Curt McDaniel – Chief Legal Officer and Board Secretary – Ferring Pharmaceuticals
” Today we have a very special guest, Her Excellency Mrs. Toyin Saraki. She is Founder-president of The Wellbeing Foundation Africa, a Nigerian philanthropist with two decades of advocacy covering maternal and infant health; ending gender-based discrimination and violence and improving education, socio-economic empowerment and community livelihoods for women and families in Africa. She is also a lawyer and a mother of four.

Please welcome H.E. Mrs Saraki.”

Interview:

Can you tell us about your work to reduce maternal and infant mortality in Africa?

MamaCare: At the Wellbeing Foundation Africa, we place midwives at the centre of our efforts to reduce Maternal and Infant mortality. Over 230,000 women have taken part in our MamaCare programme, Antenatal and Postnatal classes, delivered by a team of 55 midwives to mothers in healthcare facilities across Kwara, Ogun, Osun, Lagos, Kaduna states in Nigeria and the Federal Capital Territory.

Our MamaCare mothers are now achieving the now standard number of antenatal eight visits recommended by the WHO, and we are yet to lose a single one to death in childbirth. Critically midwives are aware of warning signs to both mother and baby’s health during pregnancy and can recognise and intervene when the situation needs to be escalated before it becomes fatal. As well as avoiding immediate tragedy, antenatal education is incredibly effective at promoting positive perinatal outcomes in the long term, as parents acquire knowledge of the physical and psychological factors that affect their health and that of the unborn child.

We know that some of the barriers that increase the risks a mother’s risk can be reduced through a strong and trusting relationship between a mother and midwife. For example, some women perceptive that they are in better control of the delivery process when they are at home and are therefore reluctant to deliver in a hospital. A midwife can act as a strong advocate for facility-based delivery, meaning should a mother or infant experience complications and be inside a hospital they are more to access live saving care in time.

EmONC: But since we first launched MamaCare in 2015 there has been a great deal of organisational learning. We realised that you can only begin to address maternal mortality through the MamaCare approach -educating a mother, providing access to a midwife, and empowering her to deliver in a facility. Ultimately if when she is delivering in that facility, the healthworkers around her are not equipped to deal with a complication, then our work to prevent maternal and infant mortality has failed at the most critical hurdle.

From this understanding, our Emergency Obstetric and Newborn Care EmONC programme, in partnership with the Liverpool School of Tropical Medicine and Johnson and Johnson, was born. Our EmONC training takes place healthcare facilities and equips doctors, nurses and midwives, as a collective team, with the skills and experience needed to overcome obstetric emergencies by using anatomical models. At assessment visit to Kwara, I asked a Doctor how the use of models and the training had affected his outcomes. His response was both illuminating and chilling. Before the use of anatomical models, live births had been a training ground for nurses, midwives and doctors. Unfortunately, in Nigeria our healthworker education all too often does not use cadavers or models, and as a result practitioners do not develop valuable practical experience that cannot be learned through a textbook.

Our team now has trained 600 ‘master trainers’ across a staggering 16 Local Government Associations in Kwara State, establishing ten EmONC Skill Laboratories in ten selected Core-Training Medical Facilities. These 600 master trainers have gone on to train a further 62,800 health workers. The number of up-skilled frontline health workers continues to percolate, as the impact in lives-saved grows. I am hopeful of a Nigeria where this technology and training was available across the nation.

WASH: But even when an mother is educated through antenatal and post-natal classes, has access to a midwife during pregnancy, and trained expert healthworker team on standby during delivery – we still cannot guarantee that preventable maternal and infant deaths will not occur.

There is a World Bank survey on healthcare facilities in Nigeria that really shocked me to the core. 69% of health care facilities said that they could conduct deliveries. But yet only 29% of labour room’s in Nigeria have access to running water. I thought hold up a second, that means that the majority of those healthcare facilities are offering deliveries when they cannot provide the midwives and doctors conducting them with access to safe water. Deliveries are therefore being carried out with hands that have not been sufficiently sterilized. Hands that are not clean. Not because of dirty habits but because these facilities lack running water.

In Nigeria over a woman’s lifetime she has a 1 in 13 risk of maternal death, a staggering reality. Sepsis accounts for 17% of maternal deaths. Strategic approaches to reducing maternal mortality which focus on clinical interventions and strengthening healthcare are critical in addressing the problem of haemorrhage and eclampsia, but neglect sepsis. Which we know is linked to poor WASH.

That is why we launched our WASH programme. I advocate at a parliamentary level for greater resources to be allocated to WASH structures in healthcare facilities. While on the frontline through our Teach Clean programme we train health workers and cleaners on the best hygiene and sanitation practises within facilities. MamaCare has also been integrated a WASH approach, and we go into schools to teach not just personal, social, health and economic education but also WASH skills. Sometimes it as simple as how to wash your hands properly. An incredibly basic but valuable skills that is a wonderfully cost effective way of saving lives.

MamaCare360 Approach: Ultimately all of our Maternal and Infant mortality programmes are governed by our MamaCare 360 approach, the understanding that to protect mothers and babies we need to focus on solutions that holistically tackle all of the causes of preventable death.

We need MamaCare to drive behavioural change to make women an empowered and informed partner in her families’ health, both during, and after pregnancy; we need EmONC to ensure when she gets to the facility she is cared for by safe and skilled pairs of hands; and we need WASH to ensure that those hands that deliver and care for her infant are also clean.

And as you’re here at Ferrings shows, we need to also ensure midwives, nurses, and doctors have access to the medicines and medical tool resources needed to save lives.

Ultimately midwives really drive all our work, they are interlocutors between our Foundation, its aims, child bearing women, other healthworkers and policy makers.

Why is this so close to your heart?

Personal Tragedy of Delivering Twins and Losing a Child.
My personal story of tragedy during childbirth plays out thousands of times a day every day in Nigeria. Close to 200 million people inhabit Nigeria, we are Africa’s most populous country, but we are also where nearly 20% of all global maternal deaths happen.

The year I was born in Nigeria the infant mortality rate was 195 in 1000 births. Meaning that during that year almost one in five babies did not live to celebrate their first birthday. Today infant mortality is 75 per 1000 live births. That less that one in ten babies that do not survive past five. While in my lifetime there has been a change, but this is clearly not enough.

You describe your experience as an unavoidable reality for many women in Nigeria. How did your personal experience motivate you to advocate for women who don’t have a voice?

We have the technology we have the knowledge, we have the medicines, and we now need to deliver the healthcare. The state of the healthcare system in Nigeria means we are failing child bearing women and their infants. In the current environment, these deaths are unavoidable, yet conversely they are completely avoidable, as we know how to prevent complications and treat them when they do arise. What happened to me 27 years ago shouldn’t have happened then, and it is a tragedy that it continues to happen today.

Similar to most developing countries, in Spain women have a 1 in 21,500 lifetime risk of dying during pregnancy, childbirth or post-abortion. In Nigeria that risk is 1 in 21. Nowhere does inequality have stark impacts than healthcare. In my country we women deserve better, our lives and that of our infants are not less valuable than women in Spain.

Gender equality is also a big part of your work at the Foundation. Can you tell us why ending gender-based discrimination is so important to improving maternal health outcomes?

Child Bearing Women: Ultimately social and biological differences mean women and men experience different health risk and have health seeking behaviour, health outcomes and responses from health systems. Of course women are not a homogenous group, however, gender inequity, poverty among women, weak economic capacity, sexual and gender-based violence including female genital mutilation are major impediments that disproportionally affect women their ability to experience optimal health and wellbeing. These impediments become more pronounced in the face of under resourced maternal care services. As a result, we at the Wellbeing Foundation view generating gender equality as a major part we will improve maternal health outcomes. Women carry the burden of childbirth; and it vital that our societies ensure this service labour of love is not fraught with unnecessary dangers.

Nurses and Midwives: Gender based discrimination also impacts the ability of health workers to provide quality maternal care. Nurses and midwives represent half of the professional health workforce and are overwhelming, although not exclusively, women. They play a critical role not only in delivering healthcare to millions of child bearing women, and are key to transforming health policies, disease prevention, and emergency care. In March 2019, the WHO and partners produced a report on the Global Health and Social Workforce, that found that statistically speaking ‘women deliver global health and men lead it’. We now know that women comprise 70% of the global health workforce, but only 25% hold senior roles.

Equally troublingly in a global survey conducted by the ICM and the WHO, 37% of midwives reported that they have experienced harassment at work, whether from colleagues or patients. Gender inequality within the sector is not only unacceptable but it also ultimately weakens the quality of healthcare that we are able to provide. This is why the Wellbeing Foundation, and myself as the International Confederation of Midwives’ Global Goodwill ambassador, assert that respect for both Midwives and their work in maternity care is a non-negotiable necessity and demand that a midwife’s workplace must be free from sexual harassment and gender discrimination. This as an absolute essential element of a functioning, effective decent and dignified health system.

At Ferring, we’re passionate about building families and reducing maternal mortality, particularly through the prevention of post-partum haemorrhage. Can you tell us about the impact of post-partum haemorrhage in Nigeria, and across Africa?

Post-partum haemorrhage is a sudden, terrifying condition, that the approximately 12,000 women who die in my country battle against and lose. This number is so staggeringly large that it is difficult to fully comprehend. But every maternal death is an individual tragedy. Can just ask you to consider the reality for each one those women. You’ve just given birth. You’re filled with emotion, you’re exhausted and elated. You’re relieved and excited holding your baby, who is safe and well. But something’s not quite right. You’re told by your doctor that there’s a, issue. You’re panicking and disorientated and you realise you’re bleeding uncontrollably. It dawns on you and those around you that if you not treated in the short to immediate future, you will certainly die.

Maternal mortality is not only a colossal waste of life but remains a constant, and impenetrable barrier to development. Investing in better maternal health has a ripple effect across families, communities and therefore entire countries. This is why the work you are doing here at Ferrings to provide heat-stable carbetocin to treat post-partum haemorrhage at an affordable to publicly funded healthcare facilities and facilities operating on a social marketing basis in low- and lower-middle income countries.

As the leading cause of maternal mortality, working to treating post-partum haemorrhage has been at the core of my foundation’s mission. Which is why the Wellbeing Foundation Africa participated in the WOMEN trial, an initiative of the London School of Hygiene and Tropical Medicine, which enrolled 20,000 women, to look at the efficiency of using Tranexamic Acid to combat Post-Partum Haemorrhage.

We know that medicines are only part of the solution – together, we need to change healthcare systems. What top three changes need to be made to the system to stop women dying while giving life?

Quality Healthworker Training –While focus was (and should be) on gaps to access, gaps to quality cannot be neglected. Health systems are primarily made up of people, and as a result we must invest in upskilling and training health workers we are to build a universal health coverage which is meaningful

Water, Sanitation, and Hygiene Infrastructure – Without WASH structures in place, a trained midwife, nurse, or doctor, therefore, as a professional dedicated to saving the lives of mothers and infants, is faced with the troubling prospect of having to use water that they cannot be sure is clean and therefore they potentially expose themselves and the mother to deadly infection.

Personal Heath Record Books. Without PHR books a woman may arrive at a hospital she has never been to before with a complication during delivery to be treated by a team she has never met. In these instances, a lack of records can be life threatening. Medical professionals in emergencies need to be able to quickly and accurately ascertain the correct course of intervention. This is why in 2006, shortly after I first started the foundation we developed our Integrated Maternal Newborn and Child Health Personal Healthcare Records (PHR) Books, Nigeria’s Federal Ministry of Health and National Primary Health Care Development Agency’s Midwives Service Scheme.

Do you think that international community can achieve the Sustainable Develop Goals (SDGs) to reduce maternal mortality by 2030?

Although more people around the world are living better lives compared to a decade ago, inequities and inequalities persist as challenges that impede progress. I am aware that we have a long road ahead to 2030 if we are to successfully protect, progress and promote the objectives promised by the sustainable development goals. However, I am impatiently optimistic based on the dedication of people I meet and the pervading sense of urgency that has enveloped each related conversation and event I have been a part of. I believe we will only be able to deliver the SDG 3 – good health and well-being for all with broad sector support. Though it was our political leaders that made these promises, we must all part of efforts, particularly in the private sector, to deliver them. Which is why it is so important that organisation’s like Ferrings are committing to deliver lifesaving medicines to low and middle income countries at an affordable and sustainable cost.

Your story reminds all of us here at Ferring why we come to work every day. What message do you have for Ferring employees?

My message is simple – your work saves lives. I hope this continues to motivate you when the going gets tough to get out of bed each morning and give each and every day your all. As you all know in this room, more than most, child bearing women are not dying because of conditions we cannot prevent or treat. We must do everything in our power to ensure that the quality care is accessible to women everywhere.