How Anambra state runs over 630 PHCs with 150 nurses, midwives

By Alfred Ajayi

KAMELITA  Onyeka is a public health nurse and officer-in-charge (OIC) of the Otuocha Primary Health Centre (PHC) in Anambra East Local Government Area of Anambra State.

She supervises two other employees – a laboratory technician and a midwife – engaged under the revived Midwives Service Scheme (MSS), courtesy the Basic Health Care Provision Fund (BHCPF).

Despite the deployment of the young midwife, Kamelita still feels overburdened with the workload at the facility.

“As the OIC, I stay in this facility from Monday to Friday every week. It is difficult for me to take a leave. Even when I go home on weekends, calls keep coming for my attention. It’s too demanding,” shesaid.

At a point, she was compelled to engage another unemployed midwife, who she pays from her salary. She added,

“I don’t want to kill myself. I engaged her so that when I am not there, she will relieve me. I came back just yesterday night and already, they are calling me now, telling me that somebody is in labour.

“The midwife I employed to assist is there, but they don’t want her to take the delivery. The husband of the woman will not let me rest.”

When Radio Nigeria asked Kamelita why she kept mute about the poor attitude of the new government-employed midwife to the job, Kamelita replied “she keeps begging me not to tell anybody,” was her response, adding, “but the truth is it looks like she is working somewhere else. She comes in, at most, three times a month.”

Kamelita’s testimony about the new midwife is in tandem with Radio Nigeria’s findings in some other health centres.

All the OICs this reporter spoke with chorused about how the assistants do not take the job seriously.

One, who wished to remain anonymous, said she agreed to an arrangement with the newly posted midwife that she can come to work two days a week.

Let me just tell you the truth, most of them, if not all, work elsewhere with private hospitals. We reached an agreement with the one here. She comes only on Mondays and Wednesdays. She was here yesterday and will be here tomorrow.

“She works somewhere in Awka. I can’t really blame her because we, the OICs, who earn more than N100,000 every month, are complaining that it is not enough, how much more someone receiving N30,000. And most of
them are married,” she explained.

The midwife deployed to the Isuaniocha PHC, Chidinma Alike, left the job less than one year after her engagement. She said she could no longer cope with the “pittance” she was getting from the scheme.

Chidinma is a mother of two and in her late twenties. She is one of the 60 midwives engaged in 2021. Radio Nigeria sought to ascertain the reasons behind her decision.

Nursing mothers at Isuaniocha PHC
Nursing mothers at Isuaniocha PHC

“The remuneration is very poor. I am a registered nurse and midwife. I have the two certificates. Someone that has a family is being paid N30,000 in the Nigeria of today and you have to work the whole of the week. It was taking much of my time. If the pay is good, we can say no problem, it is worth it,” she responded.

Chidinma has just been replaced with another midwife, Chinemelum Muogbo, who resumed work in early October.

The problem of workload is a common tale across PHCs visited in Awka North, Aguata, Anambra East, Ogbaru and Onitsha South local government areas.

At Ula PHC, Ekwulobia in Aguata local government area, the OIC, Roseline Nwankwo had been awake throughout the night preceding the visit by the reporter. She was attending to Chinemerem Obi, a heavily pregnant woman, whose bundle of joy arrived a few hours before the visit.

Roseline spoke on her challenges.

“I am the OIC and the only government staff at that facility. The lady you met there is a volunteer. It is not easy at all. I do almost everything:  immunization, ante-natal, delivery and so on. That is why I engaged a volunteer.”

With an impression that the reporter was from the BHCPF, Roseline passionately appealed for more hands to ease the workload on her.

“Please, I need more staff. You people should send us more before somebody dies here,” she pleaded.

However, the story is heartwarming at Mgbakwu PHC, Awka North, where a nursing mother, Esther Nwune, testified to the impact of the deployment of a midwife to the facility.

I have been coming to this facility since 2014. But I have been seeing positive changes since 2021,” Esther enthused.

Comparing her delivery experience in 2014 with that of her sister recently, Esther submitted that the difference was clear,

“That time, the nurses here were very careless, doing things as they wanted. But, now, the midwife here is very wonderful. She is friendly and empathetic. She is really doing well.”

The OIC of the facility, Virginia Nduka, was equally full of accolades for the midwife.

“The Basic Health Care Provision Fund posted a midwife before I came last year. It makes a lot of difference during delivery and antenatal care. The woman helps us a lot. It is a relief to me,” Virginia said.

Anambra State though adjudged the best in terms of maternal mortality in the South-East region, has lost 20 pregnant women to various birth-related complications between January and June 2022. The development was hinged on the fact that a good number of women still patronize quacks for ante-natal and child delivery.

A consultant community physician at the Nnamdi Azikiwe University Teaching Hospital, Nnewi, Dr Chinomnso Nnebu, advised residents against patronizing prayer houses for antenatal care.

“Some faith-based organizations will keep pregnant women in and be praying for them instead of advising them to go to the hospital. Faith works but faith without work is dead,” Nnebu said.

“We need to educate pregnant women to stop giving birth in prayer houses because those places cannot manage pregnancy complications,” he warned.

With Dr Nnebu’s warning , many citizens of the state believe that the pitiable conditions of most primary
health centres, especially in the five selected local government areas, leaving the locals with no option but to embrace other alternatives.

A community leader in Mmiata-Anam, Matthias Ameke said the state government was culpable:

“The health centres do not have the necessary facilities. Also, they are grossly understaffed. The workers are generally under-trained. They don’t even know what to do. All these discourage patronage of public health centres.”

MSS Poorly Implemented

The Midwives Service Scheme (MSS) came into being in 2009 to reduce maternal mortality and as one of the initiatives targeted at fast-tracking the attainment of the Millennium Development Goals (MDGs).

Latest figures showed that Nigeria had so far recorded maternal mortality rate of 917 per 100,000 live births in 2022, while infant mortality rate was 56.220 deaths per 1000 live births, showing a 2.57 per cent decline from 2021 when the infant mortality rate was 57.701 deaths per 1,000 live births.

Also, in 2022, the mortality rate of infants aged under a year in the country is at 56.68 per cent, signifying about 56 deaths of children under the age of one year per 1,000 live births.

This, in the view of many respondents, is because the scheme has not been efficiently implemented to achieve its lofty objectives. Ideally, MSS is meant to engage newly graduated midwives, the unemployed and the retired ones for a period of one year in rural areas, where the rate of maternal mortality is higher.

Under the scheme, four of such facilities with the capacity to provide basic essential obstetric care are clustered around a secondary care facility with the capacity to provide comprehensive emergency obstetric care. This is to further increase the chances of survival for any endangered woman and her unborn baby.

Unfortunately, before the recent recruitment of 85 nurses and midwives by the agency, the MSS was a forgotten scheme in the state.

“MSS was functional around 2019 to my knowledge. But with this basic health, I know the agency employed about 60 midwives,” Ijeoma Onuora, a staff nurse, midwife and OIC, Aguata PHC, Ekwulobia, stated.

The MSS, despite being a collaboration among the three tiers of government to improve maternal and child health indices in rural Nigeria, the case in Anambra does not reflect this ideal because the state government is yet to show financial commitment to enhance sustainability. The story is worse for the local governments, which are currently undemocratically administered and can hardly embark on any capital intensive project apart from salary payment.

Poor remuneration of professionals

Apart from the negative impacts the meagre monthly stipend paid to those engaged under the MSS have on the scheme, the general poor remuneration of nurses and midwives in the employ of Anambra State
government is another discouragement.

Okwudilichukwu Udeze, a Staff Nurse Midwife recruited in 1982, feels unfulfilled three years to her retirement.

“Somebody who is about to retire, you don’t have a place you can call your own house, even if it is two-bedroom. They are not paying us well. That is the reason our colleagues are running abroad.

“One of the persons I graduated with went to the US and every time she calls I would always tell her my father is not well, I could not leave him that time. Now, it is too difficult for me to go,” Okwudilichukwu, who currently heads Saint Monica Anglican PHC, Onitsha, lamented.

Maternal mortality reduction a mirage without midwives

Midwives are considered critical to the smooth and efficient running of primary health centres, as well as governmental efforts to drastically reduce child and maternal mortality.

“The aim of MSS will be defeated if you don’t have qualified and competent midwives handling deliveries and antenatal care at the PHCs,” IfeyinwaMesigo, a Chief Nursing Officer, maintained.

Ifeyinwa shed further light, “A PHC should have midwives to handle ante-natal and deliveries. Not all labour is meant for a midwife. We were trained to attend to normal labour. As a matter of fact, a midwife is not supposed to deliver a woman who carries her first pregnancy. But, most of them come to PHCs”

“A midwife knows when to refer the expectant mother when the baby is still okay to increase the chances of survival. You have a live mother and a live baby. But, the untrained ones don’t know all these. They just want to prove to the clients that they know what they are doing.”

Despite the availability of skilled birth attendants at MSS facilities, women still deliver at home in some parts of the country.
These are true reflections of the realities in Anambra State, where women, especially those residing in rural communities as mentioned earlier, still prefer traditional birth attendants.

More midwives will be recruited – Government

Efforts to get the reaction of the Executive Secretary of the Anambra State Primary Health Care Development Agency (ASPHCDA), Dr Chioma Ezenyimulu, to various issues raised, especially the unsustainable way
of implementing MSS in the state, did not yield positive results.

Several calls put across to her on three different days (September 7, 19 and 26, 2022) were ignored as she did not pick nor return them. Three SMS messages were equally sent, stating the purpose of seeking her reaction. She never responded to any of them.

They were followed up with another whatsApp message on the same September 26, at 6.30pm, reminding her of the previous messages and calls. She read the message as indicated by the two blue marks on the app, but, there was no reaction from her until the time of filing this report.

However, Dr Ezenyimulu had in previous interviews acknowledged that the BHCPF part being used to engage midwives under the revived MSS is bringing succour to the benefiting PHCs, while the massive recruitment
promised by the state government is being awaited.

Strengthening that position, the Anambra State Commissioner for Health, DrAfamObidike, reiterated to Radio Nigeria the commitment of the present administration to addressing the manpower gap in the health sector of the state.

“As I told you earlier, we shall recruit staff into our primary health centres when we are done with the job interviews we are conducting to fill the vacancies in the general hospitals. The general hospitals are also short-staffed.

“We are aware of where there is gap and we shall fill the gaps with the recruitments to be done immediately we are done with the general hospitals,” DrObidike assured.

As gratifying as the assurance by the commissioner sounds, it is not clear if the recruitment will be able to address the acute shortfall in the manpower strength of these PHCs, especially regarding nurses and midwives.

For instance, if the recommendation of four midwives per facility, as prescribed by the 2006 Minimum Ward Health Care Package for Primary Health Care is adhered to, the state, currently with a total of 152 nurses and midwives, needs to recruit over 3,000 nurses and midwives to effectively cover all its 638 primary health centres.

Will the much-anticipated recruitment absorb this number of nurses and midwives at the expense of other professionals? This is a question only the state government can answer.

OIC, Amansea PHC Eunice Obi educatina a nursing mother on exclusive breastfeeding
OIC, Amansea PHC Eunice Obi educatina a nursing mother on exclusive breastfeeding

Moreover, Eunice Obi, the OIC, Amansea PHC, is indifferent to the hues and cries about shortage of nurses and midwives.

“They have trained some of us, who are not certified nurses, to take safe deliveries and we are doing it effectively. That is why I am not bothered much about the deployment of midwives. Nurses and midwives are necessary. But some of us are effectively filling the gaps,” Eunice asserted.

One of the previous initiatives of government targeted at reducing child and maternal mortality, especially in under-served communities is task-shifting to Community Health Workers (CHEWs). However, while task-shifting has undoubtedly offered a cost-effective expansion of the overall human resources for health (HRH) pool, skilled birth
attendance offered by the midwives will help to reduce the burden of maternal mortality. It will also help to improve utilization of services by women in the affected localities.

According to findings, the last massive recruitment of nurses and midwives into the local government system in Anambra State was in 2004, under the administration of Dr Chris Ngige. However, the total of 400 employed then has been reduced to 152.

Comrade Edith Onwuka, Anambra State chairman of the National Association of Nigerian Nurses and Midwives
Comrade Edith Onwuka, Anambra State chairman of the National Association of Nigerian Nurses and Midwives

“Some retired, some died, some have left for greener pastures. Every year, government does little employment into secondary health care, leaving unattended-to the primary healthcare system that should be invested in,” Comrade Edith Onwuka, Anambra State chairman of the National Association of Nigerian Nurses and Midwives, explained.

Towards effective MSS implementation

Proffering solutions to the problem, Comrade Onwuka recommended regularizing those engaged under MSS into the state civil service.

“Even these people recruited into the MSS under the umbrella of BHCPF are still receiving N30,000 in the Nigeria of today. They will not all stay. If they want the MSS to flourish, the government should regularize those employed under the scheme into the state civil service.

“In total, they have employed 85, but I don’t know how many of them are remaining because the state government is still not augmenting the N30,000.

    “We are also pushing for the state government to start paying rural posting allowance to those under regular civil service so that they will agree to go to rural areas to serve,” Onwuka said.

    For the Programme Manager, Justice, Development and Peace/Caritas (JDPC), Nnewi, OnyekachiOlolo, the Federal Government should not allow the state governments to frustrate its good intentions with the MSS.

    “I advise that the Federal Government should not wait for the states. The Federal Government should take the issue of these MSS midwives seriously. Give them what is due to them from the Salary, Wages and Income Commission. Scale them appropriately so that they can stay,” Ololo appealed.

    *This report published in October 2022 is supported by the International Budget Partnership (IBP), and the International Centre for Investigation Reporting (ICIR).

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