Godwin Y. Afenyadu

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.

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 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.

Estimating Maternal Mortality Level in Rural Northern Nigeria by the Sisterhood Method

Maternal mortality is one of the major challenges to health systems in sub Saharan Africa. This paper estimates the lifetime risk of maternal death and maternal mortality ratio (MMR) in four states of Northern Nigeria. Data from a household survey conducted in 2011 were utilized by applying the “sisterhood method” for estimating maternal mortality. Female respondents (15–49 years) were interviewed thereby creating a retrospective cohort of their sisters who reached the reproductive age of 15 years. A total of 3,080 respondents reported 7,731 maternal sisters of which 593 were reported dead and 298 of those dead were maternal-related deaths. This corresponded to a lifetime risk of maternal death of 9% (referring to a period about 10.5 years prior to the survey) and an MMR of 1,271 maternal deaths per 100,000 live births; 95% CI was 1,152–1,445 maternal deaths per 100,000 live births. The study calls for improvement of the health system focusing on strategies that will accelerate reduction in MMR such as availability of skilled birth attendants, access to emergency obstetrics care, promotion of facility delivery, availability of antenatal care, and family planning. An accelerated reduction in MMR in the region will contribute towards the attainment of the Millennium Development Goal of maternal mortality reduction in Nigeria.

Early results of an integrated maternal, newborn, and child health program, Northern Nigeria, 2009 to 2011

BackgroundThis paper describes early results of an integrated maternal, newborn, and child health (MNCH) program in Northern Nigeria where child mortality rates are two to three times higher than in the southern states. The intervention model integrated critical health systems changes needed to reinvigorate MNCH health services, together with community-based activities aimed at mobilizing and enabling women to make changes in their MNCH practices. Control Local Government Areas received less-intense statewide policy changes.MethodsThe impact of the intervention was assessed using a quasi-experimental design, comparing MNCH behaviors and outcomes in the intervention and control areas, before and after implementation of the systems and community activities. Stratified random household surveys were conducted at baseline in 2009 (n = 2,129) and in 2011 at follow-up (n = 2310), with women with births in the five years prior to household surveys. Chi-square and t-tests were used to document presence of significant improvements in several MNCH outcomes.ResultsBetween baseline and follow-up, anti-tetanus vaccination rates increased from 69.0% to 85.0%, and early breastfeeding also increased, from 42.9% to 57.5%. More newborns were checked by trained health workers (39.2% to 75.5%), and women were performing more of the critical newborn care activities at follow-up. Fewer women relied on the traditional birth attendant for health advice (48.4% to 11.0%, with corresponding increases in advice from trained health workers. At follow-up, most of these improvements were greater in the intervention than control communities. In the intervention communities, there was less use of anti-malarials for all symptoms, coupled with more use of other medications and traditional, herbal remedies. Infant and child mortality declined in both intervention and control communities, with the greatest declines in intervention communities. In the intervention communities, infant mortality rate declined from 90 at baseline to 59 at follow-up, while child mortality declined from 160 to 84.ConclusionsThese results provide evidence that in the context of ongoing improvements to the primary health care system, the participatory and community-based interventions focusing on improved newborn and infant care were effective at changing infant care practices and outcomes in the intervention communities.

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.

Female Health Workers at the Doorstep: A Pilot of Community-Based Maternal, Newborn, and Child Health Service Delivery in Northern Nigeria

Deployment of resident female Community Health Extension Workers (CHEWs) to a remote rural community led to major and sustained increases in service utilization, including antenatal care and facility-based deliveries. Key components to success: (1) providing an additional rural residence allowance to help recruit and retain CHEWs; (2) posting the female CHEWs in pairs to avoid isolation and provide mutual support; (3) ensuring supplies and transportation means for home visits; and (4) allowing CHEWs to perform deliveries. Deployment of resident female Community Health Extension Workers (CHEWs) to a remote rural community led to major and sustained increases in service utilization, including antenatal care and facility-based deliveries. Key components to success: (1) providing an additional rural residence allowance to help recruit and retain CHEWs; (2) posting the female CHEWs in pairs to avoid isolation and provide mutual support; (3) ensuring supplies and transportation means for home visits; and (4) allowing CHEWs to perform deliveries. ABSTRACT 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.

Mobile clinic services to serve rural populations in Katsina State, Nigeria: perceptions of services and patterns of utilization

INTRODUCTION Topographical, cultural, socio-economic and developmental factors combine to create significant barriers to health services delivery in areas of Northern Nigeria, resulting in poor health outcomes in states such as Katsina. The Katsina State Ministry of Health has introduced a mobile clinic service to provide primary health care to particularly inaccessible communities. This study reports early evidence of beneficiary and provider perceptions of the service, and indicators of initial coverage. METHODS Key informant interviews were held with community leaders and service providers from communities receiving mobile clinic services from across six local government areas (LGAs), selected to represent diversity of conditions across the state. Exit interviews were conducted with 455 service users across three sites. Data on utilization were collated from routine service records and from a survey of a representative sample of households across the six LGAs. RESULTS Beneficiaries reported high levels of satisfaction with respect to most aspects of the mobile clinic service. However, there was significant variation in ratings of service quality. Concerns for beneficiaries included the lack of privacy provided, waiting times and lack of guidance on follow-up care. Providers of the service reported high levels of satisfaction with the work, highlighting the reach of services and the teamwork involved. Antenatal care (ANC) coverage of 30% of pregnant women-well above the average for the northern states-was achieved in one LGA, though much lower rates were secured elsewhere. DISCUSSION Data indicate that while services are generally well-received there are clear opportunities for strengthening quality of service provision. Improved service supervision and monitoring-potentially linked to performance-based financing mechanisms-promise to raise general quality of care to that demonstrated as attainable in the best performing LGAs. Provider reports suggesting high levels of motivation are notable in a general healthcare work environment with high rates of absenteeism.

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.

Lessons learned from setting up the Nahuche Health and Demographic Surveillance System in the resource-constrained context of northern Nigeria

Background The present time reflects a period of intense effort to get the most out of public health interventions, with an emphasis on health systems reform and implementation research. Population health approaches to determine which combinations are better at achieving the goals of improved health and well-being are needed to provide a ready response to the need for timely and real-world piloting of promising interventions. Objective This paper describes the steps needed to establish a population health surveillance site in order to share the lessons learned from our experience launching the Nahuche Health and Demographic Surveillance System (HDSS) in a relatively isolated, rural district in Zamfara, northern Nigeria, where strict Muslim observance of gender separation and seclusion of women must be respected by any survey operation. Discussion Key to the successful launch of the Nahuche HDSS was the leaderships determination, stakeholder participation, support from state and local government areas authorities, technical support from the INDEPTH Network, and international academic partners. Solid funding from our partner health systems development programme during the launch period was also essential, and provided a base from which to secure long-term sustainable funding. Perhaps the most difficult challenges were the adaptations needed in order to conduct the requisite routine population surveillance in the communities, where strict Muslim observance of gender separation and seclusion of women, especially young women, required recruitment of female interviewers, which was in turn difficult due to low female literacy levels. Local community leaders were key in overcoming the populations apprehension of the fieldwork and modern medicine, in general. Continuous engagement and sensitisation of all stakeholders was a critical step in ensuring sustainability. While the experiences of setting up a new HDSS site may vary globally, the experiences in northern Nigeria offer some strategies that may be replicated in other settings with similar challenges.Background The present time reflects a period of intense effort to get the most out of public health interventions, with an emphasis on health systems reform and implementation research. Population health approaches to determine which combinations are better at achieving the goals of improved health and well-being are needed to provide a ready response to the need for timely and real-world piloting of promising interventions. Objective This paper describes the steps needed to establish a population health surveillance site in order to share the lessons learned from our experience launching the Nahuche Health and Demographic Surveillance System (HDSS) in a relatively isolated, rural district in Zamfara, northern Nigeria, where strict Muslim observance of gender separation and seclusion of women must be respected by any survey operation. Discussion Key to the successful launch of the Nahuche HDSS was the leaderships determination, stakeholder participation, support from state and local government areas authorities, technical support from the INDEPTH Network, and international academic partners. Solid funding from our partner health systems development programme during the launch period was also essential, and provided a base from which to secure long-term sustainable funding. Perhaps the most difficult challenges were the adaptations needed in order to conduct the requisite routine population surveillance in the communities, where strict Muslim observance of gender separation and seclusion of women, especially young women, required recruitment of female interviewers, which was in turn difficult due to low female literacy levels. Local community leaders were key in overcoming the populations apprehension of the fieldwork and modern medicine, in general. Continuous engagement and sensitisation of all stakeholders was a critical step in ensuring sustainability. While the experiences of setting up a new HDSS site may vary globally, the experiences in northern Nigeria offer some strategies that may be replicated in other settings with similar challenges.