An orthopaedic surgeon at the Federal Medical Centre (FMC), Umuahia, in Abia State, Peace Amaraegbulam, observed that the Nigerian children she had encountered, who had cerebral palsy, lacked access to quality medical care and social support.

Cerebral palsy is a brain-related disability that makes movement and balance difficult.

To contribute to improving the situation, in November 2017, Mrs Amaraegbulam founded The Straight Child Foundation (TSCF), a nonprofit, as a platform for providing support to children with the condition.

But what Mrs Amaraegbulam did not know was that she was also creating an opening that would, a year later, allow children with foot deformities to access free and effective treatment.

As an orthopaedic surgeon at FMC Umuahia, part of Mrs Amaraegbulam’s work is treating children with clubfoot, a congenital (present-at-birth) deformity that twists the foot inward and downward, causing the child to walk by the side of their foot with much pain and difficulty.

About 9,000 of Nigeria’s seven million yearly newborns have clubfoot. That is 4.5 per cent of the global 200,000 annual incidences. But because out-of-pocket treatment per case could cost as much as N200,000 ($485), according to Uchenna Oluwatosin, head of the Physiotherapy department at FMC, one of several hindrances to effective treatment in Nigeria is the lack of funds to commence or conclude treatment.

2-years-5-months old Chimamanda Onyealusi holds her brace happily.

Thankfully, children in six Nigerian states can now access free and effective treatment. The events that birthed the solution began when Mrs Amaraegbulam travelled to the U.S. in early 2018 as a scholar under the International Surgical Skills Scholarship of the American Academy of Orthopaedic Surgeons, which included a one-week observership at Columbia University in New York where she had a mentor in Joshua Hyman, a Professor of orthopaedic surgery at the university.

Miraclefeet

During one of their in-person chats, Mr Hyman, who is also a medical advisory board member at Miraclefeet (a U.S.-based nonprofit supporting care providers across 29 countries to increase access to effective clubfoot treatment), inquired about what challenges Mrs Amaraegbulam was facing with her clubfoot patients back in Nigeria.

“I told him that many parents were not able to complete the Ponseti care for their children, and a lot of time, they are not able to provide the casting materials. They are not able to afford the braces for the maintenance,” she explained.

Clinic workers casting POP on a baby’s foot as his mother watches

After hearing this, Mr Hyman suggested that Miraclefeet could extend its support to Nigeria and that Mrs Amaraegbulam’s nonprofit and FMC could be its gateway into the country.

He then promised to share the idea with Miraclefeet for possible consideration. And when he did, it sounded like something Miraclefeet had been waiting for.

“It was very helpful for us that there was an existing organisation trusted and recommended by one of our advisory board members,” Noé Rajerison, Miraclefeet’s associate director of programmes, said.

In the months following, Miraclefeet entered a partnership with TSCF to create awareness about clubfoot in Nigeria and provide free treatment, beginning with a clinic at the FMC Umuahia where Mrs Amaraegbulam works. Miraclefeet’s representatives arrived in Nigeria and trained staff of TSCF and other volunteers from FMC Umuahia in a clubfoot treatment method called Ponseti. It also committed to providing all the treatment materials for free every quarter while FMC provided space as a clubfoot clinic where children with the deformity can access free care every Thursday.

Ponseti treatment method

So what is Ponseti about?

There are several treatment methods for clubfoot. But Ponseti, which is non-surgical, is globally accepted to be cost-effective and records over 95 per cent success in treatment outcomes, especially for under-two children. It involves casting and bracing phases, otherwise called correction and maintenance.

A baby’s previous cast is being removed so the old cast can be replaced.

The correction phase lasts between five to eight weeks. It involves a caregiver gently manipulating the foot upward and forward every week and casting the foot with Plaster of Paris or POP (a powder-made plaster applied after being soaked in water and capable of sticking when dry) to hold the foot to the desired position and prevent it from jerking back to its pre-manipulation state.

The correction phase ends only when each of the four fundamental components of a clubfoot case is corrected, with each week’s manipulation and casting intended to fix at least one component.

Clinic workers casting POP on a baby’s deformed feet after manipulation.

Mr Oluwatosin, the head of the physiotherapy department at FMC, identified these components as CAVE; C for cavus (a deformity in the midfoot); A for adductus (an anomaly in the foot’s middle bones), V for varus (a defect in the foot’s forefront), and E for equinus (an ankle deformity bending the foot downward).

Maintenance Phase

The maintenance phase is done using braces. A brace comprises a special shoe (or boot) and a bar as long as the distance between the child’s shoulders. When the child wears the shoes, the shoe’s bottom is clipped to the bar, allowing each leg and foot to keep a degree of distance from each other to sustain the upward and forward correction.

Tochukwu Ekwueme, a clinic asstistant, explains to a mother the function of the shoe and how it is worn.

Three months into the maintenance phase, the child wears the brace for 23 hours every day. After three months, the child continues to wear it but only while sleeping for at least three years.

To encourage parents to bring their children to FMC for treatment, Miraclefeet supports TSCF to take awareness programmes to local communities in Abia State – working with community leaders to educate families about the deformity and availability of free treatment, and collaborating with primary healthcare centres to refer cases to FMC Umuahia.

Tochukwu Ekwueme, a clubfoot clinic assistant at FMC explains what a brace is to a mother.

Through this process, 202 children have had their feet corrected at FMC Umuahia free of charge since July 2018. That is massive, said Mrs Amaraegbulam, who added that until Miraclefeet came in, the number of clubfoot patients she saw since she started working at FMC Umuahia in 2015 were very few.

‘Start small and then grow bigger’

But for Miraclefeet, FMC was just a test ground for something bigger because, since 2019, it has expanded care to five additional hospitals in five states: Nnamdi Azikiwe University Teaching Hospital, Anambra; University of Uyo Teaching Hospital, Akwa Ibom; Irua Specialist Teaching Hospital, Edo; Alex Ekwueme Federal University Teaching Hospital, Ebonyi; and Federal Medical Centre, Kogi.

“When we go into a new country, we start small and then grow bigger year after year,” said Mr Rajerison. “And TSCF had a great team who could help test and refine clubfoot programme strategies that work in Nigeria to hopefully scale to other regions.”

Together, the six centres have treated 583 cases, one of them being one-year-and-four-months-old Winner Chinonso who had clubfoot on both feet.

Before Winner turned five months old, Peculiar, his mother, saw a post on Facebook about the free treatment at FMC. She travelled with him every week from Aba to FMC (about one hour-10-minutes journey by commercial bus) for treatment. Winner is on braces now; his feet look normal, and he walks and plays freely with other children.

“Sometimes, I would just tell myself, if it wasn’t corrected, I wouldn’t have been happy in this my life because I know each time I look at his feet, I would really feel sad,” 29-year-old Peculiar said. “I am just happy that looking at him now, his feet are okay, and he can walk.”

Meanwhile, Miraclefeet plans to add two extra clinics before the end of this year, with a target to scale the programme to a national level with time and help integrate it into the public health system.

“We’re working diligently with our local partner(s) and strategic allies to ensure that we eliminate disability caused by clubfoot in Nigeria,” Emmanuel Otoo, Miraclefeet’s director of programmes, said. But he acknowledges that a multi-group collaboration is required to achieve the target.

“For Nigeria to own a national programme, it’s important for affiliated community-based and public health groups to have some key skills – organisational, advocacy, negotiation, resource mobilisation, human resources,” he said. “It’s crucial that we advocate to ensure the government, through the relevant ministries, takes the responsibility for driving the agenda of quality and timely clubfoot treatment while MiracleFeet provides support,” Mr Otoo said.

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