Marked variability in institutional deliveries and neonatal outcomes during the COVID-19 lockdown in Nigeria.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic and the interventions to mitigate its spread impacted access to healthcare, including hospital births and newborn care. This study evaluated the impact of COVID-19 lockdown measures on newborn service utilization in Nigeria. METHODS: The records of women who delivered in hospitals and babies admitted to neonatal wards were retrospectively reviewed before (March 2019-February 2020) and during (March 2020-February 2021) the COVID-19 pandemic lockdown in selected facilities in Nigeria. RESULTS: There was a nationwide reduction in institutional deliveries during the COVID-19 lockdown period in Nigeria, with 14 444 before and 11 723 during the lockdown-a decrease of 18.8%. The number of preterm admissions decreased during the lockdown period (30.6% during lockdown vs 32.6% pre-lockdown), but the percentage of outborn preterm admissions remained unchanged. Newborn admissions varied between zones with no consistent pattern. Although neonatal jaundice and prematurity remained the most common reasons for admission, severe perinatal asphyxia increased by nearly 50%. Neonatal mortality was significantly higher during the COVID-19 lockdown compared with pre-lockdown (110.6/1000 [11.1%] vs 91.4/1000 [9.1%], respectively; p=0.01). The odds of a newborn dying were about four times higher if delivered outside the facility during the lockdown (p<0.001). CONCLUSIONS: The COVID-19 lockdown had markedly deleterious effects on healthcare seeking for deliveries and neonatal care that varied between zones with no consistent pattern.

Use of off-label compounded oral sildenafil in the management of persistent pulmonary hypertension of the newborn: A case report.

We report a case of a newborn with persistent pulmonary hypertension (PPHN) due to meconium aspiration syndrome with associated lung collapse. Echocardiogram revealed features of persistent pulmonary hypertension. He was treated with compounded oral sildenafil. Oral sildenafil has proven to be effective and safe in the management of PPHN in neonates with persistent pulmonary hypertension. Therefore, in situations where inhaled nitric oxide is not available it may be used as an alternative therapy in PPHN. Further randomized controlled studies are needed to determine its efficacy and pharmacokinetics.

Early onset of neurological features differentiates two outbreaks of Lassa fever in Ebonyi state, Nigeria during 2017-2018.

Lassa fever (LF) is an acute viral haemorrhagic illness with various non-specific clinical manifestations. Neurological symptoms are rare at the early stage of the disease, but may be seen in late stages, in severely ill patients.The aim of this study was to describe the epidemiological evolution, socio-demographic profiles, clinical characteristics, and outcomes of patients seen during two Lassa fever outbreaks in Ebonyi State, between December 2017 and December 2018. Routinely collected clinical data from all patients admitted to the Virology Centre of the hospital during the period were analysed retrospectively. Out of a total of 83 cases, 70(84.3%) were RT-PCR confirmed while 13 (15.7%) were probable cases. Sixty-nine (83.1%) patients were seen in outbreak 1 of whom 53.6% were urban residents, while 19%, 15%, and 10% were farmers, students and health workers respectively. There were 14 (16.8%) patients, seen in second outbreak with 92.9% rural residents. There were differences in clinical symptoms, signs and laboratory findings between the two outbreaks. The case fatality rates were 29.9% in outbreak 1 and 85.7% for outbreak 2. Neurological features and abnormal laboratory test results were associated with higher mortality rate, seen in outbreak 2. This study revealed significant differences between the two outbreaks. Of particular concern was the higher case fatality during the outbreak 2 which may be from a more virulent strain of the Lassa virus. This has important public health implications and further molecular studies are needed to better define its characteristics.

Why does uptake of family planning services remain sub-optimal among Nigerian women? A systematic review of challenges and implications for policy.

BACKGROUND: Over the years, family planning uptake in Nigeria has remained low and this is as a result of the various challenges and barriers faced by women. The aim of this study was to systematically review studies on family planning services undertaken in Nigeria in order to understand the challenges to uptake of the services and the policy implications. METHODS: A PubMed search was performed in June 2020 and studies that investigated challenges of family planning uptake in Nigeria published in English between 2006 and 2020 were sought. A combination of the search terms family planning, contraceptives, challenges, barriers, Nigeria was used. Review articles, case reports, and case studies were excluded. Studies that did not report barriers or challenges to family planning or contraceptives were excluded. RESULT: Twenty seven studies carried out in Nigeria which provided sufficient information were identified and used for this review. The Uptake of family planning recorded in the reviewed studies ranges from 10.3 to 66.8%. Challenges that are client related include education, desire for more children, uncertainty about its need, partner disapproval, previous side effects, religious beliefs, culture disapproval, age, marital status, and wealth index, residence, ignorance, embarrassment, domestic violence and sexual factor. Health service related factors identified include cost, difficulty accessing services, and procurement difficulties. Recommendations for family planning propram and policy include targeting of health service delivery for improvement, focus on gender issues and male involvement, involvement of religious leaders, targeting of younger women for better education and counseling, and continuous awareness creation and counseling among others. CONCLUSION: The review has shown that uptake of family planning remains low in Nigeria and challenges abound. We recommend that strategies that are multi-sectoral should be applied to address the multi-pronged challenges facing uptake of family planning services.

Implementing bubble continuous positive airway pressure in a lower middle-income country: a Nigerian experience.

Bubble CPAP (bCPAP) is used for respiratory distress (RD) in neonates. The leading causes of neonatal mortality can lead to severe RD. Many neonatal deaths are preventable using evidence-based interventions like bCPAP as part of a comprehensive approach. The study aimed to assess the implementation of a multi-center, comprehensive hospital-based bCPAP program in a low-middle-income country using a low-cost bCPAP device. Seven established hospitals in three Nigerian States were selected using purposive sampling. A respiratory support program was developed and implemented using the Pumani® bCPAP. Neonates <28 days old with severe RD, birth weight >1000g and breathing spontaneously, were eligible. The program lasted 22 months. Focus group discussions and in-depth interviews of healthcare workers and hospital administrators were used in program assessment. Content analysis of qualitative data completed. The staff reported that the bCPAP device was easy to use and effective. All staff reported comfort in eligible patient identification, effective set up and bCPAP administration. All study sites experienced varying degrees of electric power interruption and oxygen availability and affordability. Staff training, staffing disruptions, data collection challenges and use of improvised bCPAP contributed to low enrollment. Advocacy, direct program support, and innovation using locally available resources improved enrollment. Professional organization collaboration, competency-based training and peer mentoring contributed to program success. Thorough pre-program assessment, with comprehensive understanding of all aspects of the existing system within the local context which are likely to impact the introduction of a new program is important to implementation success.

Nutritional status of school age children in Abakaliki metropolis, Ebonyi State, Nigeria.

BACKGROUND: Malnutrition is a major public health problem with short and long-term adverse effects on children particularly in middle and low-income countries. Three out of every ten under-five children are said to be stunted and 19.4% underweight in Nigeria. In Ebonyi State, between 2013 and 2015, the proportion of preschool children with chronic undernutrition rose from 16.2 to 20.6%. Little is documented about the nutritional status of school-age children in Ebonyi State and Nigeria. METHODS: We conducted a descriptive cross-sectional study among 780 children aged 6 to 12 years from 10 primary schools in Abakaliki metropolis. A multistage sampling method was used to select the participants. A pre-tested interviewer-administered structured questionnaire was used to collect information from the children and their parents. Body Mass Index (BMI), Z scores of the weight for age, BMI for age and height for age were obtained using the WHO AnthroPlus software. We estimated the prevalence of undernutrition, over-nutrition, underweight, thinness, stunting, overweight and obesity. RESULT: Out of 751 pupils that participated, 397 (52.9%) were females and 595 (79.2%) were in public schools. The overall prevalence of undernutrition was 15.7% and that of over-nutrition was 2.1%. The prevalence of underweight, thinness and stunting, overweight and obesity were 8, 7.2, 9.9, 1.4 and 0.7% respectively. The proportion of pupils who were thin was higher among males (8.7%), those attending public schools (8.6%) and those dwelling in rural parts of the metropolis (14.3%) compared to females (5.8%) private school attendees (1.9%) and urban dwellers (4.6%). Stunting was found to be higher among pupils attending public schools (11.8%) compared to those attending private schools (2.5%). The prevalence of stunting was 19.3% among the pupils residing in rural areas and 5% among the pupils living in urban areas of the metropolis. No pupil in private schools was underweight. Over-nutrition was not found among the pupils in rural areas. CONCLUSION: Both under and over nutrition exist in Abakaliki metropolis. Undernutrition is the more prevalent form of malnutrition among school age children in the metropolis.

Comparative outcome of overhead and total body phototherapy for treatment of severe neonatal jaundice in Nigeria.

Background: In Nigeria, neonatal jaundice is commonly treated by overhead phototherapy with neonates lying supine, often with effective exposure of less than one half of the body surface. Total body exposure in phototherapy has been in use for less than 2 years in Nigeria, but is available in only five neonatal centres.Aim: To compare the effectiveness of total body exposure (TBPE) with the conventional partial exposure (COPT) for treatment of hyperbilirubinaemia.Methods: Eleven datasets from 10 neonatal units across Nigeria were retrieved. They included neonates with severe hyperbilirubinaemia treated with TBPE using the Firefly® device (MTTS Asia) as a test group. The remainder of the patients, the controls, were treated with COPT. Any requirement for exchange blood transfusion (EBT) in either group was documented. Total serum bilirubin (TSB) >213.8 µmol/L (12.5 mg/dL) was treated as severe hyperbilirubinaemia. The efficiency of the intervention was determined according to the time taken for a severe case to be downgraded to mild at ≤213.8 µmol/L.Results: A total of 486 patients were studied, 343 controls and 143 cases. Mean (SD) postnatal age was 6 days (0.7) for cases and 5 (0.9) for controls, for gestational age (GA) in completed weeks was 36 (0.5) for cases and 37 (0.7) for controls and for birthweight was 2.7 kg (0.25) for cases and 2.7 (0.22) for controls. Mean (SD) pre-intervention TSB was 299.3 (35.7) µmol/L for cases and 327.3 (13.9) for controls. Severity downgrade day was Day 2 (0.4) for cases and Day 5 (1.1) for controls. Overall relative EBT rate was 6% for cases and 55% for controls (p= 0.0001), and early preterm relative EBT rate was 0% for cases and 68% for controls (p < 0.01).Conclusion: TBPE was quicker and safer for reduction of hyperbilirubinaemia and patients rarely required EBT. TBPE is recommended for rapid reduction of serum bilirubin levels and the reduction of treatment costs, morbidity and mortality in low- and middle-income countries.Abbreviations: EBT, exchange blood transfusion; TBPE, total body exposure technique; COPT, conventional partial exposure; TSB, total serum bilirubin; SB, serum bilirubin; NNJ, neonatal jaundice; SCNU, special care neonatal unit; LMIC, low- and middle-income countries; HIC, high-income countries; LED, light-emitting diode.

Determinants of antenatal care utilisation in sub-Saharan Africa: a systematic review.

OBJECTIVES: To identify the determinants of antenatal care (ANC) utilisation in sub-Saharan Africa. DESIGN: Systematic review. DATA SOURCES: Databases searched were PubMed, OVID, EMBASE, CINAHL and Web of Science. ELIGIBILITY CRITERIA: Primary studies reporting on determinants of ANC utilisation following multivariate analysis, conducted in sub-Saharan Africa and published in English language between 2008 and 2018. DATA EXTRACTION AND SYNTHESIS: A data extraction form was used to extract the following information: name of first author, year of publication, study location, study design, study subjects, sample size and determinants. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist for reporting a systematic review or meta-analysis protocol was used to guide the screening and eligibility of the studies. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to assess the quality of the studies while the Andersen framework was used to report findings. RESULTS: 74 studies that met the inclusion criteria were fully assessed. Most studies identified socioeconomic status, urban residence, older/increasing age, low parity, being educated and having an educated partner, being employed, being married and Christian religion as predictors of ANC attendance and timeliness. Awareness of danger signs, timing and adequate number of antenatal visits, exposure to mass media and good attitude towards ANC utilisation made attendance and initiation of ANC in first trimester more likely. Having an unplanned pregnancy, previous pregnancy complications, poor autonomy, lack of husband's support, increased distance to health facility, not having health insurance and high cost of services negatively impacted the overall uptake, timing and frequency of antenatal visits. CONCLUSION: A variety of predisposing, enabling and need factors affect ANC utilisation in sub-Saharan Africa. Intersectoral collaboration to promote female education and empowerment, improve geographical access and strengthened implementation of ANC policies with active community participation are recommended.

A review of the incidence and determinants of catastrophic health expenditure in Nigeria: Implications for universal health coverage.

BACKGROUND: In the Nigerian context, preconditions for financial catastrophe are operational as there is high out-of-pocket spending (OOPS) on health with low capacity to pay, presence of user fees, and poor prepayment insurance coverage. We reviewed the incidence and determinants of catastrophic health expenditure (CHE) in Nigeria. METHODS: Databases including PubMed, OVID, EMBASE, CINAHL, and Web of Science were searched for primary research studies on the incidence and determinants of CHE in Nigeria published between 2003 and 2018. Search terms used include household, out-of-pocket expenditure, catastrophic health expenditure, and Nigeria. RESULTS: Twenty studies that met the inclusion criteria were included in the review. At 10% of total household and nonfood expenditure, the incidence of CHE was 8.2% to 50%, while 3.2% to 100% households incurred CHE at 40% of nonfood expenditure. The incidence of CHE was higher among inpatients and studies with lower threshold definitions. Outpatient CHE was highest for type 2 diabetes and tuberculosis while human immunodeficiency virus (HIV) care incurred the most CHE among inpatients. Determinants of CHE include wealth status, age, gender, place of residence/geographical location, household size/composition, educational status, health insurance status, illness, and health provider types. CONCLUSION: There is a high incidence of CHE across various common health conditions in Nigeria. CHE was more among the poor, elderly, rural dwellers, private facility utilization, female gender, and noninsured among others. We recommend expansion of the National Health Insurance Scheme via informal social and financing networks platforms. Increased budgetary allocation to health and intersectoral collaboration will also play a significant role in CHE reduction.

Apparent overuse of antibiotics in the management of watery diarrhoea in children in Abakaliki, Nigeria.

BACKGROUND: Diarrhoea remains an important cause of childhood mortality in Nigeria, with Rotavirus and Cryptosporidium reported to have the highest contribution. However, high use of antibiotics for treatment of paediatric diarrhoea has been observed, although World Health Organization guidelines discourage the use of antibiotics for treating acute diarrhoea. Here we investigated more closely management and treatment practices for acute paediatric diarrhoea, both in home and healthcare settings. METHODS: Children under 5 years of age (n = 199) presenting at healthcare centres in Abakaliki, Nigeria with acute watery diarrhoea were included in the study. Background information on the children was collected by questionnaire, including home treatments, and clinical information including symptoms and treatment were provided by the healthcare centres. Analysis of faecal samples from the children indicated that over 90% had Rotavirus infection and over 6% Cryptosporidium infection. Data were compiled in a spreadsheet and analysed for associations between variables and use of antibiotics using logistic regression analysis. RESULTS: Although most children were treated supportively (oral rehydration solution and intravenous fluids at home and in healthcare settings, respectively) over 15% were given anti-diarrhoea drugs at home and over 85% were also prescribed antibiotics at the healthcare centre, mostly ciproflaxin, but also metronidazole and gentamycin. The only variable positively associated with antibiotic prescription was diarrhoea more than three times per 24 h at admission. CONCLUSIONS: It is clear that young children presenting with acute watery diarrhoea to healthcare centres in Abakaliki are likely to be prescribed antibiotics, despite there being no obvious reason that this treatment is appropriate. Our study results support the need for institution-based antimicrobial stewardship being implemented in Nigeria.

The practice of Breastfeeding by Healthcare Workers in the Federal Teaching Hospital; Abakaliki; South-Eastern Nigeria

Background. Optimal breastfeeding practices include exclusive breastfeeding (EBF) for the first 6 months of life; followed by continued breastfeeding with adequate complementary foods on to at least 2 years of age. This is expected to be well known and practised by healthcare workers (HCWs) who are in the position to educate the community. Objective. To determine the actual breastfeeding practices of HCWs in a tertiary hospital in south-eastern Nigeria. Methods. We conducted a cross-sectional; descriptive study among female HCWs at the Federal Teaching Hospital; Abakaliki; southeastern Nigeria; using a self-administered; semi-structured questionnaire. Results. One hundred HCWs were recruited; including doctors; nurses; pharmacists and other HCWs. Only 3 practised EBF with all their children; their cited reasons being a busy work schedule (61.8); EBF being too stressful (18.4); ignorance of benefits of EBF (13.2) and lack of family support (3.9). Only 1 breastfed their babies up to 2 years. The reasons for failing to do so included refusal of the child to breastfeed (32.6); another pregnancy (30.4); feeling it was shameful (10.9) and feeling that the baby was too old (8.7). Conclusion. There are obvious shortcomings in breastfeeding practices among HCWs. They need to be empowered and supported to promote and support breastfeeding among their patients in particular and society in general