Against One More Silent Monster Eating Nigeria Away, Child Mortality

Several things are cheap in Nigeria, from pure water to jollof rice, everyone can agree on how accessible these are and unfortunately, the same goes for Nigeria’s child mortality rate. It is a shocking and scary reality that isn’t only cheap, but Nigeria happens to rank very high globally. The sad part in all this […]

Several things are cheap in Nigeria, from pure water to jollof rice, everyone can agree on how accessible these are and unfortunately, the same goes for Nigeria’s child mortality rate. It is a shocking and scary reality that isn’t only cheap, but Nigeria happens to rank very high globally. The sad part in all this is that most of these children die of preventable causes. Let’s break down the numbers a bit.

As of 2023, out of 1000 live births, there are 105 deaths. Currently, Nigeria ranks number two on the highest infant mortality rates in the world with no less than 260,000 children dying every year. To bring this closer to home, that’s about 700 children dying daily. However, these are not just numbers though, these are human beings, people with full lives, families, purpose and futures snuffed out prematurely.

According to Immunization Specialist Dr Fatima Kumo at Nigeria Governors’ Forum(MNCH), we live in a dimension of normalised crisis where many simply view the loss of a child as a sad or unfortunate reality rather than the preventable systemic failure that it is.

“With an Under-5 mortality rate that has historically hovered around more than 100 per 1,000 live births, the loss of a child is often viewed as a “sad reality of life” rather than a systemic failure that can mostly be prevented. ”

The three evils: Malnutrition, Inadequate Healthcare and Misinformation
At the heart of child mortality lies three major culprits, the first being malnutrition. This is no random reality or occurrence but the product of the increasingly wide gap between social classes combined with recurring insurgency, especially in Northern Nigeria. Malnourished children are most susceptible to infections and illnesses, chief among them being diarrhoea.
Dr Fatima explains this cause and effect dynamic by using a swiss cheese analogy.

“Imagine five slices of Swiss cheese lined up. Each slice represents a defense: Nutrition, Vaccination, Clean Water, Maternal Education, and Clinical Access. Each slice has holes (failures). A child is malnourished (Hole 1), doesn’t have a clean environment (Hole 2), catches a preventable bug (Hole 3), the mother doesn’t recognize the danger signs due to lack of education (Hole 4), and the nearest clinic is out of stock of antibiotics (Hole 5). The child doesn’t die of “one thing”; they die because the system failed them on five different levels.”

On the other hand, Public Health Nutritionist Ayooluwa Okunjola believes that adopting a systematic thinking approach would help in better understanding the reality of child mortality in Nigeria but the loss is not attributed to a single cause but a chain of risks that build up over time that often starts before they are born.

“A child born underweight or weak because the mother lacked good nutrition or great antenatal care. That child will then grow in an environment with unsafe water, poor sanitation or food insecurity. When illness strikes, the child’s body is already vulnerable and the immune system is not strong enough to fight it. When the child falls sick, survival depends on if the signs are noticed early or if they’re able to seek care or better transport is available and if the health facility has trained staff, medicine and equipment in place.”

Why are Nigerians still indifferent towards the threat of child mortality?
Perhaps indifference might be a bit too strong a word but the gap between the frequency of child deaths and the average Nigerian’s response to it is too wide and should not be so. Nothing at all should normalise the occurrence of losing a child not to talk of it becoming a repeated daily pattern in the hundreds. Dr. Fatima believes that this indifference is a result of low public awareness.

“Unlike an outbreak of Ebola or Lassa Fever, which creates immediate panic and constitutes breaking news, child mortality is a slow, quiet erosion. Children die one by one in rural villages or overcrowded urban slums from preventable causes like diarrhea, pneumonia, and malaria. These don’t make for headlines.”

However, we live in a country already encumbered by systemic factors that allow an ignorance like this to linger. Chief among them is the socio-cultural factor where norms and perceptions hinder people from seeing child mortality for what it is, instead they’re quick to ascribe every other range of explanations from the mystical to simple acceptance. The idea of a child dying of measles or diarrhoea is so bizarre because it’s so preventable that the only way to deal with this reality psychologically is to believe that some dark agency or malevolent spirit decided to kill the child, so we find many people share this philosophy which is further grounded for them by repetitive occurrence. Also, the Nigerian society is a deeply religious one that this is our first form of coping mechanism of acceptance in dealing with trauma. The enormity of under five years olds dying can only be processed for some as an act of God as the ultimate supreme who gives and takes at will.

This constitutes further limitations to the eradication of the challenge of child mortality. She believes the foremost limitation is the crisis of trust and health literacy gap further facilitated by factors like disrespectful maternity care, sociocultural factors and accessibility challenges.

“A mother who is shouted at by a nurse during her first delivery is unlikely to return when her child has a fever. We talk about Free Healthcare, but if a mother has to spend a lot of money on transport to reach a facility through roads that are oftentimes poorly accessible.”

Another unhelpful factor is the fact that the truth of this reality is not often reported in many indigenous languages. Therefore, it becomes easy for myths and misconceptions to fester among communities that lack access to facts in a language that they understand.

“The local herbalist or religious leader is often more culturally accessible, speaks the local language, and offers empathy that the clinical system lacks”

The SARMAAN Solution

Source: eHealth Africa

Fortifying Nigeria against the big mountain of child mortality is SARMAAN (Safety and Antimicrobial Resistance of Mass Azithromycin in Children), a project led by the Nigeria Ministry of Health. Based on the findings from a MORDOR trial conducted in three sub-saharan countries; Malawi, Tanzania and Niger, the administration of azithromycin was seen to have reduced the mortality rate of under – 5 children by 14% cumulatively. According to a research article in the Journal of New England Medicine, the mass distribution of azithromycin has shown much potential in reducing the prevalence of infections like malaria and pneumonia which are leading causes of child mortality.
This realization with the backing of the AVENIR trial in Niger, led to the first iteration of SARMAAN in 2022 beginning with 24 local governments across Jigawa state to determine the effectiveness of Mass Administration of Azithromycin to children between 1 – 11 months old.
SARMAAN II kicked off in Sokoto in 2024, expanding the mass distribution to children between 1 – 59 months old across 23 LGAs through a collaborative effort between the Ministry of Health, key implementing partners and community health workers.

Not a fight for one but all

The fight against child mortality is clearly a collective one and while the fight is ongoing, one is compelled to ask if child mortality be completely eradicated? The answer to this is a little complicated and Dr Fatima thinks it is a no and yes situation.

“Total eradication as in zero deaths is biologically impossible, but reaching bendable Levels like below 25 per 1,000 as per the SDGs is absolutely possible.”

Indeed, there have been efforts by individuals and organisations to combat this harsh reality threatening Nigeria’s future. Many of them have been supported by the government, but somehow this is still not enough and not too surprising as the monster is a systemic one muscled on the bones of cultural perceptions. Dr. Fatima’s recommendation is cross level one. In what she called the Nigerian blueprint, she suggested prioritizing universal health coverage through primary health centres. She also stressed the need to incentivize antenatal care and immunization.

“We must start funding the PHCs in every ward. 80% of child deaths can be prevented at the PHC level with basics such as vaccinations, rehydration, oxygen, antimalarials, health education talks, etc. Give incentives for mothers to attend antenatal care and complete the immunization schedule.”

Okunjola echoed this sentiment by emphasizing the need to make PHCs more functional.

“We need to ensure that the over 34,000 primary healthcare centres that we have are fully equipped with skilled midwives, consistent supplies of clean water and basic life saving commodities, 24/7 maternal childcare services like immunization, antibiotics, ORS and so on. If these are in place then we can be assured that the frontline is strong and the chain of risk is broken before it starts.”

Furthermore, he added that poverty as a system needs to be dealt with to remove the cost of survival to shift the possibility of care to clinical needs rather than it hinging on the amounts present in the parent or caregiver’s bank account. Equally, strengthening the community management of malnutrition and proper engagement intervention to reflect the decision making dynamics in Nigerian homes would help. He also emphasized the need for trust and strategic allocation of resources.

“Build trust by the consistent removal of informal costs which is an incentive for caregivers to come to the hospital early and not when it is a very severe case. Focus resources where the losses are rampant as the mortality is not evenly spread so there is a need to target local government areas with high intensity and equip them with trained staff, healthcare commodities and outreaches.”

Finally, the gulf between data and storytelling has to be shrinked because what we don’t measure accurately cannot be fixed. For there to be more awareness, insights have to be interpreted beyond technical terms. Also with data, the gap between the underserved and most served communities can be bridged.