Understanding rural women's preferences for telephone call engagement with primary health care providers in Nigeria: a discrete choice experiment.

BACKGROUND: The COVID-19 pandemic has accelerated the use of mobile phones to provide primary health care services and maintain continuity of care. This study aims to understand rural women's preferences for telephone call engagement with primary health care providers in Nigeria. METHODS: A discrete choice experiment was conducted alongside an action research project that empowered primary health care workers to develop and implement a telephone call intervention to assess and enhance experiences with facility childbirth care. Between January and March 2022, 30 providers from 10 primary health care facilities implemented the choice experiment among rural women who had institutional childbirth to elicit service user preferences for telephone call engagement. The women were asked to express their preferred scenario for telephone call engagement with their primary health care providers. Generalised linear mixed models were used to estimate women's preferences. RESULTS: Data for 460 women were available for the discrete choice experiment. The study showed that rural women have preferences for telephone call engagement with primary health care providers. Specifically, women preferred engaging with female to male callers (ß=1.665 (95% CI 1.41, 1.93), SE=0.13, p<0.001), preferred call duration under 15 min (ß=1.287 (95% CI 0.61, 1.96), SE=0.34, p<0.001) and preferred being notified before the telephone engagement (warm calling) (ß=1.828 (95% CI 1.10, 2.56), SE=0.37, p<0.001). Phone credit incentive was also a statistically significant predictor of women's preferences for engagement. However, neither the availability of scheduling options, the period of the day or the day of the week predicts women's preferences. CONCLUSIONS: The study highlights the importance of understanding rural women's preferences for telephone call engagement with healthcare providers in low-income and middle-income countries. These findings can inform the development of mobile phone-based interventions and improve acceptability and broader adoption.

Women's perceptions of telephone interviews about their experiences with childbirth care in Nigeria: A qualitative study.

Our objective is to investigate women's perceptions of phone interviews about their experiences with facility childbirth care. The study was conducted between October 2020 and January 2021, in Gombe State, Nigeria. Participants were women aged 15-49 years, who delivered in ten study Primary Health Care centres, provided phone numbers, and consented to a follow-up telephone interview about their childbirth experience. The phone interviews took place 14 months after the delivery and consisted of a quantitative survey about women's experiences of facility childbirth followed by a set of structured qualitative questions about their experiences with the phone survey. Three months later 20 women were selected, based on their demographic characteristics, for a further in-depth qualitative phone interview to explore the answers to the structured qualitative questions in more depth. The qualitative interviews were analysed using a thematic approach. We found that most of the women appreciated being called to discuss their childbirth experiences as it made them feel privileged and valued, they were motivated to participate as they viewed the topic as relevant and thought that their interview could lead to improvements in care. They found the interview procedures easy and perceived that the call offered privacy. Poor network connectivity and not owning the phone they were using presented challenges to some women. Women felt more able to re-arrange interview times on the phone compared to a face-to-face interview, they valued the increased autonomy as they were often busy with household chores and could rearrange to a more convenient time. Views about interviewer gender diverged, but most participants preferred a female interviewer. The preferred interview length was a maximum of 30 minutes, though some women said duration was irrelevant if the subject of discussion was important. In conclusion, women had positive views about phone interviews on experiences with facility childbirth care.

How valid are women's reports of the antenatal health services they receive from Community Health Workers in Gombe State north-eastern Nigeria?

BACKGROUND: Community health workers (CHWs) in low- and middle-income countries are key to increasing coverage of maternal and newborn interventions through home visits to counsel families about healthy behaviours. Household surveys enable tracking the progress of CHW programmes but recent evidence questions the accuracy of maternal reports. We measured the validity of women's responses about the content of care they received during CHW home visits and examined whether the accuracy of women's responses was affected by CHW counselling skills. METHODS: We conducted a criterion validity study in 2019, in Gombe State-Nigeria, and collected data from 362 pregnant women. During accompanied CHW home visits the content of CHW care and the presence or absence of 18 positive counselling skills were observed and documented by a researcher. In a follow-up interview three months later, the same women were asked about the care received during the CHW home visit. Women's reports were compared with observation data and the sensitivity, specificity, and area under receiver curve (AUC) calculated. We performed a covariate validity analysis that adjusted for a counselling skill score to assess the variation in accuracy of women's reports with CHW counselling skills. RESULTS: Ten indicators were included in the validity analysis. Women consistently overestimated the content of care CHWs provided and no indicator met the condition for individual-level accuracy set at AUC ≥ 0.6. The CHW counselling skill score ranged from 9-18 points from a possible 18, with a mean of 14.3; checking on client history or concerns were the most frequently missed item. There was evidence that unmarried women and the relatively most poor women received less skilled counselling than other women (mean counselling scores of 13.2 and 13.7 respectively). There was no consistent evidence of an association between higher counselling skill scores and better accuracy of women's reports. CONCLUSIONS: The validity of women's responses about CHW care content was poor and consistently overestimated coverage. We discuss several challenges in applying criterion validity study methods to examine measures of community-based care and make only cautious interpretation of the findings that may be relevant to other researchers interested in developing similar studies.

Supervised Machine Learning Empowered Multifactorial Genetic Inheritance Disorder Prediction.

Fatal diseases like cancer, dementia, and diabetes are very dangerous. This leads to fear of death if these are not diagnosed at early stages. Computer science uses biomedical studies to diagnose cancer, dementia, and diabetes. With the advancement of machine learning, there are various techniques which are accessible to predict and prognosis these diseases based on different datasets. These datasets varied (image datasets and CSV datasets) around the world. So, there is a need for some machine learning classifiers to predict cancer, dementia, and diabetes in a human. In this paper, we used a multifactorial genetic inheritance disorder dataset to predict cancer, dementia, and diabetes. Several studies used different machine learning classifiers to predict cancer, dementia, and diabetes separately with the help of different types of datasets. So, in this paper, multiclass classification proposed methodology used support vector machine (SVM) and K-nearest neighbor (KNN) machine learning techniques to predict three diseases and compared these techniques based on accuracy. Simulation results have shown that the proposed model of SVM and KNN for prediction of dementia, cancer, and diabetes from multifactorial genetic inheritance disorder achieved 92.8% and 92.5%, 92.8% and 91.2% accuracy during training and testing, respectively. So, it is observed that proposed SVM-based dementia, cancer, and diabetes from multifactorial genetic inheritance disorder prediction (MGIDP) give attractive results as compared with the proposed model of KNN. The application of the proposed model helps to prognosis and prediction of cancer, dementia, and diabetes before time and plays a vital role to minimize the death ratio around the world.

Influence of context on quality improvement priorities: a qualitative study of three facility types in Lagos State, Nigeria.

BACKGROUND: Quality improvement (QI) collaboratives are increasingly popular. However, there is a need for an in-depth understanding of the influence of context on its implementation. We explored the influence of context on the change concepts considered by public primary (primary health centres), public secondary (public hospitals) and private (private facilities) collaboratives established to improve maternal and newborn health outcomes in Lagos State, Nigeria. METHODS: Between February 2019 and January 2020, we conducted a qualitative study using meeting reports, key informant interviews and participant observation. Data were analysed using the high-quality health system framework for assessing health system and user experience that distinguished three quality domains: quality impacts, processes of care and health system foundations. RESULTS: Nineteen change concepts and 158 change ideas were observed across 28 facility QI teams. Change concepts and ideas prioritised were influenced by government and non-governmental leaders but ultimately shaped by facility QI capacity, time allocated for QI activities and availability of local data. Of the three quality domains, process of care, including patient satisfaction, received the most attention across facility types. There was considerable variation in the change concepts considered across domains. For example, more public hospitals focused on complication management because of a relatively high prevalence of and capacity to manage maternal complications; primary health centres focused more on complication referrals, while private facilities prioritised revenue generation. Problems with availability of resources were particularly highlighted in primary health centres which had relatively less financial commitment from stakeholders. CONCLUSION: Our findings provide insights into QI collaboratives' mechanism of change in which external stakeholders, including government, drove QI priorities for action but the ultimate decisions depended on local realities of facilities. Our findings underscore the need for strong QI leadership and sufficient resources to enable facility QI teams to prioritise change concepts for greater health impact.

To call or not to call: exploring the validity of telephone interviews to derive maternal self-reports of experiences with facility childbirth care in northern Nigeria.

BACKGROUND: To institutionalise respectful maternity care, frequent data on the experience of childbirth care is needed by health facility staff and managers. Telephone interviews have been proposed as a low-cost alternative to derive timely and actionable maternal self-reports of experience of care. However, evidence on the validity of telephone interviews for this purpose is limited. METHODS: Eight indicators of positive maternity care experience and 18 indicators of negative maternity care experience were investigated. We compared the responses from exit interviews with women about their childbirth care experience (reference standard) to follow-up telephone interviews with the same women 14 months after childbirth. We calculated individual-level validity metrics including, agreement, sensitivity, specificity, area under the receiver operating characteristic curve (AUC). We compared the characteristics of women included in the telephone follow-up interviews to those from the exit interviews. RESULTS: Demographic characteristics were similar between the original exit interview group (n=388) and those subsequently reached for telephone interview (n=294). Seven of the eight positive maternity care experience indicators had reported prevalence higher than 50% at both exit and telephone interviews. For these indicators, agreement between the exit and the telephone interviews ranged between 50% and 92%; seven positive indicators met the criteria for validation analysis, but all had an AUC below 0.6. Reported prevalence for 15 of the 18 negative maternity care experience indicators was lower than 5% at exit and telephone interviews. For these 15 indicators, agreement between exit and telephone interview was high at over 80%. Just three negative indicators met the criteria for validation analysis, and all had an AUC below 0.6. CONCLUSIONS: The telephone interviews conducted 14 months after childbirth did not yield results that were consistent with exit interviews conducted at the time of facility discharge. Women's reports of experience of childbirth care may be influenced by the location of reporting or changes in the recall of experiences of care over time.

Improving maternal and newborn health services in Northeast Nigeria through a government-led partnership of stakeholders: a quasi-experimental study.

OBJECTIVES: This study aimed to quantify change in the coverage, quality and equity of essential maternal and newborn healthcare interventions in Gombe state, Northeast Nigeria, following a four year, government-led, maternal and newborn health intervention. DESIGN: Quasi-experimental plausibility study. Repeat cross-sectional household and linked health facility surveys were implemented in intervention and comparison areas. SETTING: Gombe state, Northeast Nigeria. PARTICIPANTS: Each household survey included a sample of 1000 women aged 13-49 years with a live birth in the previous 12 months. Health facility surveys comprised a readiness assessment and birth attendant interview. INTERVENTIONS: Between 2016-2019 a complex package of evidence-based interventions was implemented to increase access, use and quality of maternal and newborn healthcare, spanning the six WHO health system building blocks. OUTCOME MEASURES: Eighteen indicators of maternal and newborn healthcare. RESULTS: Between 2016 and 2019, the coverage of all indicators improved in intervention areas, with the exception of postnatal and postpartum contacts, which remained below 15%. Greater improvements were observed in intervention than comparison areas for eight indicators, including coverage of at least one antenatal visit (71% (95% CI 62 to 68) to 88% (95% CI 82 to 93)), at least four antenatal visits (46% (95% CI 39 to 53) to 69% (95% CI 60 to 75)), facility birth (48% (95% CI 37 to 59) to 64% (95% CI 54 to 73)), administration of uterotonics (44% (95% CI 34 to 54) to 59% (95% CI 50 to 67)), delayed newborn bathing (44% (95% CI 36 to 52) to 62% (95% CI 52 to 71)) and clean cord care (42% (95% CI 34 to 49) to 73% (95% CI 66 to 79)). Wide-spread inequities persisted however; only at least one antenatal visit saw pro-poor improvement. CONCLUSIONS: This intervention achieved improvements in life-saving behaviours for mothers and newborns, demonstrating that multipartner action, coordinated through government leadership, can shift the needle in the right direction, even in resource-constrained settings.

From Theory to Implementation: Adaptations to a Quality Improvement Initiative According to Implementation Context.

As countries continue to invest in quality improvement (QI) initiatives in health facilities, it is important to acknowledge the role of context in implementation. We conducted a qualitative study between February 2019 and January 2020 to explore how a QI initiative was adapted to enable implementation in three facility types: primary health centres, public hospitals and private facilities in Lagos State, Nigeria.Despite a common theory of change, implementation of the initiative needed to be adapted to accommodate the local needs, priorities and organisational culture of each facility type. Across facility types, inadequate human and capital resources constrained implementation and necessitated an extension of the initiative's duration. In public facilities, the local governance structure was adapted to facilitate coordination, but similar adaptations to governance were not possible for private facilities. Our findings highlight the importance of anticipating and planning for the local adaptation of QI initiatives according to implementation environment.

Operationalising effective coverage measurement of facility based childbirth in Gombe State; a comparison of data sources.

Estimating effective coverage of childbirth care requires linking population based data sources to health facility data. For effective coverage to gain widespread adoption there is a need to focus on the feasibility of constructing these measures using data typically available to decision makers in low resource settings. We estimated effective coverage of childbirth care in Gombe State, northeast Nigeria, using two different combinations of facility data sources and examined their strengths and limitations for decision makers. Effective coverage captures information on four steps: access, facility inputs, receipt of interventions and process quality. We linked data from the 2018 Nigerian Demographic and Health Survey (NDHS) to two sources of health facility data: (1) comprehensive health facility survey data generated by a research project; and (2) District Health Information Software 2 (DHIS2). For each combination of data sources, we examined which steps were feasible to calculate, the size of the drop in coverage between steps and the resulting estimate of effective coverage. Analysis included 822 women with a recent live birth, 30% of whom attended a facility for childbirth. Effective coverage was low: 2% based on the project data and less than 1% using the DHIS2. Linking project data with NDHS, it was feasible to measure all four steps; using DHIS2 it was possible to estimate three steps: no data was available to measure process quality. The provision of high quality care is suboptimal in this high mortality setting where access and facility readiness to provide care, crucial foundations to the provision of high quality of care, have not yet been met. This study demonstrates that partial effective coverage measures can be constructed from routine data combined with nationally representative surveys. Advocacy to include process of care indicators in facility summary reports could optimise this data source for decision making.

Predictors and Utilization of Health Institution Services for Childbirth among Mothers in a Southern Nigerian City.

BACKGROUND: Poor maternal health indices, including high maternal mortality, are among Nigeria's major public health problems. Most of these deaths can be prevented by timely access and utilization of maternity healthcare services by women. Aim/Objective. This study seeks to identify factors affecting the utilization of health facilities for the delivery of babies among mothers in Calabar, Cross River State, Nigeria. Methodology. The study was a community-based cross-sectional study. A structured questionnaire was administered to 422 women of reproductive age residents in the study area who had given birth at least once within the last five years prior to the survey using a multistage random sampling technique. Data generated were entered, coded, and analyzed using Statistical Packages for Social Sciences (SPSS version 22.0), and results were presented in tables and charts. Chi-squared tests and multiple logistic regression were used for the identification of variables associated with health facility-based delivery. RESULT: The mean age of respondents was 27.3 years (SD = 8.4). Fifty-two percent of the respondents utilized the health facility for delivery, 89.6% attended at least one antenatal clinic (ANC), and 18.9% completed at least 3 ANC sessions. There was a statistically significant association between health facility delivery and marital status (P=0.007), education (P=0.042), and family size (P=0.002). Older women (OR = 0.7, CI = 0.169-3.714), Christians (OR = 1.9, CI = 0.093-41.1), divorcees (OR = 3.7, CI = 0.00-0.00), and respondents who registered early (first trimester) for ANC (OR = 4.9, CI = 0.78-31.48) were found to be higher users of delivery services at the health facility. CONCLUSION: Community health intervention focusing on improving the knowledge and awareness of the significance of utilizing available delivery services at the healthcare facility should be developed and implemented.

Stated job preferences of three health worker cadres in Ethiopia: a discrete choice experiment.

Attracting, training and retaining high-quality health workers are critical for a health system to function well, and it is important to know what health workers value in their roles. Many studies eliciting the labour market preferences of health workers have interviewed doctors or medical students, and there has been little research on the job preferences of lower-skilled cadres such as community health workers, mid-skilled clinical care staff such as nurses and midwives, or non-patient facing staff who manage health facilities. This study estimated the job preferences of public health sector community health extension workers (HEWs), care providers including nurses and midwives, and non-patient-facing administrative and managerial staff in Ethiopia. We used a discrete choice experiment to estimate which aspects of a job are most influential to health worker choices. A multinomial logistic regression model estimated the importance of six attributes to respondents: salary, training, workload, facility quality, management and opportunities to improve patient outcomes. We found that non-financial factors were important to respondents from all three cadres: e.g., supportive management [odds ratio (OR) = 2.96, P-value = 0.001] was the only attribute that influenced the job choices of non-patient-facing administrative and managerial staff. Training opportunities (OR = 3.45, P-value < 0.001), supportive management (OR = 3.26, P-value < 0.001) and good facility quality (OR = 2.42, P-value < 0.001) were valued the most amongst HEWs. Similarly, supportive management (OR = 3.22, P-value < 0.001), good facility quality (OR = 2.69, P-value < 0.001) and training opportunities (OR = 2.67, P-value < 0.001) influenced the job choices of care providers the most. Earning an average salary also influenced the jobs choices of HEWs (OR = 1.43, P-value = 0.02) and care providers (OR = 2.00, P-value < 0.001), which shows that a combination of financial and non-financial incentives should be considered to motivate health workers in Ethiopia.

'A seamless transition': how to sustain a community health worker scheme within the health system of Gombe state, northeast Nigeria.

Health interventions introduced as part of donor-funded projects need careful planning if they are to survive when donor funding ends. In northeast Nigeria, the Gombe State Primary Health Care Development Agency and implementing partners recognized this when introducing a Village Health Worker (VHW) Scheme in 2016. VHWs are a new cadre of community health worker, providing maternal, newborn and child health-related messages, basic healthcare and making referrals to health facilities. This paper presents a qualitative study focussing on the VHW Scheme's sustainability and, hence, contributes to the body of literature on sustaining donor-funded interventions as well as presenting lessons aimed at decision-makers seeking to introduce similar schemes in other Nigerian states and in other low- and middle-income settings. In 2017 and 2018, we conducted 37 semi-structured interviews and 23 focus group discussions with intervention stakeholders and community members. Based on respondents' accounts, six key actions emerged as essential in promoting the VHW Scheme's sustainability: government ownership and transition of responsibilities, adapting the scheme for sustainability, motivating VHWs, institutionalizing the scheme within the health system, managing financial uncertainties and fostering community ownership and acceptance. Our study suggests that for a community health worker intervention to be sustainable, reflection and adaption, government and community ownership and a phased transition of responsibilities are crucial.

Improving the quality of routine maternal and newborn data captured in primary health facilities in Gombe State, Northeastern Nigeria: a before-and-after study.

OBJECTIVES: Primary objective: to assess nine data quality metrics for 14 maternal and newborn health data elements, following implementation of an integrated, district-focused data quality intervention. SECONDARY OBJECTIVE: to consider whether assessing the data quality metrics beyond completeness and accuracy of facility reporting offered new insight into reviewing routine data quality. DESIGN: Before-and-after study design. SETTING: Primary health facilities in Gombe State, Northeastern Nigeria. PARTICIPANTS: Monitoring and evaluation officers and maternal, newborn and child health coordinators for state-level and all 11 local government areas (district-equivalent) overseeing 492 primary care facilities offering maternal and newborn care services. INTERVENTION: Between April 2017 and December 2018, we implemented an integrated data quality intervention which included: introduction of job aids and regular self-assessment of data quality, peer-review and feedback, learning workshops, work planning for improvement, and ongoing support through social media. OUTCOME MEASURES: 9 metrics for the data quality dimensions of completeness and timeliness, internal consistency of reported data, and external consistency. RESULTS: The data quality intervention was associated with improvements in seven of nine data quality metrics assessed including availability and timeliness of reporting, completeness of data elements, accuracy of facility reporting, consistency between related data elements, and frequency of outliers reported. Improvement differed by data element type, with content of care and commodity-related data improving more than contact-related data. Increases in the consistency between related data elements demonstrated improved internal consistency within and across facility documentation. CONCLUSIONS: An integrated district-focused data quality intervention-including regular self-assessment of data quality, peer-review and feedback, learning workshops, work planning for improvement, and ongoing support through social media-can increase the completeness, accuracy and internal consistency of facility-based routine data.

Provision of essential evidence-based interventions during facility-based childbirth: cross-sectional observations of births in northeast Nigeria.

OBJECTIVES: To measure the provision of evidence-based preventive and promotive interventions to women, and subsequently their newborns, during childbirth in a high-mortality setting. DESIGN AND PARTICIPANTS: Cross-sectional observations of care provided to women, and their newborns during the intrapartum and immediate postpartum period using a standardised checklist capturing healthcare worker behaviours regarding lifesaving and respectful care. SETTING: Ten primary healthcare facilities in Gombe state, northeast Nigeria. The northeast region of Nigeria has some of the highest maternal and newborn death rates globally. MAIN OUTCOME MEASURES: Data on 50 measures of internationally recommended evidence-based interventions and good practice. RESULTS: 1875 women were admitted to a health facility during the observation period; of these, 1804 gave birth in the facility and did not experience an adverse event or death. Many clinical interventions around the time of birth were routinely implemented, including provision of uterotonic (96% (95% CI 93% to 98%)), whereas risk-assessment measures, such as history-taking or checking vital signs were rarely completed: just 2% (95% CI 2% to 7%) of women had their temperature taken and 12% (95% CI 9% to 16%) were asked about complications during the pregnancy. CONCLUSIONS: The majority of women did not receive the recommended routine processes of childbirth care they and their newborns needed to benefit from their choice to deliver in a health facility. In particular, few benefited from even basic risk assessments, leading to missed opportunities to identify risks. To continue with the recommendation of childbirth care in primary healthcare facilities in high mortality settings like Gombe, it is crucial that birth attendant capacity, capability and prioritisation processes are addressed.

Assessing capacity of health facilities to provide routine maternal and newborn care in low-income settings: what proportions are ready to provide good-quality care, and what proportions of women receive it?

BACKGROUND: Good quality maternal and newborn care at primary health facilities is essential, but in settings with high maternal and newborn mortality the evidence for the protective effect of facility delivery is inconsistent. We surveyed samples of health facilities in three settings with high maternal mortality to assess their readiness to provide routine maternal and newborn care, and proportions of women using facilities that were ready to offer good quality care. Surveys were conducted in 2012 and 2015 to assess changes over time. METHODS: Surveys were conducted in Ethiopia, the Indian state of Uttar Pradesh and Gombe State in North-Eastern Nigeria. At each facility the staffing, infrastructure and commodities were quantified. These formed components of four "signal functions" that described aspects of routine maternal and newborn care. A facility was considered ready to perform a signal function if all the required components were present. Readiness to perform all four signal functions classed a facility as ready to provide good quality routine care. From facility registers we counted deliveries and calculated the proportions of women delivering in facilities ready to offer good quality routine care. RESULTS: In Ethiopia the proportion of deliveries in facilities classed as ready to offer good quality routine care rose from 40% (95% confidence interval (CI) 26-57) in 2012 to 43% (95% CI 31-56) in 2015. In Uttar Pradesh these estimates were 4% (95% CI 1-24) in 2012 and 39% (95% CI 25-55) in 2015, while in Nigeria they were 25% (95% CI 6-66) in 2012 and zero in 2015. Improved facility readiness in Ethiopia and Uttar Pradesh arose from increased supplies of commodities, while in Nigeria facility readiness fell due to depleted commodity supplies and fewer Skilled Birth Attendants. CONCLUSIONS: This study quantified the readiness of health facilities to offer good quality routine maternal and newborn care, and may help explain inconsistent outcomes of facility care in some settings. Signal function methodology can provide a rapid and inexpensive measure of such facility readiness. Incorporating data on facility deliveries and repeating the analyses highlighted adjustments that could have greatest impact upon routine maternal and newborn care.

Factors influencing the early initiation of breast feeding in public primary healthcare facilities in Northeast Nigeria: a mixed-method study.

INTRODUCTION: The early initiation of breast feeding is a high-impact intervention that gives newborns a better chance of survival. We assess the barriers and facilitators influencing the practice of early breast feeding of newborns in public primary healthcare facilities (PHCs) in Northeast Nigeria, to influence the planning of programmes targeted at improving newborn care in the region. METHOD: We used an explanatory mixed-method approach. We conducted case observation of childbirths and newborn care for the quantitative arm, and interviewed mothers and birth attendants 1 hour after childbirth for the qualitative arm. The analysis for the quantitative arm was done with SPSS V.23. For the qualitative arm, we transcribed the audio files, coded the texts and categorised them using thematic analysis. RESULT: We observed 393 and 27 mothers for the quantitative and qualitative arms of the study, respectively. The quantitative arm shows that 39% of mothers did not breastfeed their newborns within 1 hour of birth. The qualitative arm shows that 37% of mothers did not breastfeed within 1 hour of birth. Themes that describe the barriers to early breast feeding in public PHCs are: birth attendants' unwillingness or inability to accommodate mothers' safe traditional practices, ineffective rooming-in practices, staff shortages, lack of privacy in the lying-in ward and poor implementation of visiting-hour policy in public PHCs. The pregnant women denied safe traditional birth practices like chanting, praying or reading religious books during delivery are five times more likely not to breastfeed newborns within the first hour of birth (relative risk=4.5, 95% CI 1.2-17.1) compared with pregnant women allowed these practices. CONCLUSION: Stakeholders must increase their focus on improving breastfeeding practices in public PHCs. Instituting policies that protect mothers' privacy and finding innovative ways to accommodate and promote safe traditional practices in the intrapartum and postpartum period in PHCs will improve the early breast feeding of newborns in these PHCs.

Toward improving respectful maternity care: a discrete choice experiment with rural women in northeast Nigeria.

Introduction: There is a limited understanding of the importance of respectful maternity care on utilisation of maternal and newborn health services. This study aimed to determine how specific hypothetical facility birth experience of care attributes influenced rural Nigerian women's stated preferences for hypothetical place of delivery. Methods: Attributes were identified through a comprehensive review of the literature. These attributes and their respective levels were further investigated in a qualitative study. We then developed and implemented a cross-sectional discrete choice experiment with a random sample of 426 women who had facility-based childbirth to elicit their stated preferences for facility birth experience of care attributes. Women were asked to choose between two hypothetical health facilities or home birth for future delivery. Choice data were analysed using multinomial logit and mixed multinomial logit models. Results: Complete data for the discrete choice experiment were available for 425 of 426 women. The majority belonged to Fulani ethnic group (60%) and were married (95%). Almost half (45%) had no formal education. Parameter estimates were all of expected signs suggesting internal validity. The most important influence on choice of place of delivery was good health system condition, followed by absence of sexual abuse, then absence of physical and verbal abuse. Poor facility culture, including an unclean birth environment with no privacy and unclear user fee, was associated with the most disutility and had the most negative impact on preferences for facility-based childbirth. Conclusion: The likelihood of poor facility birth experiences had a significant impact on stated preferences for place of delivery among rural women in northeast Nigeria. The study findings further underline the important relationship between facility birth experience and utilisation. Achieving universal health coverage would require efforts toward addressing poor facility birth experiences and promoting respectful maternity care, to ensure women want to access the services available.

Understanding mistreatment during institutional delivery in Northeast Nigeria: a mixed-method study.

BACKGROUND: Improving quality of care including the clinical aspects and the experience of care has been advocated for improved coverage and better childbirth outcomes. OBJECTIVE: This study aimed to explore the quality of care relating to the prevalence and manifestations of mistreatment during institutional birth in Gombe State, northeast Nigeria, an area of low institutional delivery coverage. METHODS: The frequency of dimensions of mistreatment experienced by women delivering in 10 health facilities of Gombe State were quantitatively captured during exit interviews with 342 women in July-August 2017. Manifestations of mistreatment were qualitatively explored through in-depth interviews and focus groups with 63 women living in communities with high and low coverage of institutional deliveries. RESULTS: The quantitative data showed that at least one dimension of mistreatment was reported by 66% (95% confidence interval (CI) 45-82%) of women exiting a health facility after delivery. Mistreatment related to health system conditions and constraints were reported in 50% (95% CI 31-70%) of deliveries. In the qualitative data women expressed frustration at being urged to deliver at the health facility only to be physically or verbally mistreated, blamed for poor birth outcomes, discriminated against because of their background, left to deliver without assistance or with inadequate support, travelling long distances to the facility only to find staff unavailable, or being charged unjustified amount of money for delivery. CONCLUSIONS: Mistreatment during institutional delivery in Gombe State is highly prevalent and predominantly relates to mistreatment arising from both health system constraints as well as health worker behaviours, limiting efforts to increase coverage of institutional delivery. To address mistreatment during institutional births, strategies that emphasise a broader health systems approach, tackle multiple causes, integrate a detailed understanding of the local context and have buy-in from grassroots-level stakeholders are recommended.

Coverage and equity of maternal and newborn health care in rural Nigeria, Ethiopia and India.

BACKGROUND: Despite progress toward meeting the Sustainable Development Goals, a large burden of maternal and neonatal mortality persists for the most vulnerable people in rural areas. We assessed coverage, coverage change and inequity for 8 maternal and newborn health care indicators in parts of rural Nigeria, Ethiopia and India. METHODS: We examined coverage changes and inequity in 2012 and 2015 in 3 high-burden populations where multiple actors were attempting to improve outcomes. We conducted cluster-based household surveys using a structured questionnaire to collect 8 priority indicators, disaggregated by relative household socioeconomic status. Where there was evidence of a change in coverage between 2012 and 2015, we used binomial regression models to assess whether the change reduced inequity. RESULTS: In 2015, we interviewed women with a birth in the previous 12 months in Gombe, Nigeria (n = 1100 women), Ethiopia (n = 404) and Uttar Pradesh, India (n = 584). Among the 8 indicators, 2 positive coverage changes were observed in each of Gombe and Uttar Pradesh, and 5 in Ethiopia. Coverage improvements occurred equally for all socioeconomic groups, with little improvement in inequity. For example, in Ethiopia, coverage of facility delivery almost tripled, increasing from 15% (95% confidence interval [CI] 9%-25%) to 43% (95% CI 33%-54%). This change was similar across socioeconomic groups (p = 0.2). By 2015, the poorest women had about the same facility delivery coverage as the least poor women had had in 2012 (32% and 36%, respectively), but coverage for the least poor had increased to 60%. INTERPRETATION: Although coverage increased equitably because of various community-based interventions, underlying inequities persisted. Action is needed to address the needs of the most vulnerable women, particularly those living in the most rural areas.

Characterising innovations in maternal and newborn health based on a common theory of change: lessons from developing and applying a characterisation framework in Nigeria, Ethiopia and India.

Government leadership is key to enhancing maternal and newborn survival. In low/middle-income countries, donor support is extensive and multiple actors add complexity. For policymakers and others interested in harmonising diverse maternal and newborn health efforts, a coherent description of project components and their intended outcomes, based on a common theory of change, can be a valuable tool. We outline an approach to developing such a tool to describe the work and the intended effect of a portfolio of nine large-scale maternal and newborn health projects in north-east Nigeria, Ethiopia and Uttar Pradesh in India. Teams from these projects developed a framework, the 'characterisation framework', based on a common theory of change. They used this framework to describe their innovations and their intended outcomes. Individual project characterisations were then collated in each geography, to identify what innovations were implemented where, when and at what scale, as well as the expected health benefit of the joint efforts of all projects. Our study had some limitations. It would have been enhanced by a more detailed description and analysis of context and, by framing our work in terms of discrete innovations, we may have missed some synergistic aspects of the combination of those innovations. Our approach can be valuable for building a programme according to a commonly agreed theory of change, as well as for researchers examining the effectiveness of the combined work of a range of actors. The exercise enables policymakers and funders, both within and between countries, to enhance coordination of efforts and to inform decision-making about what to fund, when and where.