Child birth, a gel in time

Maryam Sharif had a false alarm, and the nurses sent her back home. Then she went into labour by evening. Thirteen hours of prolonged agonising labour left her bleeding. She went unconscious before her new little girl arrived. Only a tiny three-gramme tube of chlorhexidine gel stood between the newborn and definite life-threatening infection. In […]

Maryam Sharif had a false alarm, and the nurses sent her back home. Then she went into labour by evening.

Thirteen hours of prolonged agonising labour left her bleeding. She went unconscious before her new little girl arrived.

Only a tiny three-gramme tube of chlorhexidine gel stood between the newborn and definite life-threatening infection.

In three easy steps memorized from a chart, Shefarat Abdullahi smeared on the gel, and saved the newborn.

Then she pushed three tablets of misoprostol down the new mother. “The bleeding just stopped,” Sharif recalls.

No one at home

Sharif didn’t choose to give birth at home, but six of every 10 births are at home—down from only 7 between 2003 and 2013, according to the National Demographic Health Survey.

Among more than 281,000 pregnancies each year in Bauchi state, eight of every 10 births are at home, and nearly half of them are without anyone present. Local customs consider home births normal and hospital delivery abnormal.

Unassisted births leave women vulnerable to risks and newborns in resource-poor high-risk environments susceptible to infections. Up to 2,000 women die each year from childbirth complications.

The numbers haven’t changed much since 2003, suggests the NDHS, ranking Bauchi among states with newborn and maternal death rates nearly double the national average.

Some 12,000 newborns die each year before Day 28—a third of them from infections that include tetanus to which newborn umbilical cords are susceptible.

Upon birth, the umbilical cord remains open and vulnerable for at least 24 hours.

Mothers giving birth on their own have learnt to pack the cord with cow dung, increasing chances of microbes getting in to cause local infection or spreading through tiny newborns to cause widespread infection.

Chlorhexidine, an antiseptic, prevents infection by sealing up the freshly cut vessels and stops microbes from getting in for up to 48 hours after the cord shrivels enough to naturally fall off.

Umbilical cord

A project—Targeted State High Impact Project (TSHIP)—funded by the US government and implemented by a consortium of five partners in Bauchi state helped pushed the evidence for chlorhexidine.

Bauchi took on chlorhexidine in 2013, shortly after Sokoto.

“We use it on the umbilical cord of the child,” explains Sarauniya Matthew, chief nursing officer at a maternity centre in Tirwun, Bauchi where volunteers like Abdullahi encourage women to visit for delivery.

“It helps us prevent tetanus. It has helped us reduce neonatal deaths.”

Until 2013, health workers in primary health centres, birth attendants and lone birthing mothers swabbed cords with methylated spirit.

That has been found to cause micro injuries that still predispose babies to infections, says Dr Halima Mukadass, deputy chief of party at John Snow Inc, principal implementer of TSHIP in Bauchi state.

Medicine list

Chlorhexidine has made it onto a list of essential medicines recommended by the United Nations Commission on Life-Saving Commodities.

A new policy prompted purchase of 290,000 tubes of the gel, paid for with money taken off fuel subsidy, for distribution to some 1,000 health facilities supported under the Subsidy Reinvestment Programme.

Nigeria has expanded the 13-drug list to 16, and eight more states have adopted the gel.

“Before now, we used spirit after bathing [the child]. It takes a long time before healing takes place,” says Salome Agomoh, chief nursing officer at a primary health centre in Yalwa, Bauchi.

Some women from Abdullahi’s community of Birshi in Lushi go there after she convinces them to have hospital births.

Nigerian government has also altered how the gel is used, from single application at birth to a seven-day repeated application, in hopes of giving mothers continuity and preventing them from returning to using cow dung once they exhaust the tiny tube of gel.

But trials pioneered in Bangladesh, Pakistan and Nepal have shown no significant advantage of a seven-day application over a single at-birth use.

Two pharmaceutical firms Drugfield and Tuyil have acquired approval by the drug regulator NAFDAC to produce the gel in larger 25g packs—and three others are in line—pushing total national production capacity to 60 million tubes a year.

“We use only once. When we express it on the umbilical cord, it will dry up. It is very effective,” says Agomoh. She adds her clinic has never run out of stock since Bauchi government began paying for the gel, but “we need more of supply so it does not cut off.”

Exhaustion

The fear of stockout is real.

In the run-up to a change in administration in May this year, old stock of chlorhexidine and misoprostol—used to prevent bleeding after birth outside hospitals—ran out.

Procurement memos sat on desk as government ministries virtually shut down.

Agencies like the United Nations Population Agency stepped in on request by TSHIP to provide 137,000 misoprostol tablets and 50,000 tubes of chlorhexidine gel, according to Mukadass.

Estimates indicate Bauchi has a supply of the gel to last the next six months, and its drug management agency has quantified how much gel it would need in the next two years.

At around N10m in monthly spending to ensure the gels move from health centres and into the hands of women like Abdullahi, it is uncertain whether a new government will back the projections with money.

Figures suggest the gel has benefitted some 150,000 newborns, but government officials admit Bauchi is yet to quantify just how many babies its spending on chlorhexidine might have saved. Instead, the government is open to research to help it determine figures to back up its decision, according to officials in Bauchi State Primary Health Care Development Agency.

TSHIP, which ends after five years since 2009, is already pitching chlorhexidine to Uganda for cord care, but wants evidence of its effectiveness to propel continued use. A window remains open on the dosage of the gel, so long as mothers and children still get them, says Mukadass.

“If infections are the largest cause of newborn deaths, then [they] become the place to target,” she says of the gel.

“As the states are using it, they will bring stronger evidence.”

Much of the evidence go no further than Sharif’s newborn baby surviving the odds.