health institutions.
“The referral pathways are often terrible at primary health centres. When you do not have a proper referral pathway, your patients will suffer, which is what is happening over there. Also, there is a need for the government to equip the primary health centres as many of them lack facilities with which to attend to patients.
“Similarly, manpower is a challenge and efforts should be made to engage more workers at health centres in order to save lives,” she added.
For Mr Daneshananda of AMURT, Nigeria in general and Ebonyi in particular should endeavour to ensure that primary health centres in rural communities were open 24/7 in order to cater for issues that could occur during odd hours.
“There is a need for primary health centres to be open 24/7 in order to help emergency situations at late hours,” he said, adding that doing that would save a lot of women and children in rural areas.
But a Kaduna State-based medical practitioner, John Yakusak, noted that it was impossible to have 24-hour service at primary health centres “without getting staff that would do shifts.”
“The government in Ebonyi and indeed other states in Nigeria should get more health workers employed in order not to overburden the nurses and other support staff who work there. The major challenge today in the medical profession is that health workers are so stressed that they hardly have time for themselves. This is not supposed to be so.
“It is high time Nigeria began to give incentives to those studying medicines in the universities. It is critical to give students incentives to study Medicine and Surgery, and give them attractive pay packages when they graduate. By so doing, we will have more doctors in the country willing to visit health centres in rural communities,” he said.