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

Background: This 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. Methods. The 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. Results: Between 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. Conclusions: These 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. © 2013 Findley et al.; licensee BioMed Central Ltd.

The study was conducted in the three northern Nigerian states where PRRINN has expanded its MNCH activities, namely Katsina, Yobe, and Zamfara, with respective populations of 5.8, 2.3, and 3.3 million, according to the 2006 population census of Nigeria. These states are part of the Sahelian zone, with an alternation of dry and wet seasons. The program focuses on the rural communities, where most of the residents are subsistence farmers, pastoralists, or traders. The level of literacy is low, particularly among women, where over 80% are unable to read or write. Half or more of the women do not listen to the radio or watch television at least once a week. Compared to the southern zones of Nigeria where primary care use is widespread, there is very little primary care service use in the northern zones of Nigeria. In these states, less than 50% of women had any antenatal care in their last pregnancy, over 85% delivered at home without assistance of a skilled attendant, and about 75% had no postnatal care. These states had the lowest immunization coverage rates, under 10% of 12–23 month olds, and the lowest rates of utilization of health care services for treating sick children. The intervention design reflects the integration of two different approaches to the improvement of health care. First, the design uses the PRECEDE-PROCEDE framework for health promotion through system-wide changes in health planning and implementation which facilitate changes in MNCH health knowledge, practices, and outcomes, incorporating participatory methods and operations research to assess progress in achieving changes at each stage [28]. Second, the intervention design is implemented spatially through a cluster approach, which focuses on reducing the three delays to emergency obstetrical care [29-31]. The program focuses on improving MNCH care by clusters of Local Government Areas (LGAs) per state, which each comprise a catchment area for emergency obstetrical care (EOC) services, with one Comprehensive EOC facility per 500,000 people. Making referral to this Comprehensive EOC facility are four Basic EOC facilities (each serving 100,000 people with the Comprehensive EOC facility serving the other 100,000 people) and eight “24/7” facilities providing maternal care. A total of 15 LGAs were selected as the first intervention clusters, 4–6 per state. The remaining LGAs had statewide policy changes without focused clinical or community activities to improve health system infrastructure and MNCH care demand, and served as the control communities. In addition to the development of EOC capabilities, the health system strengthening component of the intervention included midwife training and posting through the Nigerian government’s Midwife Service Scheme, establishment of planning and management techniques within existing facilities, strengthening distribution of essential drugs to PHC facilities, refurbishment of PHC equipment (as needed), training in IMCI for the PHC clinical staff, and establishing the “Primary Health Care Under One Roof,” which consolidates and coordinates the different components of primary care in one health clinic or post. Complementing these supply-side changes, are activities that create demand for MNCH services. Selected groups of villages served by primary care facilities linked to the upgraded EOC facility participate in a community engagement process, which aims to increase awareness, knowledge and practices of healthy behaviors in response to MNCH barriers. Core to this process is a participatory, community discussion group, facilitated by trained community volunteers (CVs). The community volunteers have been recruited and trained in each community, using a cascade or train the trainers model, with core trainers training CVs who in turn train new volunteers. The participatory training methodology is underpinned by key principles of adult learning, starting with discussions and reflection on personal experiences, which in turn are used to discuss potential responses/solutions women could adopt. Body memory tools (e.g., mimicking movements of the body when affected by different danger signs) help trainees remember key facts. By 2011 CVs, primarily women, had been recruited, mobilized and supported in their work in all the intervention communities. The primary responsibility of the CV is to facilitate community discussion groups through the use of jingles and other visual-auditory cues to educate about critical MNCH issues, such as danger signs for a pregnancy. In addition, the CVs also aid in identifying at risk women and children and referring them to the nearest facility. These dialogues provide an opportunity for reflection and problem solving on the most prevalent MNCH problems affecting the community. Members of the discussion groups are encouraged to share what they know with their families and peers between sessions. Community discussion group participants are encouraged to put what they have learned into practice by tackling key barriers of access to and affordability of MNCH services, including establishment of blood donor groups, community emergency savings schemes, community emergency transport schemes and a “mother’s helpers” system. This work is reinforced by mass communication activities, including the use of radio “jingles” to promote birth preparedness or childhood immunizations. The CV have been complemented by a small cadre of CHWs, community-based health workers providing selected primary health services directly to families through rotating visits or extended availability through residence in the communities, similar to the models used in other countries with volunteers and paid CHWs. These CHWs were recruited among unemployed Junior Community Health Extension Workers, previously trained by the state Schools of Health Technology, who were then given two weeks of additional training and toolkits to enable them to make home visits, engage mothers using supportive communication techniques, provide basic preventive antenatal, newborn, and child care, basic treatment and referral to the PHC, according to the Integrated Management of Newborn and Childhood Illnesses protocol. These CHW-Community Based Service Delivery (CBSD) are provided with transport to enable them to visit communities on a regular schedule, and they spend most of their time visiting families in the community. The assessment of the impact of the CBSD programs uses a quasi-experimental design using pre- and post-intervention household surveys in the intervention and control communities. The pre-intervention or baseline household survey (BHS) was conducted in 2009 and the post-intervention household survey, the follow-up household survey (FHS) was conducted in 2011. The evaluation of the impact of this integrated MNCH package takes into account both availability of program and actual individual participation in any of the program’s community-based service activities. Availability of the program activities was assessed by comparison of intervention and control areas. Individual exposure to the program was assessed by the woman’s responses to questions eliciting sources of information or health care advice. The study was approved by State Ethics Review Committees in each of the three states, as both a cross-state and individual state approval. These ethics review committees are certified by the Nigerian Federal Government’s National Health Research Ethics Committee to review and approve health research protocols for their states. The sampling plan was a stratified two-stage cluster sample, with oversampling of individuals in the MNCH intervention clusters. Individuals from MNCH clusters were oversampled using a ratio of 2:1, because MNCH clusters cover a significantly lower proportion of the population of each state. Oversampling therefore provided a sufficient sample in the intervention areas to assess the impact of key elements within the intervention package on the key MNCH outcomes. The PSU for this sample was the Local Government Area (LGA), for which there were 24 in the BHS and 15 in the FHS. For the FHS, the same intervention LGAs as the BHS were included, with the exception of LGAs of the state capitals (considered not an appropriate control for the largely rural intervention). The LGAs comprising the state capitals were included only during the baseline to assess the differences in services provided to residents patronizing urban versus rural facilities. This enabled the team to devise appropriate strategies for referral from rural to urban facilities. The state capitals were excluded in the analyses reported here. The number of households selected per LGA was proportional to the size of the LGA. The study was designed with an 80% power to detect a 2.5% change in the percentage of women delivering with the assistance of skilled birth attendants between the BHS (11%) and the FHS. The BHS was designed to be representative of all ever-married women in the household and required a sample of 5,560 households, while the FHS was designed to be representative only of ever-married women with a birth in the previous 5 years, requiring a sample of only 2,310 households. In the BHS, the sample of 5,560 households was 0.7% to 9.8% per LGA, while for the FHS the 2,310 households comprised 3.1% to 13.1% of all households. Within the LGA, the sample of households was allocated to intervention and control communities in proportion to the size of the community or village. The sampling fraction for each community was determined by information on the total households from the community leadership. Households within each selected community were randomly sampled using a procedure similar to that used in the WHO-EPI cluster surveys, namely by numbering then sampling households according to the community sampling fraction along randomly selected paths leading out from the center of the village. The household was the ultimate sampling unit. In compounds that comprised one to three households, one household was randomly chosen for interviews; in compounds with four to six households, two were surveyed; in compounds with seven or more households, three were surveyed. Within each randomly selected household, in the baseline survey, all ever-married women of childbearing age (15–49 years) were interviewed, whereas in the FHS only one ever-married women with at least one child born in the last 5 years was selected for interview. The inclusion criteria were changed for the follow-up survey because of the need to focus on women with pregnancies and births during the time period during which the intervention was implemented. In the BHS there were 6,842 women with successfully completed interviews, while in the FHS there were 2,310 completed interviews. Interviewers who had completed secondary school or higher were selected and trained to visit the selected women at home and administered a questionnaire that included translation of key concepts and terms in the local languages (e.g., Hausa, Kanuri). Most of the interviewers were females, responding to cultural expectations and beliefs that encourage female interviewers to interview female respondents. In both the BHS and FHS, the questionnaires used adopted some of the close-ended questions from the 2008 Demographic and Health Survey [14] to allow comparisons of results with other national- or state-level data. Questions were modified in line with the program goals and focused on a series of topics related to perceptions, knowledge, and practices related to MNCH outcomes. Specifically, the topics included issues related to information such as age, parity, economic status, literacy in any language, wife rank, antenatal care and delivery characteristics, source of health advice for the woman or the baby during last pregnancy, experience of labor and delivery complications, knowledge of maternal and newborn danger signs and how to respond to them, actual response to danger signs of infant and child illness, and infant and child mortality. At the analysis stage, the inclusion criteria for both surveys was narrowed to ever-married women, aged 15–49, with a birth in the previous five years. Respondents were assigned to the control or intervention groups based on the level of PRRINN-MNCH program intervention at the time of the survey. For the BHS, which was pre-intervention, the intervention LGAs included all LGAs in the first cluster receiving CEOC upgrades and related community engagement activities, while the balance were control LGAs. The FHS included the same intervention LGAs, but control LGAs in 2009 were shifted into the intervention category if they had started to receive the primary health care and community health worker interventions by the time of the FHS. The dependent variables are the key health behaviors pertaining to maternal, newborn care and care of sick children. Infant and child mortality rates were calculated using standard demographic estimation methods. The infant and child mortality rates were calculated using the retrospective reports of births and deaths in the previous 12 months and five years, per the standardized format of the Demographic and Health Surveys. Rates were calculated separately for each survey period, aggregating the reported births and deaths per household. We first verified the number of births and deaths for the appropriate reference period (one or five years) using the built-in cross-referencing between questions, excluding implausible values (e.g., deaths to children under five exceeding births, after controlling for children moving in and out of the household), and then calculated the mortality rates using the appropriate births denominator. The bi-variate and multi-variate analyses of the two sets of survey data were conducted separately, each using sampling weights based on the intervention and control areas. We examined changes in the proportion with the designated MNCH behaviour or outcome, contrasting all pre-intervention responses (all BHS) versus the post-intervention responses from the FHS, intervention versus control. We assessed the degree to which the intervention and control groups differed using the Chi-square statistic. Analyses were performed using Stata 12.0 (Statacorp, College Station, TX) and SPSS version 19.0 (SPSS Inc. Chicago, Ill).

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