Good morning. I am delighted to extend a very warm welcome to all of you to this International Day of the Midwife event, hosted jointly by the Wellbeing Foundation Africa and ACT Foundation.

• I pay tribute to our partners here today, all of whom are tremendous champions, advocates and representatives for midwives. The ACT Foundation of course, which supports our MamaCare programme in twenty healthcare facilities in Lagos. Thank you, as ever, to the National Association of Nigerian Nurses and Midwives; to the Ministry of Health, FHI360, and the Luth School of Midwifery. We are joined here today with a common vision and passion, and I am sincerely heartened by your presence and ongoing enterprise. 
• I stand before you today as the Global Goodwill Ambassador for the International Confederation of Midwives, commonly known as ‘ICM’, which represents 500,000 midwives, in 132 associations across 113 countries. Within that huge scope there are of course significant differences in the environments and conditions in which midwives operate. Wherever they work, however, midwives are the community leaders and interlocutors who are best placed to foster safe environments including, but also beyond, pregnancy, birth and breastfeeding. 

• As allies of midwives, it is incumbent upon us to advocate for the whole-system support to enable and elevate midwives as the key defenders of women’s rights – in Nigeria and around the world. Today I would like to alight on the critical elements of that whole-system support, with a particular focus on the role of women’s rights in light of the theme of this year’s International Day of the Midwife. I will also explain why I do not believe it is a coincidence that it is a day shared with ‘World Hand Hygiene Day,’ as water, sanitation and hygiene, or ‘WASH,’ is a critical factor in systemic progress for and with midwives. 

• Midwives are champions of women’s rights; but can only be effective if their rights are also secure. This includes the right for every midwife—and all health workers—to decent work and a safe and dignified workplace. Saving lives does not mean a midwife should risk her own. Sadly, as we all know, in the past year we have lost selfless Nigerian midwives. Too often midwives also suffer ‘burnout’ – from long hours carrying out a complex role, combined with the lack of basic infrastructure or professional support to deliver high-quality care. Many rural midwives represent the sole point of access to health care in remote and under-served areas. It is our first duty to keep the care-givers safe.  

• Whole-system support means providing midwives with the adequate tools, equipment, and medicine to provide the full scope of timely, high-quality care, and the capacity to carry out the WHO-recommended 8 antenatal visits. That can only be achieved through effective supply chain management and procurement, overcoming challenges related to drug selection, registration, quantification, procurement, storage and distribution, quality assurance, and information systems.  

• If 13 essential reproductive and maternal health-related commodities were more widely available, it is estimated that the lives of over 6 million women and children could be saved. Those commodities are as follows:

• Oxytocin – for post-partum haemorrhage (PPH) 
• Misoprostol – also for postpartum haemorrhage 
• Magnesium sulfate – for eclampsia and severe preeclampsia 
• Injectable antibiotics – to combat newborn sepsis 
• Antenatal corticosteroids (ANCs) – for preterm respiratory distress syndrome 
• Chlorhexidine – for newborn cord care 
• Resuscitation devices 
• Amoxicillin – for 
• Oral rehydration salts (ORS) – to treat diarrhoea 
• Zinc – also for diarrhoea 
• Female condoms 
• Contraceptive implants 
• Emergency contraception – family planning/ contraception 

• Each of these commodities form part of the toolkit with which we need to equip midwives. But they also need to be equipped with a career trajectory and security to benefit them and the communities that they serve. Health system managers, supervisors and policymakers need to better support midwives throughout their careers: from planning, for example for a midwife’s recruitment and deployment to a post, to providing supportive supervision and clinical mentoring and amplifying midwives’ leadership roles.

• Where midwives’ human resources metrics are not tracked, they cannot be managed. Thus, more data on midwives is needed: from midwifery schools on graduate profiles; from professional associations or councils on licensure, registration, and continuing professional development; and routine, robust, and up-to-date human resource information systems.  In addition, midwife-generated data streams can provide valuable feedback on how services are delivered and promote service improvements.  A comprehensive civil registration and vital statistics system must form the basis of health services and personnel decision making. That will, I have no doubt, provide the evidence needed to understand how midwives’ enhanced leadership roles can optimize health systems.

• I recently chaired a technical working group at SwitchPoint Conference in North Carolina, organised by IntraHealth International. Our focus was on gender equality and the workforce. Despite my many years of working with frontline health workers, I was shocked by some of the accounts of gender violence. As an absolute essential element of a functioning, decent and dignified health system, a midwife’s workplace must be free from sexual harassment and gender discrimination. According to a global survey conducted by the International Confederation of Midwives and the WHO,  37% of midwives reported that they have experienced harassment at work, whether from colleagues or patients. Effective interprofessional collaboration is important to keeping midwives’ workplaces safe.

• Safe workplaces also mean safe conditions of water, sanitation and hygiene: WASH. I am delighted that Dr Tedros, Director-General of the World Health Organization, has matched World Hand Hygiene Day with International Day of the Midwife. Midwives of course need clean water to facilitate a safe and healthy delivery and support families’ sanitation and hygiene needs across their lives. Everyone here today knows of healthcare facilities where midwives must pull buckets of water up from wells themselves; purchase their own examination gloves; chase livestock out of the health centre compound for lack of a proper fence; or dig makeshift pits to dispose of medical waste. 

• At the Wellbeing Foundation Africa, we launched a water, sanitation and hygiene campaign in May 2018, at the World Health Organization offices, in Abuja. We did so precisely because of the overwhelming evidence coming back to us from our frontline healthcare programmes that we had to retrace our steps – that WASH indices in Nigeria were not only poor; but were worsening in many instances. Poor WASH conditions endanger Infection Prevention and Control systems and put health workers and service users at risk. The fact that outbreaks of diseases have been so severe in Nigeria recently – with the WHO commenting that the Lassa Fever outbreak last year was unprecedented – is no coincidence. 

• Our MamaCare midwives began to advocate in healthcare facilities for better standards and taught proper handwashing techniques to staff. Their experiences informed our updated Personal, Social, Health and Economic (PSHE) education programme which takes place in schools, teaching staff and students alike the importance of good WASH standards. We already had the framework in place – and the trust of communities – to adapt our programmes to address a significant health risk, thanks to midwives. 

• But in a country of almost 200 million people we knew that we had to reach far beyond that. This is where the key relationship between frontline experience and the ability to improve capacity by achieving effective advocacy comes in. 

• As we launched the campaign last May, we announced that the Foundation would work with partners including Global Water 2020, an initiative based in Washington D.C. which is designed to accelerate progress toward water access and security for all people in developing countries, with a particular focus on increasing the availability of WASH in healthcare facilities.  A key element of that partnership is advocacy for improved WASH standards, both in Nigeria and around the world. As Special Adviser to the WHO Africa Regional Office, I strongly advocate for the WHO Sepsis Resolution to be adopted and implemented by all governments. In October 2018 the WHO introduced new and pioneering guidelines for WASH in conjunction with neglected tropical diseases. 

• In September 2018 the WBFA partnered with Unilever Lifebuoy Nigeria and Sightsavers to improve hygiene practices to impact more than 2 million children over the following 12 months. The partnership works on programmes which promote hygiene messages and prevent disease, advancing critical hygiene interventions such as handwashing with soap, addressing the issue of child illnesses and mortality due to preventable diseases.

• In many West African countries, data provided by UNICEF indicates that between 15 to 20% of newborn deaths in their first month of life are due to sepsis. According to the World Health Organization, improved access to WASH and improved handwashing for all health workers could help prevent infections, and the risk of sepsis in health facilities. We know what works for WASH standards: we must provide those standards and training for midwives. 

• As we are joined by our partners here today, I must also mention and commend them for our joint work on the Alive and Thrive programme.  I am delighted by the nucleus of critical host community support from the Lagos State Government and thank our Alive & Thrive programme partners, FHI360 for their technical support and oversight, the Association of General and Private Medical Practitioners of Nigeria, the Wellbeing Foundation Africa Team and all those involved in the organization of this conference. Thank you for your efforts as Nigeria unites to ‘Start Strong!’ for infant and child nutrition as part of a global movement.

• Alive & Thrive is an initiative to save lives, prevent illness, and ensure healthy growth and development through the promotion and support of optimal maternal nutrition, breastfeeding and complementary feeding practices in rural and urban Lagos as well as Kaduna.  Good nutrition in the first 1,000 days from conception to two years of age is critical to enable all children to lead healthier and more productive lives. Alive & Thrive works through a four-pronged approach:  policy and advocacy; interpersonal communication and community mobilization; mass communication; and the strategic use of data. Our midwives are crucial to each part of that approach and I cannot conclude my remarks here today without paying tribute to them for their work on this programme. 

• I must also pay a special tribute to our MamaCare midwives. They deliver classes in primary healthcare centres, hospitals, and at IDP camps, which are a frontline for women and their infants. Despite dire mortality rates in Nigeria – where women face around a one in thirteen risk of maternal mortality in their lifetime – we have not lost even one of our over 250,000 MamaCare mothers during childbirth. 

• Our MamaCare midwives have achieved this not only by providing classes to a global standard – and achieving the WHO benchmark recommendation of at least 8 antenatal visits – but also because they act as even more than lifesavers. They provide safe spaces and safe conversations: no subject is taboo or off-limits. They can only do this because they are part of the community that they serve. Too often, global institutions have faced push-back when trying to deliver services – examples that stand out to me include vaccinations and family planning provisions – because they attempt to do so as outsiders, without the trust of a community. 

• Placing midwives at the centre of our work gave us an army of community counsellors which has helped to drive the behavioural change to make women an empowered and informed partner. Midwives are the interlocutors between our Foundation, its aims, and women. 

• They should however become the interlocutors between every government and global institution and the communities that they serve.
  To achieve this, we must enabling and elevate midwives with whole-system support – as ‘Defenders of Women’s Rights.’ Thank you. 

Thank you to the Dutch Government, Bernard van Leer Foundation, the International Confederation of Midwives, and the Dutch Taskforce for Healthcare for hosting us and facilitating this 23rd Board Meeting.

I know that as we sit here in the Hague, all of our discussions are focused upon our shared value and commitment to ensuring that women’s, children’s and adolescents’ health (WCAH) is at the top of national, regional and global agendas. I think it is right, therefore, that the Board Meeting seeks to evaluate and enhance its political engagement at all levels.

At the World Health Assembly this year, alongside Helga Fogstad, PMNCH Executive Director, Dr Tedros Adanhom Ghebreyesus, WHO Director General, and Her Excellency Mrs Emine Erdogan, First Lady of The Republic of Turkey. I commended PMNCH’s Call to Action on Aligning Women’s, Children’s and Adolescents’ Health and Wellbeing in Humanitarian and Fragile Settings.

Given that more than two billion people live under the threat of conflict and emergencies of diverse and complex natures, and that 69 million people have been displaced by humanitarian crises, we need bold steps to enhance coordination and bring together synchronized knowledge, policies and actions for a whole-system approach to achieving health for all, routinely across nations, in order to build the resilience for effective responses in protracted emergencies and in the humanitarian-development nexus. That is why I so strongly support PMNCH’s initiative and call to action, which is best placed to bring us all together – from every sector, region, country and background – to remove the inefficiencies, identify and address gaps of capacity and delivery in every sense.

PMNCH is uniquely positioned to mobilise broader political strategies, and partnerships of all kinds, as it can act as the standard-bearer and interlocutor between the WHO, global institutions, CSOs, governments, the private sector and frontline healthcare workers. This support is invaluable to Governments and healthcare providers, who we can consider to be the duty-bearers. 

At the Wellbeing Foundation Africa, of which I am the Founder-President, we have learned the value which emanates from engagement with PMNCH in Nigeria, as members who supported the ‘Saving One Million Lives’ campaign, the promotion of routine administration of the reinforced ORS-Zinc formula for management of diarrhoea, and the Midwives Service Scheme, a public sector collaborative initiative, designed to mobilize midwives, including newly qualified, unemployed and retired midwives, for deployment to selected primary health care facilities in rural communities.

I must report from Nigeria that whilst there has been an improved focus on surveillance – and a growing acceptance of the fact that suitable civil registration and vital statistics systems will be essential if we are to achieve universal health coverage – I hope that these milestones in accountability also able to catalyse improved services at the frontline. That can only be achieved with expanded investment in primary health.

I strongly support the PMNCH position that we must put women, children and adolescents at the heart of universal health coverage. The relationship between achieving health for all and WCAH must be at the core of our advocacy as the former is simply unachievable without significant improvements to the latter. 

It is of course no coincidence that women, children and adolescents – despite accounting for 60% of the global population – tend to constitute the groups with the least political influence and power, which is why United Nations, WHO and national policies must explicitly highlight and focus on WCAH as part of their UHC strategies. 

Only then can we claim to be truly working towards the principle of “leaving no one behind,” which is central to the Sustainable Development Goals and the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030).

On a final note, as the Global Goodwill Ambassador for the International Confederation of Midwives, one of our co-hosts this week, I must highlight the launch at the World Health Assembly this year, of the report ‘Strengthening quality midwifery education for Universal Health Coverage 2030: A transformative approach to improving quality of care’ produced by ICM, alongside WHO, UNFPA and UNICEF. Women and newborns are the most vulnerable in humanitarian and fragile settings where quality midwifery education saves lives by preparing all midwives to legislate for and respond to emergency health situations. As a critical element in achieving UHC and WCAH, I am sure that we all know that midwives can and do lead the way.

As Nigeria’s first and oldest country member of this esteemed and dedicated alliance, I am honoured by the Wellbeing Foundation Africa’s PMNCH Board Observer Privileges, and delighted to extend a warm welcome to Helen Clark, former Prime Minister of New Zealand, as Chair of PMNCH – who I know will ensure that women’s, children’s and adolescents’ health and wellbeing are reinforced as a global priority. Thank you.

Good morning. It is a pleasure to join you to present the Goodwill Message of Mrs Toyin Ojora Saraki, Founder-President of the Wellbeing Foundation Africa (WBFA), Global Goodwill Ambassador for the International Confederation of Midwives (ICM) and Special Adviser to the Independent Advisory Group to the World Health Organization Regional Office for Africa.

Thank you to Dr Tunde Segun, Country Director for MamaYe! Evidence for Action, for the kind invitation to join you today on this 7th MamaYe Day, to discuss such an elemental and yet crucial aspect of health care service deliver: accountability. 

According to the Global Strategy For Women and Children’s Health, the tracked indicators in Nigeria are some of the worst in Africa, with one of the fastest growing populations globally: our population is likely to reach 440 million people by 2050. We know the key issues Nigeria faces: from having the second largest number of people living with HIV, the highest burden of malaria globally – which remains the top cause of child illness and death – to having the second highest burden of stunted and malnourished children in the world. 

To achieve accountability in health service delivery, we must be able to accurately assess the demographic need for health: which necessitates a well-designed civil registration and vital statistics (CRVS) system. Only with the collection and dissemination of accurate data can we hope to ensure effective delivery, evaluation and monitoring of sustainable, effective public health strategies. 

In the late 1950s, Professor David Morley developed the ‘Road to Health’ chart in Nigeria for monitoring the growth of infants and young children. This home-based chart was originally designed to monitor growth in resource-poor countries, but developed into a record of a child’s growth and development, kept by parents – it was revolutionary in its time. At the Wellbeing Foundation Africa, we took that concept and designed the Personal Health Record (PHR), a book in which the medical records of each mother and child are recorded and stored for future reference and analysis. The PHR evolved from a child immunisation and growth record to a comprehensive CRVS tool. 

This forms part of what I call the value of a statistical life. Without a centralised health database for many families to rely upon and keep them informed of the necessary health processes in a child’s first thousand days of life, the PHR came as an innovation that placed this knowledge directly into the mothers’ hands, and empowered her to provide, analyse and follow-up on her own data – to be in control of her own situational analysis. Home-based records have since been successfully deployed in countries like the UK and Japan.

Registering births and linking birth registration to vaccinations is an important part of CRVS and social accountability. Nigeria is currently battling with a situation where only 1 in 4 children, of our population of 198 million citizens, is immunised against preventable diseases. The Global Alliance for Vaccine and Immunisation 
(GAVI) has revealed that despite considerable investment – of about $700 million – we only have total immunization coverage of around 30%. CRVS would allow us to hold Governments accountable for their policy, spending and distribution decisions – including in cases such as this. 

At the United Nations General Assembly in New York last September I attended the launch of the IAP report ‘Private Sector: Who is Accountable.’ That report rightly called on governments, parliaments, private sector partners and multilateral agencies to establish effective accountability systems. As I noted at the time, only two countries in Africa have met the Abuja declaration to pledge 15% of their government budgets to health. Meanwhile, tuberculosis kills more than 4,000 people every single day. This can be avoided – and there are five key interventions which would take us far closer to delivering the 2030 Agenda and achieving universal health coverage:

1. Civil registration and vital statistics systems must be implemented and strengthened to allow Governments to prepare for epidemics and allocate investment where it is needed the most. CRVS is the only way to ensure that we leave no-one behind. 

1. Investment in family, community and primary healthcare – along with hospitals where needed – to bolster healthcare wherever people need it; in rural areas and urban, cities and villages.
2. Government investment in strengthening health insurance systems is also paramount to achieving Universal Health Coverage – in Nigeria and around the world, too many people are plunged into poverty by health emergencies that they or their families experience.

1. Non-communicable diseases kill over 41 million people every year. The Director-General of the WHO, Dr. Tedros, has rightly highlighted the NCD crisis and it must be a core focus of all Government programmes. Strengthening the primary health tier is key to prevention, detection and treatment of NCDs.

1. Finally, and most importantly, the murder of young midwife and mother Saifura Hussaini Ahmed Khorsa in Nigeria last year must spur Governments and global institutions on to strengthen security provisions for frontline health workers, in particular those who work in fragile humanitarian settings. Women and newborns are the most vulnerable in humanitarian and fragile settings where quality midwifery education saves lives by preparing all midwives to prepare for and respond to emergency health situations. 

We know that the road to universal health coverage does not rest upon singular interventions, but rather on a plethora of interconnected  interventions and initiatives; from water, sanitation and hygiene standards in healthcare facilities to breastfeeding education and training for healthcare workers. In a country as large as Nigeria, resilience throughout the whole nation’s system is necessary if we are going to be able to tackle critical health emergencies in fragile settings, for example in the north-east. That is why a strengthened primary health care system is imperative as the foundation and bedrock of achieving health for all and should be a focal point for investment. 

Thank you once again for the kind invitation to join you today, and I look forward to working with all of you for stronger, more accountable, and safer health systems.