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.

Reinvigorating health systems and community-based services to improve maternal health outcomes: case study from northern Nigeria.

BACKGROUND: Maternal health outcomes in Nigeria, the most populous African nation, are among the worst in the world, and urgent efforts to improve the situation are critical as the deadline (2015) for achieving the Millennium Development Goals draws near. OBJECTIVE: To evaluate the results of an integrated maternal, newborn, and child health (MNCH) program to improve maternal health outcomes in Northern Nigeria. DESIGN: The intervention model integrated critical health system and community-based improvements aimed at encouraging sustainable MNCH behavior change. Control Local Government Areas received less intense statewide policy changes. METHODS: We assessed the impact of the intervention on maternal health outcomes in 3 northern Nigerian states by comparing data from 2360 women in 2009 and 4628 women in 2013 who had a birth or pregnancy in the 5 years prior to the survey. RESULTS: From 2009 to 2013, women with standing permission from their husband to go to the health center doubled (from 40.2% to 82.7%), and health care utilization increased. The proportions of women who delivered with a skilled birth attendant increased from 11.2% to 23.9%, and the proportion of women having at least 1 antenatal care (ANC) visit doubled from 24.9% to 48.8%. ANC was increasingly provided by trained community health extension workers at the primary health center, who provided ANC to 34% of all women with recent pregnancies in 2013. In 2013, 22% of women knew at least 4 maternal danger signs compared with 10% in 2009. Improvements were significantly greater in the intervention communities that received the additional demand-side interventions. CONCLUSIONS: The improvements between 2009 and 2013 demonstrate the measurable impact on maternal health outcomes of the program through local communities and primary health care services. The significant improvements in communities with the complete intervention show the importance of an integrated approach blending supply- and demand-side interventions.

Comparison of high- versus low-intensity community health worker intervention to promote newborn and child health in Northern Nigeria.

BACKGROUND: In Northern Nigeria, infant mortality rates are two to three times higher than in the southern states, and, in 2008, a partnership program to improve maternal, newborn, and child health was established to reduce infant and child mortality in three Northern Nigeria states. The program intervention zones received government-supported health services plus integrated interventions at primary health care posts and development of community-based service delivery (CBSD) with a network of community volunteers and community health workers (CHWs), who focus on educating women about danger signs for themselves and their infants and promoting appropriate responses to the observation of those danger signs, consistent with the approach of the World Health Organization Integrated Management of Neonatal and Childhood Illness strategy. Before going to scale in the rest of the state, it is important to identify the relative effectiveness of the low-intensity volunteer approach versus the more intensive CBSD approach with CHWs. METHODS: We conducted stratified cluster sample household surveys at baseline (2009) and follow-up (2011) to assess changes in newborn and sick child care practices among women with births in the five prior years (baseline: n = 6,906; follow-up: n = 2,310). The follow-up respondents were grouped by level of intensity of the CHW interventions in their community, with "low" including group activities led only by a trained community volunteer and "high" including the community volunteer activities plus CBSD from a CHW providing one-on-one advice and assistance. t-tests were used to test for significant differences from baseline to follow-up, and F-statistics, which adjust for the stratified cluster design, were used to test for significant differences between the control, low-intensity, and high-intensity intervention groups at follow-up. These analyses focused on changes in newborn and sick child care practices. RESULTS: Anti-tetanus vaccination coverage during pregnancy increased from 69.2% at baseline to 85.7% at follow-up in the intervention areas. Breastfeeding within 24 hours increased from 42.9% to 59.0% in the intervention areas, and more newborns were checked by health workers within 48 hours (from 16.8% at baseline to 26.8% at follow-up in the intervention areas). Newborns were more likely to be checked by trained health personnel, and they received more comprehensive newborn care. Compared to the control communities, more than twice as many women in intervention communities knew to watch for specific newborn danger signs. Compared to the control and low-intensity intervention communities, more mothers in the high-intensity communities learned about the care of sick children from CHWs, with a corresponding decline those seeking advice from family or friends or traditional birth attendants. Significantly fewer mothers did nothing when their child was sick. High-intensity intervention communities experienced the most decline. Those who did nothing for children with fever or cough declined from 35% to 30%, and with diarrhea from 40% to 31%. Use of medications, both traditional and modern, increased from baseline to follow-up, with no differentiation in use by intervention area. CONCLUSION: The community-based approach to promoting improved newborn and sick child care through community volunteers and CHWs resulted in improved newborn and sick child care. The low-intensity approach with community volunteers appears to have been as effective as the higher-intensity CBSD approach with CHWs for several of the key newborn and sick child care indicators, particularly in the provision of appropriate home care for children with fever or cough.

Awareness of critical danger signs of pregnancy and delivery, preparations for delivery, and utilization of skilled birth attendants in Nigeria.

Maternal mortality in northern Nigeria is among the highest in the world. To understand better the pathways through which the socio-demographic environment affects awareness of obstetric danger signs (i.e., potential problems associated with pregnancy), preparations for delivery, and skilled birth attendance, we conducted a survey of 5,083 women with recent pregnancies in three northern Nigerian states. Only 25% attended antenatal care (ANC), and 91% of all births took place at home. Less than one-third knew three or more danger signs of pregnancy or labor and delivery. Higher socioeconomic status was associated with knowledge of danger signs, but not with knowledge of life-threatening, critical danger signs. Antenatal care visits did not increase knowledge of critical danger signs, but they were associated with skilled birth attendance. Knowledge of critical pregnancy danger signs also was associated with skilled birth attendance. Improving the quality and coverage of ANC will ensure greater awareness of the critical danger signs. Future research is needed to identify creative and innovative ways to strengthen strategies for educating pregnant women about danger signs and in facilitating uptake of delivery services.

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.

Maternal mortality in northern Nigeria: findings of a health and demographic surveillance system in Zamfara State, Nigeria.

The aim of this study was to estimate: (1) the lifetime risk (LTR) of maternal death; and (2) the maternal mortality ratio (MMR) in the Zamfara State of northern Nigeria. Data from the Nahuche Health and Demographic Surveillance System were utilized using the 'sisterhood method' for estimating maternal mortality. Female respondents (15-49 years) from six districts in the surveillance area were interviewed, creating a retrospective cohort of their sisters who had reached the reproductive age of 15 years. Based on population and fertility estimates, we calculated the LTR of maternal death and the MMR. A total of 17,087 respondents reported 38,761 maternal sisters of whom 3592 had died and of whom 1261 were maternal-related deaths. This corresponded to an LTR of maternal death of 8% (referring to a period of about 10.5 years prior to the survey) and an MMR of 1049 deaths per 100,000 live births (95% confidence interval, 1021-1136). The study provides documented evidence of high maternal mortality in the study area and the state as a whole. Thus, there is a need to improve the health system with an emphasis on interventions that will accelerate reduction in MMR such as the availability of skilled birth attendants and emergency obstetric care, promotion of facility delivery and antenatal care attendance. This can be achieved through a holistic approach and is critical in order to accelerate progress in meeting the Millennium Development Goal of maternal mortality reduction.