Improving Human Resources for Health means Retaining Health-Workers: Application of the WHO-Recommendations for the Retention of Health-Workers in Rural Northern-Nigeria.

INTRODUCTION: Nigeria is one of 57 countries with critical shortage of health workers (HWs). Strategies to increase and equitably distribute HWs are critical to the achievement of Health Millennium/Sustainable Development Goals. We describe how three Northern Nigeria states adapted World Health Organisation (WHO)-recommended incentives to attract, recruit, and retain midwives. METHODS: Secondary analysis of data from two surveys assessing midwife motivation, retention, and attrition in Northern Nigeria; and expert consultations. RESULTS: Midwives highlighted financial and non-financial incentives as key factors in their decisions to renew their contracts. Their perspectives informed the consensus positions of health managers, policymakers and heads of institutions, and led to the adaptation of the WHO recommendations into appropriate state-specific incentive packages. CONCLUSIONS: The feedback from midwives combined with an expert consultation approach allowed stakeholders to consider and use available evidence to select appropriate incentive packages that offer the greatest potential for helping to address inadequate numbers of rural midwives.

Female health workers at the doorstep: a pilot of community-based maternal, newborn, and child health service delivery in northern Nigeria.

INTRODUCTION: Nigeria has one of the highest maternal mortality ratios in the world. Poor health outcomes are linked to weak health infrastructure, barriers to service access, and consequent low rates of service utilization. In the northern state of Jigawa, a pilot study was conducted to explore the feasibility of deploying resident female Community Health Extension Workers (CHEWs) to rural areas to provide essential maternal, newborn, and child health services. METHODS: Between February and August 2011, a quasi-experimental design compared service utilization in the pilot community of Kadawawa, which deployed female resident CHEWs to provide health post services, 24/7 emergency access, and home visits, with the control community of Kafin Baka. In addition, we analyzed data from the preceding year in Kadawawa, and also compared service utilization data in Kadawawa from 2008-2010 (before introduction of the pilot) with data from 2011-2013 (during and after the pilot) to gauge sustainability of the model. RESULTS: Following deployment of female CHEWs to Kadawawa in 2011, there was more than a 500% increase in rates of health post visits compared with 2010, from about 1.5 monthly visits per 100 population to about 8 monthly visits per 100. Health post visit rates were between 1.4 and 5.5 times higher in the intervention community than in the control community. Monthly antenatal care coverage in Kadawawa during the pilot period ranged from 11.9% to 21.3%, up from 0.9% to 5.8% in the preceding year. Coverage in Kafin Baka ranged from 0% to 3%. Facility-based deliveries by a skilled birth attendant more than doubled in Kadawawa compared with the preceding year (105 vs. 43 deliveries total, respectively). There was evidence of sustainability of these changes over the 2 subsequent years. CONCLUSION: Community-based service delivery through a resident female community health worker can increase health service utilization in rural, hard-to-reach areas.

Performance based financing and uptake of maternal and child health services in yobe sate, northern Nigeria.

Reported maternal and child health (MCH) outcomes in Nigeria are amongst the worst in the world, with Nigeria second only to India in the number of maternal deaths. At the national level, maternal mortality ratios (MMRs) are estimated at 630 deaths per 100,000 live births (LBs) but vary from as low as 370 deaths per 100,000 LBs in the southern states to over 1,000 deaths per 100,000 LBs in the northern states. We report findings from a performance based financing (PBF) pilot study in Yobe State, northern Nigeria aimed at improving MCH outcomes as part of efforts to find strategies aimed at accelerating attainment of Millennium Development Goals for MCH. Results show that the demand-side PBF led to increased utilization of key MCH services (antenatal care and skilled delivery) but had no significant effect on completion of child immunization using measles as a proxy indicator. We discuss these results within the context of PBF schemes and the need for a careful consideration of all the critical processes and risks associated with demand-side PBF schemes in improving MCH outcomes in the study area and similar settings.

Awareness, use, and unmet need for family planning in rural northern Nigeria.

Access to quality reproductive health and family planning services remain poor in Nigeria. We present results on family planning awareness and use from a survey of 3,080 women (age 15-49 years) in Jigawa, Katsina, Yobe, and Zamfara States. About 43.0% had heard of any method of contraception whereas 36.6% had heard of any modern method. Overall, 7.0% of all currently married women reported ever using a method of contraception; 4.4% used a modern method and 2.9% used a traditional method. Only 1.3% of women in union (currently married or cohabiting) used modern contraception methods at the time of the survey; 1.3% of women in union used traditional methods. Unmet need for family planning was 10.3%. Low family planning use in the presence of low awareness and low felt need suggests, among other things, a need to increase awareness and uptake and make family planning commodities available.

Using community-based research to shape the design and delivery of maternal health services in Northern Nigeria.

Maternal mortality ratios in northern Nigeria are among the worst in the world, over 1,000 per 100,000 live births in 2008, with a very low level and quality of maternity services. In 2009, we carried out a study of the reasons for low utilisation of antenatal and delivery care among women with recent pregnancies, and the socio-cultural beliefs and practices that influenced them. The study included a quantitative survey of 6,882 married women, 119 interviews and 95 focus group discussions with community and local government leaders, traditional birth attendants, women who had attended maternity services and health care providers. Only 26% of the women surveyed had received any antenatal care and only 13% delivered in a facility with a skilled birth attendant for their most recent pregnancy. However, those who had had at least one antenatal consultation were 7.6 times more likely to deliver with a skilled birth attendant. Most pregnant women had little or no contact with the health care system for reasons of custom, lack of perceived need, distance, lack of transport, lack of permission, cost and/or unwillingness to see a male doctor. Based on these findings, we designed and implemented an integrated package of interventions that included upgrading antenatal, delivery and emergency obstetric care; providing training, supervision and support for new midwives in primary health centres and hospitals; and providing information to the community about safe pregnancy and delivery and the use of these services.