Reducing rural maternal mortality and the equity gap in northern Nigeria: the public health evidence for the Community Communication Emergency Referral strategy.

The Sustainable Development Goal (SDG) maternal mortality target risks being underachieved like its Millennium Development Goal (MDG) predecessor. The MDG skilled birth attendant (SBA) strategy proved inadequate to end preventable maternal deaths for the millions of rural women living in resource-constrained settings. This equity gap has been successfully addressed by integrating a community-based emergency obstetric care strategy into the intrapartum care SBA delivery strategy in a large scale, northern Nigerian health systems strengthening project. The Community Communication Emergency Referral (CCER) strategy catalyzes community capacity for timely evacuations to emergency obstetric care facilities instead of promoting SBA deliveries in environments where SBA availability and accessibility will remain inadequate for the near and medium term. Community Communication is an innovative, efficient, equitable, and culturally appropriate community mobilization approach that empowers low- and nonliterate community members to become the communicators. For the CCER strategy, this community mobilization approach was used to establish and maintain emergency maternal care support structures. Public health evidence demonstrates the success of integrating the CCER strategy into the SBA strategy and the practicability of this combined strategy at scale. In intervention sites, the maternal mortality ratio reduced by 16.8% from extremely high levels within 4 years. Significantly, the CCER strategy contributed to saving one-third of the lives saved in the project sites, thereby maximizing the effectiveness of the SBAs and upgraded emergency obstetric care facilities. Pre- and postimplementation Knowledge, Attitude, and Practice Survey results and qualitative assessments support the CCER theory of change. This theory of change rests on a set of implementation steps that rely on three innovative components: Community Communication, Rapid Imitation Practice, and CCER support structures. Innovative communication body tools and the rote learning Rapid Imitation Practice training methodology enabled low-literate volunteers to saturate their communities with informed group discussions transferring communication capacity and ownership to the discussion participants. CCER is especially efficient because virtually every timely, community referral for emergency maternal care results in a saved life, whereas on average, only one in every eight births delivered by an SBA (12%) is expected to be a delivery-associated complication requiring lifesaving care.

Reducing Maternal Mortality by Strengthening Community Maternal Support Systems: Findings from a Qualitative Baseline Study in Northern Nigeria.

The "three delays model" illustrates how issues around obstetric emergency can lead to maternal deaths. This study applied in-depth interviews of key community gatekeepers in 16 rural communities across two states in northern Nigeria to evaluate the presence and functionality of key community maternal support systems for reducing maternal mortality. Findings show that only one out of the 16 communities had all the key support systems. Five rural communities reported that pregnant women have standing permission to visit health facilities during obstetric emergencies. A quarter of the communities reported the presence of transport for maternal emergencies. One rural community each reported the existence of community savings for obstetric emergencies and the presence of blood donor groups. Establishing and/or strengthening community support systems, ensuring citizens are well-informed about maternal danger signs and preparing for safe pregnancies can enable communities overcome the delays and reduce maternal mortality especially in low resource settings.