Advancing Survival in Nigeria: A Pre-post Evaluation of an Integrated Maternal and Neonatal Health Program

Regional trends, spatial patterns and determinants of health facility delivery among women of reproductive age in Nigeria: A national population based cross-sectional study

BACKGROUND

Globally, about 810 women die daily from pregnancy and childbirth complications, and the burden is highest in Africa. The United Nations sustainable development goal has a maternal mortality ratio (MMR) target of 70 per 100,000 live births by 2030. Nigeria, the largest country in Africa, has an MMR of 512 per 100,000 live births, thus there is need for intensified efforts to reduce maternal deaths in the country. Proper utilisation of maternal health services including health facilities for delivery is crucial to achieving this. This study assesses the regional trends, spatial patterns and determinants of health facility delivery among women of reproductive age in Nigeria.

METHODS

This is a weighted secondary analysis of the Nigerian Demographic and Health Survey (NDHS). The sample included women who had a live birth in the preceding 5 years of the NDHS 2008, 2013 and 2018. Bivariate analysis and multilevel logistic regression were carried out to assess the determinants of health facility delivery. Trends analysis was done using bar graphs and spatial analysis showed the distribution of health facility delivery by State.

RESULTS

Forty-one percent of women delivered their last child in a health facility. The proportion of women who delivered at a health facility increased from 2008 to 2018 for all regions, with exception of the South-south region. Determinants of facility-based delivery include; ethnicity, level of education, wealth index, exposure to mass media (AOR 1.34; 95% CI 1.20-1.50), number of childbirths, number of antenatal visits (AOR 4.03; 95% CI 3.51-4.62), getting a companion to go the health facility (AOR 0.84; 95% CI 0.72-0.98), community level poverty, community level of female education, community distance to health facility, and geographical region.

CONCLUSION

There is an urgent need to deploy appropriate strategies and programme to improve health facility delivery in Nigeria.

Effects of community-based interventions for stillbirths in sub-Saharan Africa: a systematic review and meta-analysis

Background

Sub-Saharan Africa (SSA) alone contributed to 42% of global stillbirths in 2019, and the rate of stillbirth reduction has remained slow. There has been an increased uptake of community-based interventions to combat stillbirth in the region, but the effects of these interventions have been poorly assessed. Our objectives were to examine the effect of community-based interventions on stillbirth in SSA.

Methods

In this systematic review and meta-analysis, we searched eight databases (MEDLINE [OvidSP], Embase [OvidSP], Cochrane Central Register of Controlled Trials, Global Health, Science Citation Index and Social Science Citation index [Web of Science Core Collection], CINAHL [EBSCOhost] and Global Index Medicus) and four grey literature sources from January 1, 2000 to July 7, 2023 for relevant studies from SSA. Community-based interventions targeting stillbirths solely or as part of complex interventions, with or without hospital interventions were included, while hospital-only interventions, microcredit schemes and maternity waiting home interventions were excluded. Study quality was assessed using the Cochrane risk of bias and National Heart, Lung and Blood Institute's tools. The study outcome was odds of stillbirth in intervention versus control communities. Pooled odds ratios (ORs) were estimated using random-effects models, and subgroup analyses were performed by intervention type and strategies. Publication bias was evaluated by funnel plot and Egger's test. This study is registered with PROSPERO, CRD42021296623.

Findings

Of the 4223 records identified, seventeen studies from fifteen SSA countries were eligible for inclusion. One study had four arms (community only, hospital only, community and hospital, and control arms), so information was extracted from each arm. Analysis of 13 of the 17 studies which had community-only intervention showed that the odds of stillbirth did not vary significantly between community-based intervention and control groups (OR 0.96; 95% CI 0.78-1.17, I2 = 57%, p ≤ 0.01, n = 63,884). However, analysis of four (out of five) studies that included both community and health facility components found that in comparison with community only interventions, this combination strategy significantly reduced the odds of stillbirth by 17% (OR 0.83; 95% CI 0.79-0.87, I2 = 11%, p = 0.37, n = 244,868), after excluding a study with high risk of bias. The quality of the 17 studies were graded as poor (n = 2), fair (n = 9) and good (n = 6).

Interpretation

Community-based interventions alone, without strengthening the quality and capacity of health facilities, are unlikely to have a substantial effect on reducing stillbirths in SSA.

Funding

Nuffield Department of Population Health, Balliol College, the Clarendon Fund, Medical Research Council.

Types, reporting and acceptability of community-based interventions for stillbirth prevention in sub-Saharan Africa (SSA): a systematic review

Background

Community-based interventions are increasingly being implemented in Sub-Saharan Africa (SSA) for stillbirth prevention, but the nature of these interventions, their reporting and acceptability are poorly assessed. In addition to understanding their effectiveness, complete reporting of the methods, results and intervention acceptability is essential as it could potentially reduce research waste from replication of inadequately implemented and unacceptable interventions. We conducted a systematic review to investigate these aspects of community-based interventions for preventing stillbirths in SSA.

Methods

In this systematic review, eight databases (MEDLINE(OvidSP), Embase (OvidSP), Cochrane Central Register of Controlled Trials, Global Health, Science Citation Index and Social Science Citation index (Web of Science Core Collection), CINAHL (EBSCOhost) and Global Index Medicus) and four grey literature sources were searched from January 1, 2000 to July 7, 2023 for relevant quantitative and qualitative studies from SSA (PROSPERO-CRD42021296623). Following deduplication, abstract screening and full-text review, studies were included if the interventions were community-based with or without a health facility component. The main outcomes were types of community-based interventions, completeness of intervention reporting using the TIDier (Template for Intervention Description and replication) checklist, and themes related to intervention acceptability identified using a theoretical framework. Study quality was assessed using the Cochrane risk of bias and National Heart, Lung and Blood Institute's tools.

Findings

Thirty-nine reports from thirty-four studies conducted in 18 SSA countries were eligible for inclusion. Four types of interventions were identified: nutritional, infection prevention, access to skilled childbirth attendants and health knowledge/behaviour of women. These interventions were implemented using nine strategies: mHealth (defined as the use of mobile and wireless technologies to support the achievement of health objectives), women's groups, community midwifery, home visits, mass media sensitisation, traditional birth attendant and community volunteer training, community mobilisation and transport vouchers. The completeness of reporting using the TIDier checklist varied across studies with a very low proportion of the included studies reporting the intervention intensity, dosing, tailoring and modification. The quality of the included studies were graded as poor (n = 6), fair (n = 14) and good (n = 18). Though interventions were acceptable, only 4 (out of 7) studies explored women's perceptions, mostly focusing on perceived intervention effects and how they felt, omitting key constructs like ethicality, opportunity cost and burden of participation.

Interpretation

Different community-based interventions have been tried and evaluated for stillbirth prevention in SSA. The reproducibility and implementation scale-up of these interventions may be limited by incomplete intervention descriptions in the published literature. To strengthen impact, it is crucial to holistically explore the acceptability of these interventions among women and their families.

Funding

Clarendon/Balliol/NDPH DPhil scholarship for UGA. MN is funded by a Medical Research Council Transition Support Award (MR/W029294/1).

Scoping review of maternal and newborn health interventions and programmes in Nigeria

OBJECTIVE

To systematically scope and map research regarding interventions, programmes or strategies to improve maternal and newborn health (MNH) in Nigeria.

DESIGN

Scoping review.

DATA SOURCES AND ELIGIBILITY CRITERIA

Systematic searches were conducted from 1 June to 22 July 2020 in PubMed, Embase, Scopus, together with a search of the grey literature. Publications presenting interventions and programmes to improve maternal or newborn health or both in Nigeria were included.

DATA EXTRACTION AND ANALYSIS

The data extracted included source and year of publication, geographical setting, study design, target population(s), type of intervention/programme, reported outcomes and any reported facilitators or barriers. Data analysis involved descriptive numerical summaries and qualitative content analysis. We summarised the evidence using a framework combining WHO recommendations for MNH, the continuum of care and the social determinants of health frameworks to identify gaps where further research and action may be needed.

RESULTS

A total of 80 publications were included in this review. Most interventions (71%) were aligned with WHO recommendations, and half (n=40) targeted the pregnancy and childbirth stages of the continuum of care. Most of the programmes (n=74) examined the intermediate social determinants of maternal health related to health system factors within health facilities, with only a few interventions aimed at structural social determinants. An integrated approach to implementation and funding constraints were among factors reported as facilitators and barriers, respectively.

CONCLUSION

Using an integrated framework, we found most MNH interventions in Nigeria were aligned with the WHO recommendations and focused on the intermediate social determinants of health within health facilities. We determined a paucity of research on interventions targeting the structural social determinants and community-based approaches, and limited attention to pre-pregnancy interventions. To accelerate progress towards the sustainable development goal MNH targets, greater focus on implementing interventions and measuring context-specific challenges beyond the health facility is required.

Reducing maternal and neonatal mortality through integrated and sustainability-focused programming in Zambia

Reducing maternal and neonatal mortality is a critical health priority within Zambia and globally. Although evidence-based clinical interventions can prevent a majority of these deaths, scalable and sustainable delivery of interventions across low-resource settings remains uneven, particularly across rural and marginalized communities. The Zambian Ministry of Health and the Clinton Health Access Initiative implemented an integrated sexual, reproductive, maternal, and newborn health (SRMNH) program in Northern Province aimed at dramatically reducing mortality over four years. Interventions were implemented between 2018 and 2021 across 141 government-owned health facilities covering all 12 districts of Northern Province, the poorest performing province nationwide and home to over 1.4 million people, around six pillars of an integrated health system. Data on institutional delivery and antenatal and postnatal care were collected through the national Health Management Information System (HMIS). A community-based system for capturing birth outcomes was established using existing government tools and community volunteers since HMIS did not include community-based mortality. Baseline and endline population-based mortality rates were compared for program-supported areas. From the earliest period of population-based mortality reporting in 2019 to program end in 2021, there were statistically significant decreases of 41%, 45%, and 43% in maternal, neonatal, and perinatal mortality rates respectively. Between 2017 to 2021, institutional maternal, neonatal, and perinatal mortality rates across entirety of Northern Province reduced by 12%, 40%, and 41%, respectively. Service readiness and coverage for SRMNH services improved dramatically, supporting increased numbers of patients. Significant mortality reductions were achieved over a relatively short period, reinforced through an emphasis on sustainability and strengthening existing government systems. These results were attained through a consciously cost-efficient approach backed by substantially lower levels of external investment relative to prior programs, allowing many of the interventions to be successfully adopted by government within public sector budgets.

A descriptive study of healthcare-providers' experiences with the use and quality of oxytocin for the prevention of post-partum hemorrhage in Nigeria: A nation-wide survey

Background

Oxytocin is recommended as an affordable and effective drug in the prevention of postpartum hemorrhage—one of the leading causes of maternal morbidity and mortality in low- and middle-income countries, however, there are concerns about its proper use and quality. This study builds on earlier work conducted in a South-Western state in Nigeria.

Objective

The study assessed the knowledge around oxytocin, usage, storage practices and perceived quality of oxytocin used by healthcare providers that directly administer oxytocin for the prevention of postpartum hemorrhage across Nigeria.

Methods

This was a descriptive cross-sectional study that surveyed a representative sample of 6,299 healthcare providers who offer obstetrics and gynecological services and recruited from 1,894 healthcare facilities in Public and Private sectors in 12 states across Nigeria. Data were collected using an electronic questionnaire, analyzed using SPSS, and presented in frequencies and percentages.

Results

Only forty-six percent of respondents (52.8% in private; 40.0% in public sector) had proper knowledge that oxytocin storage is in the refrigerator. Proper knowledge also varied by professional cadre, doctors (71.2%); nurses (46.6%); Community Health Workers (28.4%) and by years of experience, less than 10 years (51.4%); more than 10 years (40.8%). Only 34% of the respondents (41% in private and 27.5% in public sector) reported good practices that oxytocin is stored in the refrigerator in their facilities. Most healthcare providers used oxytocin for prevention of PPH (77.9%). Oxytocin was also used for augmentation (66.7%) and induction of labor (52.6%). Half of respondents used above the WHO-recommended oxytocin dose of 10IU for prevention of PPH. Twenty-three percent of respondents reported experiencing oxytocin failure in PPH prevention of whom, 54.3% changed to another uterotonic and 37.1% doubled the dose of oxytocin for their patients.

Conclusion

Our study findings should be used to establish clinical guidelines and trainings for healthcare providers to improve their knowledge and storage practices and use to safeguard the quality of these lifesaving medicines.

Applying the RE-AIM framework in a process evaluation of the introduction of the Non-Pneumatic Anti-Shock Garment in a rural district of Zimbabwe

The Non-Pneumatic Anti-Shock Garment (NASG) is a first aid tool that can halt and reverse hypovolemic shock secondary to obstetric hemorrhage. The World Health Organization recommended the NASG for use as a temporizing measure in 2012, but uptake of the recommendation has been slow, partially because operational experience is limited. The study is a process evaluation of the introduction of NASG in a public sector health facility network in rural Zimbabwe utilizing an adapted RE-AIM, categorizing observations into the domains of: reach, effectiveness, adoption, implementation and maintenance. The location of the study was Hurungwe district, where staff members of 34 health facilities at primary (31), secondary (2) and tertiary (1) levels of care participated. We found that all facilities became skilled in using the NASG, and that the NASG was used in 10 of 11 instances of severe hemorrhage. In the cases of hypovolemic shock where the NASG was used, there were no maternal deaths and no extreme adverse outcomes related to obstetric hemorrhage in the study period. Among the 10 NASG uses, the garment was used correctly in each case. Fidelity to processes was high, especially in regard to training and cascading skills, but revisions of the NASG rotation and replacement operating procedures were required to keep clean garments stocked. Clinical documentation was also a key challenge. NASG introduction dovetailed very well with pre-existing systems for obstetric emergency response, and improved clinical outcomes. Scale-up of the NASG in the Zimbabwean public health system can be undertaken with careful attention to mentorship, drills, documentation and logistics.

Assessing the acceptability of village health workers' roles in improving maternal health care in Gombe State, Nigeria a qualitative exploration from women beneficiaries

Introduction

Maternal, and under-five mortality rates in Gombe State are disproportionately high. The Society for Family Health (a Non-Governmental Organization) in collaboration with Gombe State Primary Health Care Development Agency implemented the Village Health Worker (VHW) Program in Gombe to address the low uptakes of maternal neonatal and child health (MNCH) services and reduced the impact of healthcare worker insufficiency. VHWs are lay indigenous women trained to educate and encourage women to use MNCH services, provide simple community-based maternal and new-born care through home visits, and facilitate facility linkage. We assessed the acceptability of VHW services among women beneficiaries of the Program.

Methods

Qualitative data were obtained through six focus group discussions with 58 women beneficiaries of the VHW program who delivered within the last 12 months preceding study period (October–November 2018). Themes explored were roles and acceptability of VHWs, and the influence of VHWs on the uptake of MNCH services. We analyzed data with NVivo 12, using Grounded Theory.

Results

Participants’ mean age was 25.1 (± 5.3) years old. Most participants 39 (67%), had been in contact with a VHW for at least 10 months. VHWs visited pregnant women at home and registered them for antenatal care, provided them basic maternal healthcare, health education, and facilitated facility linkage. Participants generally accepted the VHW Program because it was community-based, VHWs were indigenous community members, delivered clear messages, and influenced husbands and mothers-in-law to support women’s’ use of MNCH services. VHWs’ interventions were perceived to have improved health literacy and the uptake of MNCH services. Participants generally admired the VHW occupation and recommended VHW program scale-up, and for VHWs to be offered basic obstetric training and employment by health facilities or the government.

Conclusion

The general acceptance and positive views of VHWs from beneficiaries of the program demonstrates the feasibility of the program to improve the uptake of MNCH services.

Developing a Common Understanding of Networks of Care through a Scoping Study

The phrase "Networks of Care" seems familiar but remains poorly defined. A health system that exemplifies effective Networks of Care (NOC) purposefully and effectively interconnects service delivery touch points within a catchment area to fill critical service gaps and create continuity in patient care. To more fully elaborate the concept of Networks of Care, we conducted a multi-method scoping study that included a literature review, stakeholder interviews, and descriptive case studies from five low- and middle-income countries. Our extended definition of a Network of Care features four overlapping and interdependent domains of activity at multiple levels of health systems, characterized by: 1) Agreement and Enabling Environment, 2) Operational Standards, 3) Quality, Efficiency and Responsibility, and 4) Learning and Adaptation. There are a series of key interrelated themes within each domain. Creating a common understanding of what characterizes and fosters an effective Network of Care can drive the evolution and strengthening of national health programs, especially those incorporating universal health coverage and promoting comprehensive care and integrated services. An understanding of the Networks of Care model can help guide efforts to move health service delivery toward goals that can benefit a diversity of stakeholders, including a variety of health system actors, such as health care workers, users of health systems, and the wider community at large. It can also contribute to improving poor health outcomes and reducing waste originating from fragmented services and lack of access.

Applying a Client-centered Approach to Maternal and Neonatal Networks of Care: Case Studies from Urban and Rural Nigeria

In Nigeria, two maternal and neonatal health Networks of Care (NOC) focus on extending the reach and quality of routine and emergency maternal and neonatal health services tailored to the different contexts. This paper uses the four domains of the NOC framework-Agreements and Enabling Environment, Operational Standards, Quality, Efficiency and Responsibility, and Learning and Adaptation-to describe the NOC, highlighting how each developed to address specific local needs. In Northern Nigeria, the NOC were established in collaboration among Clinton Health Access Initiative and the government to reduce maternal and neonatal morbidity and mortality. Health centers and communities in the network were supported to be better prepared to provide maternal and neonatal care, while birth attendants at all levels were empowered and equipped to stabilize and treat complications. The approach brought services closer to the community and facilitated rapid referrals. The NOC in Lagos State extended the reach of routine and emergency maternal and neonatal health services through organically developed linkages among registered traditional birth attendant clinics, private and public sector facilities, the Primary Healthcare Board, and the Traditional Medicine Board. Traditional birth attendants are registered, trained, and monitored by Apex Community Health Officers, whose responsibilities include collection and review of data and ensuring linkages to postpartum services, such as family planning and immunizations. While differing in their approaches, both NOC provide locally appropriate, pragmatic approaches to supporting women birthing in the community and encouraging institutional delivery to ensure that women and their babies have access to timely, appropriate, and safe services.

"I think this is the only challenge… the stigma" Stakeholder perceptions about barriers to Antenatal care (ANC) and Prevention of mother-to-child transmission (PMTCT) uptake in Kano state, Nigeria

Background

Despite the progress made so far in reducing mother-to-child transmission (MTCT), Nigeria still contributes significantly to the global burden of new pediatric HIV infections. The elimination target for MTCT has not been reached and the decline in new infections among all Global Plan countries from 2009 to 2015 was lowest in Nigeria. This qualitative study explores the barriers to uptake of prevention of mother-to-child transmission (PMTCT) intervention in Kano, the second most populous state in Nigeria.

Methods

Key informant interviews (KIIs) were conducted among twelve stakeholders who were purposively selected based on their knowledge and involvement in PMTCT program activities in the state. The KII guide explored the status and challenges of PMTCT uptake in Kano state. Qualitative data analysis was managed using NVIVO 11 software and themes were analyzed using thematic analysis.

Results

We found that the key barriers to uptake of PMTCT identified by stakeholders cut across the domains of the socio-ecological model. These include—fear of stigma associated with being seen accessing HIV related services, low male partner involvement, socio-cultural beliefs about the dangers of hospital-based delivery, poor attitude of health workers, distance/cost to facilities, issues with availability of HIV test kits and poor organization of health services.

Conclusion

The implementation of effective PMTCT programs would require innovative strategies that leverage improvement of Antenatal care (ANC) uptake as an entry point for PMTCT. In addition, sustaining engagement in care requires creating a supportive stigma-free environment in the community as well as spousal support to ensure women can navigate the socio-cultural barriers that limit access to health services.

Implementation project of the non-pneumatic anti-shock garment and m-communication to enhance maternal health care in rural Tanzania

BACKGROUND

Obstetric hemorrhage (OH) remains one of the leading causes of maternal mortality, particularly in rural Africa. Tanzania has a high maternal mortality ratio, and approximately 80% of the population accesses health care lower level facilities, unable to provide Comprehensive Emergency Obstetric Care (CEmOC). The non-pneumatic anti-shock garment (NASG) has been demonstrated to reduce mortality as it buys time for women in shock to be transported to or to overcome delays at referral facilities.

METHODS

This report describes one component of an ongoing maternal health improvement project, Empower, implemented in 280 facilities in four regions in rural Tanzania. The NASG along with a Closed User Group (CUG) mobile phone network were implemented within the overall EmOC project. Simulation trainings, repeated trainings, and close hands-on supportive supervision via site visits and via the CUG network were the training/learning methods. Data collection was conducted via the CUG network, with a limited data collection form, which also included free text options for project improvement. One-to-one interviews were also conducted. Outcome Indicators included appropriate use of NASG for women with hypovolemic shock We also compared baseline case fatality rates (CFR) from OH with endline CFRs. Data were analyzed using cohort study Risk Ratio (RR). Qualitative data analysis was conducted by content analysis.

RESULTS

Of the 1713 women with OH, 419 (24.5%) met project hypovolemic shock criteria, the NASG was applied to 70.8% (n = 297), indicating high acceptability and utilization. CFR at baseline (1.70) compared to CFR at endline (0.76) showed a temporal association of a 67% reduced risk for women during the project period (RR: 0.33, 95% CI = .19, .60). Qualitative feedback was used to make course corrections during the project to enhance training and implementation.

CONCLUSIONS

This implementation project with 280 facilities and over 1000 providers supported via CUG demonstrated that NASG can have high uptake and appropriate use for hypovolemic shock secondary to OH. With the proper implementation strategies, NASG utilization can be high and should be associated with decreased mortality among mothers at risk of death from obstetric hemorrhage.