Chamberlain Diala (PhD,
MPH) is the Associate Director, the Global Health, Population and Nutrition at FHI
360. In this exclusive chat with HealthNewsNG.com, Diala spoke extensively on the plights of pregnant women in Nigeria in the fight against malaria.
HealthNewsNG: What led to the research?
Diala: Malaria is endemic in many parts of the
country and is the leading cause of death among women and children. Many people
carry malaria parasites from previous exposures and previous mosquito bites.
Pregnant women are more vulnerable to malaria and therefore susceptible to
having pre-mature babies, anemic babies or babies that are more likely to die
before age 5 years.
All of these are impetus for the study we did
on Malaria in Pregnancy (MiP). Now we know that people tend to get their
malaria medicines from patent medicine vendors (local chemists or drug shops).
But the challenge is that when people purchase a full dose to treat malaria,
they do not finish the full dosage. They tend to stop taking the medicine as
they begin to feel better. Then they save the remaining dosages for a next
time. This is a challenge as this pattern of behavior does not clear the entire
parasite from people's system, thus making them vulnerable and susceptible to
full blown malaria with next mosquito bites.
As pregnant women are more susceptible to
malaria, the study in essence sought to understand some of the barriers
pregnant women encounter to receiving full IPTp treatment for malaria when they
come to the clinics for antenatal care (ANC), based on the recommendations of
the WHO and treaties signed by the Nigerian government to provide such services,
when pregnant women come to the clinics.
What is your view about pregnant women in
Nigeria, especially those in the study areas?
Pregnant women confront many challenges in
Nigeria (in general) and in the study areas (in particular). Many women need
the services provided at health centers, but they are challenged by a number of
factors. Many pregnant women do not know they carry malaria parasites; many do
not know the possible harmful effects endemic malaria represents to their
unborn babies.
Also, many women lack resources to travel
distances when clinics are not near their homes - especially women living in
rural areas; others wait for a long time when they visit clinics for ANC
services; yet others do not have funds to pay for informal and formal fees that
health care providers charge them when they come to the clinics.
There are also social barriers in regions of
the country where some women may require husband or mother-in-law permission to
attend ANC. There are cultural barriers where some communities prefer
traditional birth attendants (TBA) and others prefer pregnancy services offered
in places of worship.
Now, there are justifiable reasons for some of
the preferences for TBA and religious houses, however, these alternative
options have significant challenges in cases where pregnancy-related
complications may arise. The potential complications can be best addressed by skilled
providers in well-equipped health centers.
What is the study adding to the already vast
body of knowledge?
This study pulls together two main issues
that have not really been addressed by the vast body of knowledge (so to speak)
on malaria in pregnancy. It identifies the specific limitations of the health
care delivery systems and the providers who work therein, the lack of political
will on the part of policy makers to follow through on accessible and free ANC
and associated services for pregnant women.
On the other hand it identifies the
socio-ecological levels of influence and support that must be galvanized
(individual, family and community) to ensure that pregnant women use health
center services to address intersecting pre-natal care issues to ensure healthy
deliveries across the country, but also in the selected States under review.
Further, this study stratifies rural and
urban dichotomies as reported by health providers, pregnant women and in
Nasarawa State only, the unique and significant perspectives of husbands.
Your study,
though focused on malaria, could give an indication about the overall health
status of pregnant women in the study areas. Which of the various play makers
that you mentioned could help in improving the quality of healthcare available
to the pregnant women?
The central issues are two - one rests with
policy makers and the other rests with health care providers: Policy makers
must have the political will to ascertain that necessary malaria commodities
are available at all public health clinics, to make sure health care providers
are aware that such commodities are disbursed at no cost to patients and that
they sponsor training for providers to make the link between regular ANC visits
and full-dose IPTp for pregnant women.
Secondly, providers must have the appropriate
inter-personal communication skills to support patients when they come to the
clinics and the full breadth of knowledge to link ANC services to IPTp. In
ideal cases, such linkages must also extend to HIV testing for pregnant women,
so those who test positive can be placed on anti-retroviral therapy (which
should also be free of charge), to take advantage of the efficacy of such
therapies that have 92% confidence that such women have HIV-free babies.
So, you are right in your question that this
study while focused on malaria also has implications for the overall health
status of pregnant women, their babies and their families.
These responsibilities rest squarely on the
shoulders of the public health ministry. How can the private sector be
incorporated to lessen the body on the ministries of health?
At the central level, yes, the Ministry of
Health has responsibilities, but the state-level ministries of health are
equally culpable as they have the capacity to maintain the flow of malaria commodity
supply chain. Certainly, the private sector has key roles to play to help
alleviate the burdens on both the government and its people - in this case,
women and their families.
However, the challenges with private sector
health providers are that they exist to make profit, even while providing good
and decent health care. Earlier, I stated that challenges of poverty for many
families and their inability to pay for myriad (legitimate and non-legitimate) services
that range from transportation, to clinic fees imposed justly or unjustly by
the public-sector health services delivery systems. Evidence is clear that
private health services sector will impose similar if not higher fees to
deliver services to pregnant women and their families.
Malaria is ubiquitous in Nigeria. Do you
think if you had chosen another disease you would have gotten the same results?
Indeed, malaria is endemic in the country.
But it is a disease that we can do so much to prevent, as well as minimize its
impact on women, their children and their families. International development
organizations are distributing millions of free insecticide-treated bed nets
across the country. Many of the available drugs are equally effective if used
appropriately. There is much we can also do with regards to the environment
that helps to minimize breeding grounds for mosquitoes that carry malaria
diseases.
That being said, it is difficult to postulate
and transfer results from this malaria study to another disease. But I venture to say that aspects of Nigeria's health care and
services delivery systems need immediate and comprehensive restoration. Without
such significant investments, people who seek health care services for malaria
or other health issues will continue to encounter serious challenges.
Nigeria makes the right policies for the most
part, and is signatory to the right declarations, but heretofore have failed to
provide appropriate and timely funding to support its health systems and much needed
infrastructures - and this extends from the physical buildings to training of
providers to right-size staffing in many communities.
How does the research correlate with the
objectives of FHI360?
This study of malaria in pregnancy in Nigeria
fits squarely into the FHI 360 mission: the science of improving lives. The
organization is decades old and has about 11 projects in all 36 State plus
Abuja in health, education and private partnerships. FHI 360 also has expertise
in other international development sectors including agriculture, democracy and
governance, energy and technology.
Briefly describe the research team
The concept and the design for the study were
generated by me and my co-author Thad Pennas. We then recruited a research firm
- Center for Research, Evaluation and Resource Development - (CRERD) in Nigeria
to conduct the study in the two states. From the official report, we culled the
manuscript that yielded the publication in the Malaria Journal. We were also supported in this effort by key FHI 360
in-country staff, specifically those working with the C-Change/Nigeria project.
What is next following the research?
There is much need to disseminate the results of this study widely in Nigeria, specifically to policymakers and to explore ways
to ensure that systemic and institutional structures are strengthened.
Secondly, we are seeking to work with
state-level ministries of health to develop training curricular to enhance the
ability of providers to make the necessary linkages among antenatal care visits
(ANC), intermittent and preventive treatment of malaria in pregnancy (IPTp) and
prevention of mother-to-child transmission (PMTCT) of HIV through comprehensive
testing and counseling.
Third, there is a great need to improve the
linkages of health care providers and alternative cultural (traditional birth
attendants) and faith-based care and support systems. The services and support
that TBA and faith-based systems provide are important, but they have
limitations.
Recognizing those limitations and working in synergy with the
health systems for appropriate and timely referrals will ensure that these
alternative providers maintain their place in the services delivery continuum,
while ensuring the welfare of the pregnant woman and her unborn baby.
Finally, in places where women must obtain
permission to access health services, we must ensure a comprehensive education
of all key stakeholders to make paramount, the health of the mother and progeny
of the families and communities.
These will go a long way to ensure the health
of the country and reduce the disproportionate mortality and morbidity from
malaria in the general population, but specifically among pregnant women.
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