8 March 2016

Nigeria: Malaria in Pregnancy - Can Be Deadly... Can Be Prevented


Editor's Note: Over the years we have written vigorously on the things that do not work in the Nigerian health sector. This week we are starting a new series of highlighting projects and programmes that do work, showing that despite the chaos, there are pockets of excellence in sometimes unusual places. In the first story in this series, a team from Nigeria Health Watch travelled to Sokoto to find out more about a program that we gather is preventing illness and death during the most joyful period in a woman's life: during pregnancy.

We land at the Sokoto airport in what seemed to me like the middle of a sandstorm, a sirocco. I am with my colleague Thelma and it is the first time visiting the state for both of us. We get off the plane and immediately are hit with the wind, our dresses and veils fluttering behind us as we make our way into the terminal. A warm windy welcome to the seat of the Caliphate.

Sokoto holds an exciting project for us to discover, and it is all about keeping pregnant women and their unborn children healthy. The next day we make our way to Goronyo LGA, about an hour's drive from Sokoto, with our hosts, Dr. Mohammed Ibrahim and Dr. Zainab Mohammed of John Snow Incorporated (JSI), leaving the city behind for vast open fields and a long straight road.

In Goronyo, we meet Rahamu, Aisha and Halisa sitting on couches inside the Rimawa Ward Development Co-operative Society Office, all holding children in their laps. They are flanked by ladies in light green hijabs. Also in the room are a few men, members of the Rimawa Ward Development Committee. Dr. Ibrahim introduces us to Stella Abah, the JSI Service Delivery Facilitator for Goronyo Local Government, who has organized the group in the room to meet with us. Stella supported the Goronyo LGA Roll Back Malaria Manager, Alhaji Hamisu, in his duties under this particular project. Her warmth and welcome are effusive as she explains to the group why we have come, in fluent Hausa and English respectively. Even though I do not understand very much Hausa (my colleague Thelma does), I feel very much at home in this room, far away from Abuja.

The three women are only a small sample from a whole community of women who have benefited from the Malaria in Pregnancy Project (MiPP) over the past year. The project was implemented in Sokoto as a pilot intervention, to help address the complications associated with having malaria during pregnancy through a facility/community-based strategy for distribution of a drug called Sulfadoxine & Pyrimethamine, known to everyone simply as "SP". Goronyo is one of three LGAs in Sokoto State where the project was implemented starting in December 2014. The unique feature of this project is the community is squarely at the heart of it.

I ask the women to tell me what it feels like to have malaria when they are pregnant. I am curious, having never been pregnant, but also because when you grow up in Nigeria malaria seems just as much a part of life as flu season in the United States, for instance. No one ever gets surprised or flustered if you have malaria.

"In the past when we have malaria, we used to have complications. When we give birth we find that our children have gone through a lot of stress," Aisha says. She explains that they would take 'paracetamol' tablets when they had fevers and sleep under mosquito nets but oftentimes the nets were old and torn and the mosquitoes got through. The women say there are traditional medicines they would also take while pregnant, but they were not sure if those medicines helped against malaria.

Sakina Abubakar is the Officer in Charge of the Antenatal Care Department at Rimawa PHC. She tells us that having malaria during pregnancy can lead to several complications, including "premature delivery, a baby who is smaller than normal at birth, abortion and miscarriage". She certainly knows her stuff, as research shows that pregnant women are four times more vulnerable to malaria and are two times more likely to die from malaria complications compared to other adults, and malaria in pregnancy can cause mothers to have anemia and deliver low birth weight babies. The WHO has laid out a three step approach to tackling malaria in pregnancy; intermittent preventive therapy (IPT), use of Insecticide Treated Nets (ITNs), and case management of malaria illness and anemia.

At our briefing the day before, Dr. Ibrahim reeled out the statistics. "According to the 2013 NDHS, only 7 percent of women in Sokoto State received any SP during an antenatal care visit," he said, despite its being a part of the national guidelines for managing malaria in pregnancy. This means that many pregnant women with malaria are going undetected and untreated even when they attend antenatal care at their Primary Health Centre. "We realized that having SP at the health centres was not enough, we had to find a way to get it into the community, to the pregnant women themselves. This was the goal of the MIP Project, to show that community based distribution of SP could be effective in increasing the number of pregnant women covered under IPT."

The implementing organisation, JSI, had already been working in Sokoto and Bauchi states on a different maternal and child health project that also used community volunteers to increase awareness of and demand for two live-saving medicines; chlorhexidine and misoprostol, to help prevent bleeding during delivery and umbilical cord infection. We wrote about that intervention here.

The program used the same volunteers that were used for this program, my ladies in the green hijabs. Four of them and their supervisor listen intently as we begin to ask them questions. I ask them their duties, how they came to be volunteers, what changes they have seen during the 12 months of the project, as the project's foot soldiers.

Their replies are in rapid Hausa, and it is easy to see the pride with which they tell of their duties. "Our roles are to go house to house, give health talks on cleanliness, talk to women about how to stay healthy. We will 'use style' to find out if a woman is pregnant. If she says yes we will ask her how long and if she has experienced "quickening", that is, movement of the baby." There are two conditions for giving SP; either after 13 weeks of pregnancy if a skilled health worker attends to the woman and determines the gestational age, or when women experience quickening, which I am told happens between 16 and 20 weeks of pregnancy. "We tell her that we will come back the next day with a good medicine for her. When we come back, we will take off our rings, wash our hands, get a clean spoon and bring out the SP and ask her if she has taken it before. If not, we give it to her to swallow in front of us. Then we will give her a card."

The cards are color coded to indicate the number of times a woman has taken the drug. We are shown the cards, white for the first dosage, yellow for the second, and green for the third dosage. It is recommended that women take at least three dosages of SP in four week intervals, but they can take up to six doses.

Dr. Ibrahim had shared the project's results with us, but I was itching to hear from these women their own thoughts on how the Malaria in Pregnancy Project had changed the face of their communities. They spare us no details.

"Before, you will see a woman having blurred vision, and she will be throwing up and will be very weak. Since the SP was brought, they don't have these symptoms anymore."

"There is a reduction in the rate of miscarriages in women. Before they did not know that constant headache could be a sign of malaria. There are still miscarriages but now it has been drastically reduced."

"Before, pregnant women would mix all manner of herbs and drink, and their tummies will swell up and the child will die. Now they only take SP and it helps them, it has reduced still birth and maternal deaths during delivery."

"Before, the child might be very slow and weak, we used to carry cold water and splash on the face to see the child wake up after delivery. But now the children are very strong and active, they look bigger, they are very healthy."

The WDC Chairman and his executives cannot agree more. They are eager to sustain the benefits that the program has brought to their community, and it is easy to see why, for anything that benefits the health of our women and children is ultimately for the good of the whole community. In that stead they have begun monthly contributions to help pay the volunteers and their supervisor their monthly stipends. "We have added an additional 10 volunteers, so now we have 25 of them. We have written a letter to the local government, the state commissioner for health, and the state ministry of health, for the continued supply of all anti-malarial commodities monthly. Two days ago, we received a response from the state commissioner of health, saying that they have received our request and will consider it. This project has spent only one year, it cannot serve everyone. My wife is a beneficiary. We want the project to continue."

The zeal with which everyone in the room speaks about this project, the impact it has clearly had just in its first year of implementation, amazes me, a journalist trained to be skeptical. My eyes keep going back to the infants nestled in their mothers' arms. Aisha's son is eight months old, and her third child. She smiles as she explains that with her two other children, when they were small she could set them down and they will stay where she put them, but with this son, "he doesn't stay in one place! He is always moving, very active." Rahamu, also a mother of three, says the drug helped her to stay healthy and strong during her last pregnancy. Her daughter is feisty and full of smiles, and she says she started walking by age one, much earlier than her older siblings.

Halisa, whose mother is a community health volunteer, is the newest "SP mother" in the room. Her baby girl, also her third child, is 3 weeks old and soundly asleep in her grandmother's arms. "I am pleading with the government not to allow this program to stop. If I get pregnant again and it is not available I will go back to having malaria again. Please don't let this program stop."

As we leave Sokoto I realize that I will carry these women's stories with me, that when I hear of anything having to do with malaria in pregnancy, theirs are the faces that will come to mind, and I will wonder how they and their babies are doing. And I will wonder how many more stories like Rahamu, Aisha and Halisa could be out there, could be experienced by journalists like me, if only this project, and other innovative ones like it, were given a chance to grow.

Many public health challenges do not just result from personal choices; there is often something about social structure that is linked to why these problems have been so difficult to address. Despite this, except for a few programmes that have put the community at the center, such as the successful use of community delivered ivermectin for the treatment and control of onchocerchiasis, there are too few examples in Nigeria where the community have been mobilised to drive interventions. Maybe there is an important lesson here for all working in public health that goes way beyond malaria in pregnancy.

Do you know about other individuals or programmes improving health in Nigeria? We would love to hear from you.

The Malaria in Pregnancy Project was executed by the Sokoto State Government in collaboration with JSI and USAID/US Presidential Malaria Initiative (PMI), and was funded by the Bill and Melinda Gates Foundation (BMGF).


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