Dr Emilia Iwu is the Principal Investigator of the Ensuring Quality Access and Learning for Mothers and Newborns in Conflict-Affected Areas (EQUAL) study. She is also the Senior Technical Adviser, Prevention, Care and Treatment at the Institute of Human Virology Nigeria (IHVN). In this interview, Iwu who is also the Assistant Dean for the Center for Global Health, and Clinical Assistant Professor at Rutgers School of Nursing (SON) in New Jersey, USA, speaks on ways to ensure quality maternal and child care particularly in Conflict-Affected areas, the practice of community midwifery, and how the research seeks to tackle the challenge of rural-urban migration, among others.
What is the EQUAL research all about and how is IHVN involved?
EQUAL is an acronym that stands for Ensuring Quality Access and Learning for Mothers and Newborns in Conflict-Affected Contexts. It is a research study that is led by the International Rescue Committee based in New York. However, they are working with multiple partners including the Institute of Human Virology, Nigeria. The partners are in different countries.
Our technical partner is the Johns Hopkins Bloomberg School of Public Health and its university-wide Center for Humanitarian Health. Other partners are the Somali Research and Development Institute, and Université Catholique de Bukavu (Democratic Republic of Congo). So, we are working together on maternal and child health; maternal morbidity, and mortality in different countries.
For Nigeria, we have three research areas of interest. We are looking at the political economy that influences maternal and newborn health in Nigeria. The other one is midwifery education and workforce. How can we develop midwives, put them in the workforce, and support them?
What are some of the challenges they face? What are the things that make them stay where they are posted? What is working that we can continue to do, or enhance? We are also looking at their education. I will talk a little more about the process of that education and what we are looking for in that area.
The third aspect is that we are going to examine the quality of maternal and child care at health facilities. We are looking at women who come into delivery; the kind of services they get, the equipment they have, and the midwives they have on the ground to support these women.
In Nigeria, our goal is community midwifery. You know that we have two types of midwifery in Nigeria; we have community midwifery, which is the newer type of midwifery.
It has a shorter duration of the training, but they are pooled from the local communities. They are trained, and put back in those local communities to work at the primary health centres in the rural areas where we don’t have midwives to provide these services.
We are comparing them with other midwives that have been there all the time but are not available; they train but move to the cities rather than to the rural areas. We are trying to look at community midwives if they would stay rather than move out to the cities. If they would stay, what are the factors that would make them stay, and what are their challenges? We are doing this in conflict-affected areas in Yobe State.
What informs this research, especially in Nigeria?
Women of child-bearing age in sub-Saharan Africa are 50 times more likely to die during pregnancy and childbirth when compared with their counterparts in developed countries. Pregnancy, labour, and delivery should be a thing of joy; not a sickness.
Their babies are 10 times more likely to die during birth and within the first few weeks of life, so that tells you that there are things that we are doing in sub-Saharan Africa that we can do better.
Why should a woman and her child die from something that is not a sickness? Now, if you look at Nigeria, we even do worse than some of the sub-Saharan African countries. Our women are experiencing abnormally high rates of death from pregnancy, labour, and delivery and this is not acceptable.
Many of our health workers like to work in the cities rather than stay in the villages, especially those of us who have children. They want good schools, running water, electricity, and amenities that will help to make life a lot more comfortable. This makes health workers migrate to the city.
In the rural areas in some parts of the Northeast where there is insurgency, you will notice that some of the health workers posted there leave because of their safety. This is what the Nursing and Midwifery Council of Nigeria considered in approving community midwifery.
The concept of community midwifery is for young girls and young women that can go to school in the local communities to be recommended by their community leaders for training, sit for interviews, and be admitted to the programme.
Primary health centres are encouraged to hire them, and they will return to the local communities to serve their own people because they are already living there.
When we started looking for topics to research on, I approached the Nursing and Midwifery Council to ask them about researchable opportunities or topics. They suggested that we evaluate this type of midwifery project which was approved recently. This research is going to be for over five years. We are in the second year now; we are going to track the enrolled students for the next five years when they graduate and are posted into the communities. We will track them to see if they will stay in the communities and how they are faring.
The statistics of mothers who die from pregnancy, labour, and delivery in Nigeria are not numbers that we are proud to quote. There is no reason why a woman should get pregnant and die during delivery.
Studies have shown that when we have skilled birth attendants, it makes a difference in the survival of women during delivery so that is why we are doing this – if midwives are present, women survive more. So, we are going to find out about the factors that are encouraging these midwives to do what they do in the rural areas and what their hardships are. With this knowledge, the government can improve the quality of services the midwives provide and take care of the midwives themselves.
Why is the research focused on conflict-affected areas?
Well, we go to conflict-affected areas because they are local communities and also because of the poor conditions there. If a midwife can stay in that area, she can stay in other rural areas where there is no conflict. In conflict-affected areas, safety is an issue but regardless of the conflict, pregnant women need to deliver safely. There is no reason for them to die.
We are implementing the research in Yobe State because it is approved by the Nursing and Midwifery Council of Nigeria. They already have a group of community midwifery students that have been admitted and gone through the programme that we can track over time. The community midwifery programme started in Yobe State before Borno State which is why we are carrying out the research there.
How do you think your findings will help improve the availability of nurses and midwives?
Our research is community-driven. The concept is to make sure that trained nurses and midwives go back to their local communities and stay there. We know that many nurses and midwives migrate to other countries to look for better opportunities, but you will find out that there are some who are still here in local communities working. Not everybody migrates – we want to be proactive to look not only at their education. We want to look at how they are prepared to navigate issues of safety, lack of amenities, and information about the kind of setting that they will work in. Then, we will follow them up to find out the critical factors that make those who stay back in their local communities do so.
It is good to know that the Yobe State Ministry of Health is eager to get our data when we finish. They even want us to review progress every six months in line with our findings from the community.
They are very eager to find out what they can do to encourage the retention of midwives within these communities. The evidence will be helpful to the government, Nursing and Midwifery Council, Federal Ministry, and state ministries to know the community midwives who are not migrating from the rural areas where pregnant women are dying unnecessarily as well as the factors that can encourage them to stay back and then fix the things that make them want to leave.
How do you think the research will benefit Nigeria’s poor maternal indices, and human resources for health?
We are still collecting data, and hope that our findings will provide evidence that the policymakers can use to address the challenges on the ground. Every life lost during pregnancy and childbirth is human productivity loss. A family that has lost their mother has lost that capacity for the woman to provide for her children and family. We should not be losing lives like that. This is a critical area for stakeholders in the state and federal government as well as Nursing and Midwifery Council.
Our data can be used to develop the quality of education for midwives, their posting to communities, their living as well as working conditions and what makes them stay or leave. We are hoping that this will improve the working condition and how the midwives are able to deliver services in saving lives.
In Yobe State, there are already reports that in some communities where the midwives are posted, there have not been maternal deaths since the midwives arrived. That makes me happy. Information like this can inform government’s decision to allocate resources for women to stay in communities to do what they have been trained to do. Hopefully, we can save more lives with the findings from the study.