Applying a Client-centered Approach to Maternal and Neonatal Networks of Care: Case Studies from Urban and Rural Nigeria.

In Nigeria, two maternal and neonatal health Networks of Care (NOC) focus on extending the reach and quality of routine and emergency maternal and neonatal health services tailored to the different contexts. This paper uses the four domains of the NOC framework-Agreements and Enabling Environment, Operational Standards, Quality, Efficiency and Responsibility, and Learning and Adaptation-to describe the NOC, highlighting how each developed to address specific local needs. In Northern Nigeria, the NOC were established in collaboration among Clinton Health Access Initiative and the government to reduce maternal and neonatal morbidity and mortality. Health centers and communities in the network were supported to be better prepared to provide maternal and neonatal care, while birth attendants at all levels were empowered and equipped to stabilize and treat complications. The approach brought services closer to the community and facilitated rapid referrals. The NOC in Lagos State extended the reach of routine and emergency maternal and neonatal health services through organically developed linkages among registered traditional birth attendant clinics, private and public sector facilities, the Primary Healthcare Board, and the Traditional Medicine Board. Traditional birth attendants are registered, trained, and monitored by Apex Community Health Officers, whose responsibilities include collection and review of data and ensuring linkages to postpartum services, such as family planning and immunizations. While differing in their approaches, both NOC provide locally appropriate, pragmatic approaches to supporting women birthing in the community and encouraging institutional delivery to ensure that women and their babies have access to timely, appropriate, and safe services.

Increasing coverage of pediatric diarrhea treatment in high-burden countries.

BACKGROUND: Diarrhea is the second leading cause of infectious deaths in children under-five globally. Oral rehydration salts (ORS) and zinc could avert an estimated 93% of deaths, but progress to increase coverage of these interventions has been largely stagnant over the past several decades. The Clinton Health Access Initiative (CHAI), along with donors and country governments in India, Kenya, Nigeria, and Uganda, implemented programs to scale-up ORS and zinc coverage from 2012 to 2016. The programs sought to demonstrate that increases in pediatric diarrhea treatment rates are possible at scale in high-burden settings through a holistic approach addressing both supply and demand barriers. We describe the overall program model and the activities undertaken in each country. The overall goal of the paper is to share the program results and lessons learned to inform other countries aiming to scale-up ORS and zinc. METHODS: We used a triangulation approach, using population-based household surveys, public facility audits, and private outlet surveys, to evaluate the program model. We used pre- and post-program population-based household survey data to estimate the changes in coverage of ORS and zinc for treatment of diarrhea cases in children under-five in program areas. We also conducted secondary analysis of Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) surveys in surrounding regions and compared annual coverage changes in the CHAI-supported program geographies to the surrounding regions. RESULTS: Across CHAI-supported focal geographies, the average ORS coverage across the program areas increased from 35% to 48% and combined ORS and zinc coverage increased from 1% to 24%. ORS coverage increases were statistically significant in the program states in India, from 22% (95% confidence interval CI = 21-23%) to 48% (95% CI = 47-50%) and program states in Nigeria, from 38% (95% CI = 32-40%) to 55% (95% CI = 51-58%). For combined ORS and zinc, coverage increases were statistically significant in all program geographies. Compared to surrounding regions, the estimated annual changes in combined ORS and zinc coverage were greater in program geographies. Using the Lives Saved Tool and based on the coverage changes during the program period, we estimated 76 090 diarrheal deaths were averted in the program geographies. CONCLUSIONS: Increasing ORS and zinc coverage at scale in high-burden countries and states is possible through a comprehensive approach that targets both demand and supply barriers, including pricing, optimal product qualities, provider dispensing practices, stocking rates, and consumer demand.

Human-initiated disaster, social disorganization and post-traumatic stress disorder above Nigeria's oil basins.

Survivors of human-initiated disaster are at high risk for mental disorder, most notably post-traumatic stress disorder (PTSD). Studies of PTSD have tended to focus on soldiers returning home after combat or on refugees living in resettlement countries under conditions of relative safety. However, most survivors of human-initiated disasters continue to live in or near the places where they initially experienced trauma. Insufficient attention has been paid to social disorganization in situations of continuing unrest and to its role in creating or stabilizing the symptoms of PTSD. The current study took place in the Niger Delta region of Nigeria, the scene of long-standing violence and human rights abuse that reached its apogee in 1995. The investigation, which took place in 2002, focused on two villages, one that was heavily exposed to the conflict (A, the affected village), the other relatively spared (NA, not affected). Probability samples of 45 adult residents from A and 55 from NA were interviewed with a schedule that contained the PTSD module from the WHO Diagnostic Interview Schedule. The schedule also contained a measure of exposure to the violence and abuses during the height of the conflict, as well as measures of structural and social capital that are components of community resilience. These included economic security, a sense of moral order, a sense of safety and perceived social support. The six month period prevalence of PTSD was 60 percent in A, and 14.5 percent in NA. Degree of exposure to stress as well as compromised sense of moral order, not feeling safe, and perceived lack of social support were independent predictors of PTSD. In places like the Niger Delta, where people do not physically escape from past trauma, sociocultural disintegration may interfere with communal functioning, thereby eroding community capacity to promote self-healing.

Guns, health and the exploitation of natural resources.

There are about 1 million small arms in Nigeria, which contribute to a large number of politically motivated killings. These are mainly sectarian (Christian and Muslim) and ethnic, over land and water rights and the relationship between the activities of companies and the environment. In the Ogoni region of the Niger Delta, with a population of half a million in an area of just over 400 square miles, there are 100 oil wells; the local community is attempting non-violently to clean up their environment. From July 1993 to April 1994 there were about 3,000 cases of gun violence, compared with only two in the previous five years. There were 250 deaths and about 100 amputations. Other forms of violence, including rape, also increased. Routine procedures in the hospitals that remained open were disrupted, there were serious effects on the mental health of the community and many became refugees. It appears that the guns used in this episode were imported by a multinational company for use by the Nigerian police.