Ensuring women, babies survive before and after delivery

Then, as a health extension worker in a primary healthcare facility in Abi Local Government of Cross River State, he was the only experienced health worker-and the only male.“I was in charge and I had to oversee the entire facility,” he remembers. “There was no midwife-just me and ward orderlies and junior community health extension […]

Then, as a health extension worker in a primary healthcare facility in Abi Local Government of Cross River State, he was the only experienced health worker-and the only male.
“I was in charge and I had to oversee the entire facility,” he remembers. “There was no midwife-just me and ward orderlies and junior community health extension workers. I had to handle it [the birth].”
“God on my side, I was able to make it successfully. No practical knowledge, just the theoretical experience I had in school,” he admits.
The mother also made it, and with it comes a growing realisation that a long neglected cadre of health workers is crucial to reducing the number of women and children who die from complications in giving birth every year.
For years, maternal mortality ratio in Nigeria has hovered at 545 women per 100,000 live births. The figures are graphically illustrated as one woman every 30 minutes-and more disturbingly, the equivalent of a jumbo jet crashing every day.
The causes of the deaths are numerous: bleeding, breach birth, prolonged labour, placenta retained longer than usual. How they are dealt with is also critical to whether women die or survive complicated childbirth.
“Even the management of the events [of childbirth complications]  are causing deaths-deaths that can be handled by our healthworkers,” says Ebun Oyediji, a retired assistant director of nursing who now consults for the federal health ministry on reproductive health.
Training for childbirth has been the preserve of healthcare cadres higher than health extension workers. Midwives, nurses and doctors took deliveries. Community health extension workers were left with the task of delivering goods-getting women to attend hospital, going on immunization rounds to reach children in far-out communities where they work.
A growing trend has emerged in the past five years-the government increasingly pushing community health extension workers into the role of frontline healthworkers.
“The CHEWs [community health extension workers] have been found to be more in the communities than the doctors, and they are the ones handling majority of these mothers,” says Oyediji.  “The government felt that some skills should be given to them, so they will be able to save the lives of women.”
The result is a modified course in life-saving skills for a class of selected CHEWs in Ogoja at the behest of United Nations Population Fund, which also runs separate programmes in gender and reproductive health in Cross River.
It has also helped the state distribute family planning commodities since 2011, when availability of family planning commodities dropped sharply after the Nigerian government declared them free. Cross River is yet to completely take over distribution of commodities.
“Initially, life-saving skills was not meant for health extension workers,” says Bassey Duke, who coordinates reproductive health for Cross Rivers ministry of health and functions as project officer for UNFPA programmes in the state.
“But because they are the majority of health workers you find in primary health care, the federal government had to bring them into the policy, so they have to be trained also.”
Without training, CHEWs find themselves in a corner. Far-out places as Yala is three hours from Ogoja, a major hub of Cross River. A skilled community health extension worker in a place like that is the difference between a woman bleeding to death in pregnancy or getting the quickest care available, before being referred for further management.
But getting the right training for CHEWs required their roles to be clearly defined from those of midwives and doctors.
Oyediji helped consult on a course outline for community health extension workers in Cross Rivers, one of the sites where the United Nations Population Fund, which has been at the forefront of cutting down maternal deaths in Nigeria, works.
“Midwives can do things which CHEWs cannot do, but there was no programme for their [CHEWs] cadres. We had to make amendment from the midwives’ programme.
Midwives generally do not operate but they can go through veins and manage pre-eclampsia, but CHEWs cannot. “They have to refer [the case] to a place where the patient can be given immediate care so that they don’t go into fits.”
The limitations are clearly spelt out in the course. “If a woman comes to me bleeding, I know it is a complication. I am not supposed to handle it-or a breached presentation,” says Emenjor, now a worker at a primary health facility in Etung and one of three men in a class of some 20 community health extensions workers. “If labour is prolonged, I have to refer.”
After 24 years working at a primary health facility in Akam, run by Calabar municipal council, Dorothy Ene has handled cases that run the gamut of primary health care but is only beginning to see the clear lines of distinction.
She is also starting to understand the important of kangaroo care for low birth weight babies. “I never knew the baby has to be carried by the mother, against the chest, skin to skin,” Ene says.
Fresh from school and only one year in the field, Mary Nsa is still bridging her knowledge of classroom theory with realities in providing health care at Odukpani, nearly an hour from Calabar-the site of the nearest general hospital where she can refer patients she cannot manage.
“Most of the things I am seeing, the opportunity was not there for us to learn in school,” Nsa says. “The theory was there, but not the practical.”
The practicals are as straightforward as resuscitating a baby not breathing immediately after birth and the right procedure for handwashing.
“Today, I had to wash from my palm to elbow in five ways, and it must not be in a bowl but [under] running water. Even when we were doing such things before, we did it in ignorance, not the way it ought to be.”
With about 71,000 community health extension workers registered in 2012, their number is only a third the population of nurses and midwives, but the gaps they stop is becoming more critical.
The number of deliveries in hospitals has increased in the last five years, according to Nigeria Demographic Health Survey. The jump is slight-from 35% in 2008, new data in yet to be released demographic health survey this year shows up to 36 in every 100 women now deliver their babies in a health facility. But people like Nsa, Emenjor and Ene have helped in their little ways.