Menu
Menu
Menu
Menu
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.
Jigawa state is divided into 5 emirates—Dutse, Hadejia, Kazaure, Ringim and Gumel—each headed by an emir. For the pilot, we selected Jahun LGA, located 45 km from the state capital of Dutse and within the Dutse emirate. The Jahun Gunduma Council is the major governing structure for health provision in Jahun as well as Miga LGA, with responsibility for 30 primary health centers (PHCs) and Jahun General Hospital. Jahun’s population density of 152 persons/km2 is typical for the state, and was thus considered an appropriate context for the pilot with potential for scale-up to other LGAs. The close location of the state School of Health Technology—the institution that trains CHEWs—also provided logistical benefits for initial phases of the work focused on curriculum review and training. According to 2006 census figures, Jahun LGA had a total population of 229,094 people.20 The specific target for this pilot were women of childbearing age, and particularly pregnant women. There were an estimated 57,000 women of childbearing age in Jahun LGA, with approximately 20% pregnant at any given time. Within Jahun LGA, Kadawawa was selected to pilot the community-based service delivery program. Located approximately 36 km from the LGA headquarters, Kadawawa is a remote, rural community with a population of just under 16,000 people spread out across several hamlets. The terrain of the community is rough and barely accessible during the rainy season. Commercial vehicles and motorbikes get to Kadawawa once a week on market days. When health workers have to travel to and from the community, this is feasible only on market days, which fall on Fridays. Jahun General Hospital, approximately 1.5 hours away by vehicle, is the nearest basic or comprehensive obstetric care center to Kadawawa. Kadawawa is estimated to have a population of just under 3,000 women of childbearing age, with a little less than 800 pregnant women at any one time and some 600 women having children under 1 year of age. Before deployment of resident health workers, Kadawawa clinic was in a generally poor state of repair, serving only as a base for male CHEWs to provide immunization and related services on weekly visits to the community. The community of Kafin Baka was selected as the control community because, although smaller in population, it otherwise had similar baseline characteristics to Kadawawa (Table 1). It is a rural village positioned within difficult terrain. It had a dilapidated and ill-equipped, although semi-functional, health center managed by non-resident male CHEWs who provided services on an irregular basis. As in Kadawawa, there were no female CHEWs at the health facility, and there were no outreach services by female health workers of any grade. The control site provided no ANC, deliveries, or postnatal care services, although the male health workers provided immunizations. The distance to Jahun General Hospital—the nearest basic/comprehensive obstetric care center—was similar to that for residents of Kadawawa, with similar transportation costs for the journey (around 5,000 Nigerian Nairas [NGN], or about US$25). Transportation costs from the study communities to the nearest hospital were around US$25. During the study period, both the intervention and control sites received general facility upgrades through Jigawa’s implementation of a minimum service package. This focused on equipment and supplies but did not include staffing changes related to CHEWs. Pre-intervention qualitative studies were conducted to inform study design and pilot implementation, as well as to mobilize the community prior to implementation, a key feature of the Navrongo CHPS model. These studies included mapping of undeserved areas and focus group discussions (FGDs), key informant interviews, and community dialogues (durbars) to identify perceptions of factors contributing to the high rates of maternal and newborn mortality (including low service utilization) within the communities of Kadawawa and Kafin Baka.21 FGDs were held with women of childbearing age, older women who had stopped childbearing, and young unmarried girls. Discussions were also held with older men, young married men, and young unmarried men, using similar FGD guides. Key informant interviews were held with community leaders (men, women, youth, and religious leaders). Community dialogues were convened to ensure potential inclusion of community members who had not participated in other forms of consultation. Other pre-intervention studies involved in-depth interviews with CHEWs and health managers regarding the current practices and deployment of CHEWS, as well as a review of the CHEW training curriculum at the School of Health Sciences. The pre-intervention qualitative research identified 3 major types of barriers to accessing existing services: household-level barriers, including cultural norms discouraging women’s prompt access to care; facility-level barriers, largely lack of resources; and attitudinal issues, which further discouraged access to the referral facility in Jahun (Table 2). In-depth interviews with CHEWs, health managers, and government leaders also identified a range of supply-side challenges, including a shortage of midwives, isolation, and problems in the operation of the “Midwives Service Scheme” (the national scheme deploying midwives to underserved communities). They also noted the circumstances that had resulted in CHEWs evolving from what were intended to be a community-based cadre to a clinic-based cadre. CHEWs were originally trained to spend 60% of their time within the communities doing home visits and 40% at designated rural health clinics. But their postings became increasingly politicized, and a majority of them were found living in urban areas and working in urban city clinics, avoiding rural areas. Men who married the few female CHEWs that had been trained in the state often did not allow their wives to live and work in rural areas. The interviews with CHEWs and review of their training curricula indicated further barriers to effective deployment of this cadre. Deployed principally at urban general hospitals, CHEWS had had little opportunity alongside nurses and midwives to practice the skills they were taught at the School of Health Technology. Many functioned essentially as janitors or security staff at wards, or at best, were used as clerks to register hospital attendees. There was no clarity in the services that should be provided by CHEWs, and their training curriculum had neither been updated nor used as an active tool to shape the skills of students. These findings led to a concerted effort to develop the CHEW training curriculum at the School of Health Technology to reflect contemporary approaches to community health provision and define more clearly a minimum service package that could be competently delivered by the cadre. The Jigawa state Ministry of Health and the Gunduma Health System Board (the body coordinating management of health services across a cluster of LGAs within the state) developed this minimum service package, mindful of state needs and concerns. The resulting document also was put into quality use and doggedly monitored. Notably, with revisions to the manuals guiding CHEW training, senior CHEWs were accepted as “skilled birth attendants” permitted to attend uncomplicated deliveries. The pilot project was implemented over a 7-month period (February to August 2011). We adopted a quasi-experimental design to evaluate the pilot intervention: routine service data collected through the established Health Management Information Systems (HMIS) were compared for Kadawawa (intervention area) and Kafin Baka (control area), with analysis focusing on the outcomes of health post visits, ANC attendance, and facility-based deliveries. We also compared state HMIS data from the 3-year period of 2008–2010 (before introduction of the pilot) with the 3-year period of 2011–2013 (during and after the pilot) to provide insight into the sustainability of changes following the intense pilot period. The protocol for the study was approved by the Ethics Review Sub-Committee of the Jigawa Operations Research Advisory Committee.
N/A
