Reducing maternal and newborn mortality in Nigeria-A qualitative study of stakeholders’ perceptions about the performance of community health workers and the introduction of community midwifery at primary healthcare level

Human Resources for Health, Volume 17, No. 1, Year 2019

Interpretation

Background: Rural communities in Nigeria account for high maternal and newborn mortality rates in the country. Thus, there is a need for innovative models of service delivery, possibly with greater community engagement. Introducing and strengthening community midwifery practice within the Nigerian primary healthcare system is a clear policy option. The potential of community midwifery to increase the availability of skilled care during pregnancy, at birth and within postpartum periods in the health systems of developing countries has not been fully explored. This study was designed to assess stakeholders’ perceptions about the performance of community health workers and the feasibility of introducing and using community midwifery to address the high maternal and newborn mortality within the Nigerian healthcare system. Methods: This study was undertaken in two human resources for health (HRH) project focal states (Bauchi and Cross River States) in Nigeria, utilizing a qualitative research design. Interviews were conducted with 44 purposively selected key informants. Key informants were selected based on their knowledge and experience working with different cadres of frontline health workers at primary healthcare level. The qualitative data were audio-recorded, transcribed and then thematically analysed. Results: Some study participants felt that introducing community midwifery will increase access to maternal and newborn healthcare services, especially in rural communities. Others felt that applying community midwifery at the primary healthcare level may lead to duplication of duties among the health worker cadres, possibly creating disharmony. Some key informants suggested that there should be concerted efforts to train and retrain the existing cadres of community health workers via the effective implementation of the task shifting policy in Nigeria, in addition to possibly revising the existing training curricula, instead of introducing community midwifery. Conclusion: Applying community midwifery within the Nigerian healthcare system has the potential to increase the availability of skilled care during pregnancy, at birth and within postpartum periods, especially in rural communities. However, there needs to be broader stakeholder engagement, more awareness creation and the careful consideration of modalities for introducing and strengthening community midwifery training and practice within the Nigerian health system as well as within the health systems of other developing countries. This study was carried out in Bauchi State in the North-eastern part of Nigeria which has a predominantly Muslim population as well as in Cross River State which has a predominantly Christian population within the Southern part of the country. Key informant interviews within a qualitative study design were used to elicit the required information from the study participants using appropriate key informant interview (KII) guides. These KII guides were first developed, pilot-tested and finalized for use by the study researchers. The study population consisted of 44 policy makers and healthcare managers, i.e. stakeholders selected from a range of institutions in Bauchi and Cross River States. The study population consisted of senior officials within Ministries of Health and other health-related parastatals such as the State Primary Healthcare Development Agencies, Heads of health training institutions, key officials of Local Government Health Departments, Managers from health development organizations and officials from associations of frontline health workers within both Bauchi and Cross River States. (Please see Table Table11 for breakdown of policy makers and healthcare managers interviewed for the study). A purposive sampling approach was employed to select key informants for the study, based on their knowledge and/or experience working at the PHC level. The purposive sampling technique was appropriately selected as the sampling strategy to ensure that all selected key informants from both study states had a minimum of 5 years work experience with the Nigerian PHC system, covering areas such as training and capacity building of health workers, service delivery and PHC governance, thus making them well-suited to offer rich insights for addressing the study objectives. Breakdown of policy makers and healthcare managers interviewed for the study within the two states in Nigeria Interviewers with expertise in conducting key informant interviews as well as understanding of the context and culture of the study states were recruited. For quality assurance purposes, the interviewers were trained by qualitative research methodology experts on the use of the key informant guides. In addition to role plays and participating in practical exercises, they were retrained on research ethics. Prior to commencing data collection, written informed consent was sought and obtained from each study participant. Data collection using key informant interview guides took place starting in November 2015 and continued through the first and second quarters of 2016. To ensure validity, the KII guide was reviewed and quality-assured by senior health experts from the Bauchi and Cross River States Ministries of Health and researchers from the University of Ibadan in Nigeria, who provided support during the design of the study. The KII guide consisted of broad questions and follow-up probes on the performance of community health workers in maternal, newborn and child healthcare service delivery and specific actions that could be taken to improve or enhance MNCH service delivery effectiveness. The interviews were recorded using a tape recorder. Consent to be tape-recorded was sought and obtained from each respondent as part of the informed consent process. After the interviews, the interviewers transcribed the audio recordings verbatim, and the transcripts and audio recordings were sent to Population Council Country office in Nigeria for archiving. The transcripts were subsequently compared with the audio recordings to ensure completeness. A pre-determined coding framework was applied, and subsequently thematic analyses of the data were undertaken. Members of the study team who were involved during the data collection process also provided assistance in categorizing the data. Regular meetings were held by the study team in order to reach consensus on the interpretation of the data collected during the interviews. The study focused on the investigation of the perspectives of PHC managers and policy makers (rather than clients) as key stakeholders since their inputs would largely shape any official efforts at reforming or improving the performance of the Nigerian PHC system. Ethical approval was granted by Bauchi and Cross River States’ Research Ethical Committees and Population Council’s Institutional Review Board (IRB). The study was conducted based on set ethical guidelines, and informed consent was obtained from each study respondent before each interview commenced. Study respondents were assured of the confidentiality of their responses. Only generic descriptions and the location of each key informant were recorded by the researchers without explicitly identifying particular key informants vis-à-vis their specific responses or statements.

AI Digest

Study Justification:

– High maternal and newborn mortality rates in rural communities in Nigeria
– Need for innovative models of service delivery with community engagement
– Potential of community midwifery to increase access to skilled care during pregnancy, birth, and postpartum periods

Highlights:

– Introducing community midwifery can increase availability of maternal and newborn healthcare services in rural communities
– Some concerns about duplication of duties and disharmony among health worker cadres
– Suggested efforts to train and retrain existing community health workers instead of introducing community midwifery

Recommendations:

– Engage stakeholders for broader involvement and awareness creation
– Carefully consider modalities for introducing and strengthening community midwifery training and practice within the Nigerian health system and other developing countries

Key Role Players:

– Policy makers and healthcare managers from Ministries of Health, State Primary Healthcare Development Agencies, health training institutions, Local Government Health Departments, health development organizations, and associations of frontline health workers

Cost Items for Planning Recommendations:

– Stakeholder engagement activities (meetings, workshops, awareness campaigns)
– Training and retraining programs for community health workers
– Revision of existing training curricula
– Implementation of task shifting policy
– Monitoring and evaluation of community midwifery training and practice
Please note that the cost items provided are general categories and not actual cost estimates. The actual costs will depend on the specific context and implementation strategies.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a qualitative study design and interviews with key informants. While the study provides valuable insights into stakeholders’ perceptions about the performance of community health workers and the feasibility of introducing community midwifery, it is important to note that qualitative research alone may not provide generalizable findings. To improve the strength of the evidence, the study could consider incorporating quantitative data to complement the qualitative findings. Additionally, expanding the sample size and including a more diverse range of stakeholders could enhance the representativeness of the study. Finally, conducting similar studies in other regions or countries would help validate the findings and provide a broader perspective on the potential impact of community midwifery in addressing maternal and newborn mortality.

Abstract

This study was carried out in Bauchi State in the North-eastern part of Nigeria which has a predominantly Muslim population as well as in Cross River State which has a predominantly Christian population within the Southern part of the country. Key informant interviews within a qualitative study design were used to elicit the required information from the study participants using appropriate key informant interview (KII) guides. These KII guides were first developed, pilot-tested and finalized for use by the study researchers. The study population consisted of 44 policy makers and healthcare managers, i.e. stakeholders selected from a range of institutions in Bauchi and Cross River States. The study population consisted of senior officials within Ministries of Health and other health-related parastatals such as the State Primary Healthcare Development Agencies, Heads of health training institutions, key officials of Local Government Health Departments, Managers from health development organizations and officials from associations of frontline health workers within both Bauchi and Cross River States. (Please see Table Table11 for breakdown of policy makers and healthcare managers interviewed for the study). A purposive sampling approach was employed to select key informants for the study, based on their knowledge and/or experience working at the PHC level. The purposive sampling technique was appropriately selected as the sampling strategy to ensure that all selected key informants from both study states had a minimum of 5 years work experience with the Nigerian PHC system, covering areas such as training and capacity building of health workers, service delivery and PHC governance, thus making them well-suited to offer rich insights for addressing the study objectives. Breakdown of policy makers and healthcare managers interviewed for the study within the two states in Nigeria Interviewers with expertise in conducting key informant interviews as well as understanding of the context and culture of the study states were recruited. For quality assurance purposes, the interviewers were trained by qualitative research methodology experts on the use of the key informant guides. In addition to role plays and participating in practical exercises, they were retrained on research ethics. Prior to commencing data collection, written informed consent was sought and obtained from each study participant. Data collection using key informant interview guides took place starting in November 2015 and continued through the first and second quarters of 2016. To ensure validity, the KII guide was reviewed and quality-assured by senior health experts from the Bauchi and Cross River States Ministries of Health and researchers from the University of Ibadan in Nigeria, who provided support during the design of the study. The KII guide consisted of broad questions and follow-up probes on the performance of community health workers in maternal, newborn and child healthcare service delivery and specific actions that could be taken to improve or enhance MNCH service delivery effectiveness. The interviews were recorded using a tape recorder. Consent to be tape-recorded was sought and obtained from each respondent as part of the informed consent process. After the interviews, the interviewers transcribed the audio recordings verbatim, and the transcripts and audio recordings were sent to Population Council Country office in Nigeria for archiving. The transcripts were subsequently compared with the audio recordings to ensure completeness. A pre-determined coding framework was applied, and subsequently thematic analyses of the data were undertaken. Members of the study team who were involved during the data collection process also provided assistance in categorizing the data. Regular meetings were held by the study team in order to reach consensus on the interpretation of the data collected during the interviews. The study focused on the investigation of the perspectives of PHC managers and policy makers (rather than clients) as key stakeholders since their inputs would largely shape any official efforts at reforming or improving the performance of the Nigerian PHC system. Ethical approval was granted by Bauchi and Cross River States’ Research Ethical Committees and Population Council’s Institutional Review Board (IRB). The study was conducted based on set ethical guidelines, and informed consent was obtained from each study respondent before each interview commenced. Study respondents were assured of the confidentiality of their responses. Only generic descriptions and the location of each key informant were recorded by the researchers without explicitly identifying particular key informants vis-à-vis their specific responses or statements.

Materials

N/A

Innovations

The study conducted in Bauchi and Cross River States in Nigeria explores stakeholders’ perceptions about the performance of community health workers and the introduction of community midwifery at the primary healthcare level. The study suggests that introducing and strengthening community midwifery practice within the Nigerian primary healthcare system could improve access to maternal and newborn healthcare services, particularly in rural communities. However, there are differing opinions among stakeholders. Some believe that training and retraining existing cadres of community health workers through the effective implementation of the task shifting policy in Nigeria, along with revising the existing training curricula, would be a better alternative to introducing community midwifery.

To successfully implement community midwifery or alternative approaches, broader stakeholder engagement, more awareness creation, and careful consideration of modalities for training and practice are necessary. This includes addressing concerns, ensuring adequate training, and integrating community midwifery into the Nigerian healthcare system and other developing countries.

The study was published in the journal Human Resources for Health in 2019 and involved interviews with 44 key informants, including policy makers, healthcare managers, and officials from various health-related institutions. The qualitative data were analyzed thematically to gain insights into stakeholders’ perceptions and recommendations.

It is important to note that the study was conducted in Bauchi and Cross River States, which have different religious and geographical characteristics. The key informants were selected based on their knowledge and experience working with different cadres of frontline health workers at the primary healthcare level. The study used a qualitative research design and employed a purposive sampling approach to select key informants.

Ethical approval was obtained, and informed consent was obtained from each study participant. The study followed set ethical guidelines, and the confidentiality of respondents’ responses was ensured.

Overall, the study highlights the potential benefits of introducing community midwifery in Nigeria’s primary healthcare system but also acknowledges the need for further stakeholder engagement and careful consideration of alternative approaches.

AI Innovations Description

The recommendation from the study is to introduce and strengthen community midwifery practice within the Nigerian primary healthcare system. This is seen as a clear policy option to improve access to maternal and newborn healthcare services, especially in rural communities. The potential of community midwifery to increase the availability of skilled care during pregnancy, at birth, and within the postpartum period has not been fully explored in developing countries like Nigeria.

However, there are differing opinions among stakeholders. Some believe that introducing community midwifery may lead to duplication of duties among health worker cadres and create disharmony. As an alternative, they suggest training and retraining existing cadres of community health workers through the effective implementation of the task shifting policy in Nigeria, along with revising the existing training curricula.

To successfully implement community midwifery or alternative approaches, broader stakeholder engagement, more awareness creation, and careful consideration of modalities for training and practice are necessary. This includes addressing concerns, ensuring adequate training, and integrating community midwifery into the Nigerian healthcare system and other developing countries.

The study was conducted in Bauchi and Cross River States in Nigeria, utilizing a qualitative research design. Interviews were conducted with 44 key informants, including policy makers, healthcare managers, and officials from various health-related institutions. The qualitative data were analyzed thematically to gain insights into stakeholders’ perceptions and recommendations.

The study was published in the journal Human Resources for Health in 2019.

AI Innovations Methodology

The methodology used in this study involved conducting qualitative research in Bauchi and Cross River States in Nigeria. The study utilized key informant interviews with 44 stakeholders, including policy makers, healthcare managers, and officials from various health-related institutions. The key informants were selected based on their knowledge and experience working with different cadres of frontline health workers at the primary healthcare level.

The interviews were conducted using key informant interview (KII) guides that were developed, pilot-tested, and finalized by the study researchers. The study population consisted of senior officials within Ministries of Health, State Primary Healthcare Development Agencies, health training institutions, Local Government Health Departments, health development organizations, and associations of frontline health workers in Bauchi and Cross River States.

A purposive sampling approach was used to select the key informants, ensuring that they had a minimum of 5 years of work experience with the Nigerian primary healthcare system. The interviewers were trained in qualitative research methodology and research ethics to ensure the quality of data collection.

Written informed consent was obtained from each study participant before data collection. The interviews were audio-recorded, transcribed, and thematically analyzed. A pre-determined coding framework was applied, and regular meetings were held by the study team to reach consensus on the interpretation of the data.

Ethical approval was obtained from the Research Ethical Committees of Bauchi and Cross River States, as well as the Population Council’s Institutional Review Board. The study adhered to ethical guidelines, and the confidentiality of the respondents’ responses was assured.

The findings of the study were published in the journal Human Resources for Health in 2019.

Author

Dima Health

Statistics:

Citations: 5

Identifiers:

DOI: 10.1186/s12960-019-0430-0

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce

Study Countries:

Nigeria

Study Design:

Cohort Study, Cross Sectional Study, Grounded Theory

Study Approach:

Qualitative